Mental Health Unblocked

Mental Health Unblocked is a new section on this web-site. We have emphasised in practising nidotherapy that genuine unadulterated collaboration is necessary to move forward with individual problems. But collaboration requires understanding and there are still many myths and misconceptions about mental illness that stop or hinder collaboration. So this section is concerned with passing on important information about mental health  that may not be available elsewhere, either because it is very new, or often because it has been distorted or misrepresented in different media outlets. Some other information, more related to literature, is being represented in a email group currently being set up (https://petertyrer.substack.com). People will be invited to join and important messages will be posted on this page in diary form and updated when needed.

Readers of this website are invited to join this group if they wish to be involved. Go to the website and if there are problems send an email message to p.tyrer@imperial.ac.uk with the subject line ‘Mental Health Unblocked’. These details will be kept confidential.

Wednesday 13th May.   Social prescribing is likely to become an increasing part of the mental health services in the future, and we expect this to blossom in the wake of the COVID pandemic.  A piece on the subject is being published in Lancet Psychiatry very shortly.  Here are two sections from the paper:

‘ “Social prescribing” may not be a good couplet for an intervention that has the potential to transform services. It implies the dispensation of interventions, probably of the drug variety, in settings where there are many people present.  This is not an attractive notion, implying casual disregard of professional conduct, and is of course misleading. Yet it has now been embraced fulsomely to the extent that there is now a National Academy of Social Prescribing, launched by the Secretary of State for Health and Social Care, Matt Hancock, the UK on the 23 October 20191.   It is too late to change the wording at this stage in its life, but a much better couplet would have been ‘collateral interventions’.   They are interventions because this word covers a much bigger range than ‘prescribing’, and collateral because they reinforce rather than challenge conventional pathways.  So, when someone with long-term depression who has not improved after 20 years of antidepressants meets a community pharmacist, talks about ways of improving her life and, as part of social prescribing, is given the suggestion of taking up a vacancy at a local allotment. If she returns six months later to see the pharmacist, says that she has stopped the antidepressants and gives a large allotment-grown cauliflower in thanks for the intervention, we can then say social prescribing has been successful.’

Unfortunately, social prescribing has been poorly researched and comes under the general heading of ‘absence of evidence is not evidence of absence.  It is likely to be of value but many questions arise about its process, which currently concentrates on trained link workers:

‘There are three important questions to answer.

  1. Who should be referred?

The initiatives in social prescribing are focussed on primary care and supported by the use of link workers. Presently, the referrals to link workers will come from general practice, but in the near future any community resource can refer. Without guidance it is likely that link workers will be overwhelmed.

  1. Do linkworkers have the necessary skills and support to be effective?

This question cannot be answered at present, but it is unlikely to be positive.  With such a large range of people eligible to refer it is easy to envisage a Pandora’s box of problems being presented that go far beyond the abilities of a single worker to solve. There is little in the guidance about the necessary skills and training of link workers and the only common requirement is that they should have extensive local knowledge.

  1. What back-up is available for social prescribers?

At present there is a good internal network proposed for social prescribing link workers with regular meetings, supervision from more senior staff, and events for outside speakers. But is this enough, particularly when there is going to be no filter on referrals and more severe problems are bound to be encountered? The level of feedback between link workers and referrers also needs to be tightened up as at some point the process of referrals will have to be constrained.’

Social prescribing and nidotherapy are highly relevant for children as well as adults. Today I gave a talk on the subject to London child psychiatrists. It was linked to a general theme about the diagnosis of personality disorder in children and adolescents. Some people find this notion abhorrent, but one of the principles of Mental Health Unblocked is plain common sense. Nobody disputes that personality is set down in childhood so disorder must arise then also. Pretending it doesn’t exist until adulthood is nonsense.  If any child and adolescent mental health professionals want to be convinced I can send them the PowerPoint presentation.

Thursday  14th May.  People have often asked us if drug treatment can be part of nidotherapy.  It most certainly can.  But it works in two directions.  Anthea, the first person to be described in detail in the second edition of nidotherapy (she gave full permission to have the raw story set out in full) was determined to avoid taking drugs for her schizoaffective disorder (one of the schizophrenias). She had very good reasons for not taking the standard antipsychotic prescription drugs given for this condition – saying they made her feel so awful life was intolerable – and so for 17 years she had oscillating admissions as she stopped taking these drugs whenever she was outside hospital. But when assessed for nidotherapy, where collaborative treatment is paramount, we were forced into trying a form of management without drugs.  As the account in the book demonstrated, it worked like a dream, as we found out her episodes of psychosis could be condensed into a few days if she walled herself into her flat and avoided contact when unwell, and no drugs were ever needed. There is a journal which used to publish a series called The Patient Who Changed My Practice, and I wrote about her there and gave her a copy.  ‘ I am glad you were finally able to see sense’, was her short reply.

But with other people the collaborative approach sometimes leads to people appreciating the value of drug treatment, as it can lead to more favourable interaction with the world.  A scary frightening environment can suddenly become friendly and supportive if the appropriate drug is given. In this type of situation taking the right dose of drug at the right time is the key, and guidance towards this goal can be given by the joint nidotherapy approach.  Persuading doctors to allow their patients to be flexible in their use of drug treatment can often be difficult, and here the skills of the nidotherapist as an advocate can come into play. It’s all in the second edition of Nidotherapy: Harmonising the Environment with the Patient, and for those reading this piece from Europe, there will soon be a German translation to read.

Friday 15th May.  Some critics of nidotherapy follow the standard argument of ‘new wine in old bottles’, maintaining that what practitioners in mental health practise nidotherapy all the time in their work.  They also claim that the positive effects we achieve are limited and short-lasting.  These people ought to read the article by our colleague in Prince Edward Island, Canada. Dr Ben Spears:  Spears B, Tyrer H, & Tyrer P (2017). Nidotherapy in the successful management of comorbid depressive and personality disorder.  Personality and Mental Health, 11, 344-350.  (If any reader wants a copy please let me know).  This describes the mental health suffering of a woman with alleged borderline personality disorder and severe depression who tried to end her life countless times over a period of nearly 30 years.  Since a major nidotherapy initiative organised by Ben in 2012 she has completely recovered.  Any sceptical readers can be put in touch with her if they have any doubts. She attended the Annual Meeting of the British and Irish Group for the Study of Personality Disorders in 2018 and I trust all were convinced then that she was genuinely better.

Saturday 16th May.  ‘It is a truth universally acknowledged’, as Jane Austen would have said had she lived longer, ‘that the quality of relationship in the treatment of nerves far exceeds the power of the intervention’.   This is indeed universally acknowledged by all who practise psychotherapy but nobody has nailed down exactly what this quality is. There are dozens are hard-working highly informed psychotherapists who are hopeless at helping people, yet others who with minimal training who are conspicuously successful.  Many like to attract all comers by arguing that they practise ‘holistic’ or ‘eclectic’ psychotherapy but this too covers the range from utterly useless to extremely effective.

We have just finished a 30 year study of the most common mental condition in Jane Austen’s novels, anxiety/depression (equals ‘nerves’), in which three kinds of drug treatment, cognitive behaviour therapy and self-help advice were compared initially in a trial, and the patients then followed up at regular intervals.  After 30 years it is clear which treatment was the most effective of them all – cognitive behaviour therapy given by competent therapists.  This was first reported after 2 years  (Kingdon D et al (1996). The Nottingham Study of Neurotic Disorder: influence of cognitive therapists on outcome. British Journal of Psychiatry, 169, 93-97).  These findings have been reinforced by comments written at follow-up in the section marked, ‘which treatment has helped you most over the last 30 years?’ ‘The CBT I had at the beginning’ frequently appears, often with the named therapist, but only when the therapist was assessed as competent.  When the results of all the CBT patients are included there are no important differences between the outcome of CBT and other treatments.

We would like to think that good nidotherapists would also be regarded as competent CBT ones.  They concentrate on getting the right quality when they get to know people at the beginning of treatment. This is done in a way that creates trust and respect and so allows true collaboration to follow afterwards.  But measuring this is very difficult. We have nidotherapy fidelity scales but they only scratch the surface. But we must keep trying.

Sunday 17th May.   We are often asked which organisations across the world practise nidotherapy and do they have any special characteristics.  A list will follow in another post, but to begin with here is the account of a Swedish group headed by Susanne Bejerot, where nidotherapy was included as part of a training  programme.

Kognus is the name of the programme, and Susanne and her colleagues, in introducing it, latched on to an important omission in current psychiatric practice. This is the almost complete lack of mental health training for the large number of people, many without any formal qualifications, who care for people with chronic mental illness and intellectual disability.  The full account of the programme is described in:  Bejerot, S., Lindgren, A., Rosén, J. et al. Teaching psychiatry to large groups in society. BMC Medical Education 2019, 19, 148.  In summarising it I will concentrate on the parts relative to nidotherapy.

Currently we are only too well aware of these carers, as they have come into the spotlight in the COVID-19 pandemic.  In the United Kingdom we are very proud of our NHS and its staff and give them justifiable praise for their heroism and commitment during the crisis in our health services. But we also need to be giving equal thanks, support and encouragement to our unsung health carers, who have had twice the death rate of NHS staff in the UK and are in danger of being forgotten again when this crisis is over.

Susanne and her colleagues list the expectations we pass on to these tireless workers. ‘They are expected to support clients with regard to various matters, including household work, paying bills, picking up drugs from the pharmacy, and making appointments with doctors, social services professionals, and social insurance personnel. They are also expected to motivate passive clients, comfort sad clients, and calm anxious and psychotic clients. Consequently, they need to understand and handle clients with diverse and possibly severe and comorbid psychiatric disorders.’

So the aim of the Kognus programme was to upscale training.  (I do not much like the word ‘upscale’ but as a verb it describes the process of improvement and as a noun it describes high quality, so in this context it is accurate).

The Kognus programme was to provide education that is ‘interesting, relevant, useful, and affordable and preferably result in heightened professional status….for large groups of professionals with different backgrounds. The project had a patient-centered approach. The project sought to enable professional advancement, with a focus on its usefulness for society and minimal administrative requirements’.  It began its work in Stockholm but extended to  Malmö, Skellefteå, and Mölnlycke, and then nation-wide.

The third part of the programme concentrated on nidotherapy, with the aim of making each participant a good nidotherapist. ‘The task of the nidotherapist is to explore possible concrete areas that can be improved for the patient according to his/her wishes (i.e., not necessarily the wishes of the professionals). The nidotherapist assists in implementing these changes over approximately 9–12 months. Collaboration within the client’s network, to which the client consents, is crucial to achieve success. The client is an active partner to reach the selected and attainable goals.’

The training was carried out over one year.  ‘The participants represented a variety of professional backgrounds, such as working at psychiatric outpatient units, nongovernmental organizations, and employment services. No costs were involved. The first session of the course provided participants with a free textbook on nidotherapy. In the second session, their knowledge on nidotherapy was examined in a multiple-choice test.’

Some examples of treatment were also described in the article. ‘ Examples of problems included organizing the home, finding ways to finance and purchase a dishwasher, and accompanying a client who was afraid of vomiting on the bus. Notably, the nidotherapist trainee did not treat any psychiatric symptoms. At the end of the course, the trainees were examined with extensive written and oral examinations. Each participant received a score (ranging from 1 to 10) for each of the following five areas: (i) gaining trust, (ii) perseverance, (iii) flair (i.e., lateral thinking), (iv) pacing (i.e., moving forward at the right pace for the patient), and (v) collaboration.’

Kognus was a funded initiative with a fixed budget and so could not be maintained. But there is no reason why it should not continue and flourish, and when we all have to reassess our priorities after the COVID-19 crisis is over perhaps the best organised and most sensible country in the world can think again.

Monday 18th May.  One of the common comments that follows an account of someone who has been helped by nidotherapy is, ‘you can make that happen because you’re a professor.  Its very different for people like us.’  This is 90% untrue. The changes made in nidotherapy are owned and enacted by the person being treated, not by anyone else.  The other people who are the most appropriate to acknowledge are the key people practising nidotherapy, be they relatives, friends, front-line key workers, or other health professionals. Professors and senior staff are there to help develop the treatment plan, and sometimes to act as advocates when something gets stuck.  But this is just the final 10%.

Being a professor is often a handicap.  Shortly after I was interviewed for an upgrade to professor from senior lecturer, not a promotion I had asked for, I had to see a new patient at home.  I wrote to the person concerned, a widow in her early 60’s, and gave the date of my visit.  I duly arrived, possibly a few minutes late as I have a tendency in that direction.  She let me into her house, was excessively cautious and over-polite, and escorted me into her front room.

‘Just wait there a minute I’ll be with you shortly’, she said, just a little bit oilily. Nothing happened for a few minutes and I began to get a little perturbed. Then I heard a voice in the hall.  I got up, moved towards the door and opened it a fraction. The woman was speaking. ‘Could you please come as soon as possible’.  She was on the ‘phone.  After a short pause she said again, ‘please come as soon as possible, this man is an imposter’.

I returned to the ample armchair which I had been offered previously, trying to work out what was going on.  Within a few minutes she came back with an elegant tray, jug of milk and cup of tea.  ‘There you are, professor. Drink that up and I’ll see you soon’.  By now I was getting a little alarmed and, while sipping my tea, I think it was Earl Grey,  I tried to work out what was going on.  I had to have my credentials handy if I was to prove myself.

Within five minutes, it could not have been longer, a policeman arrived and was brought into the room where I was now perched uneasily on the edge of the chair. ‘This is the man, officer.  He said he was a professor, but professors don’t go around seeing people in their homes.  Could you arrest him immediately.’  But I was prepared. I produced both my academic and NHS badges and quickly convinced the policeman, who was by now a little nonplussed, that I was whom I said I was.

The policeman reassured the woman and said there was nothing he could do. ‘That’s not good enough.  I’m going to report you to your senior officer’.  We both protested but it was no good. She grabbed her coat, ushered us out of her house, and stalked off to the police station 400 yards away.

So I cannot say that professors of community psychiatry are favoured people. Professors in general are getting a hard time of it at present. One of the common criticisms in social media by people who take on the mantle of expert opinion makers is to refer to this group as ‘so-called professors’ as though they had acquired this title by underhand means. I never read about ‘so-called health-care assistants’ or ‘so-called consultant physicians’.  So what have we done to offend?

Tuesday 19th May.   The best evidence of the efficacy of a treatment is determined by a large randomised trial –  one that is free of bias and follows a predetermined protocol. We do not yet have these for nidotherapy; only two trials have been completed and both were relatively small. As a consequence a Cochrane review – the well-regarded independent group that assesses randomised trials – concluded that nidotherapy should be regarded as an experimental treatment only (Chamberlain IJ, Sampson S.  Nidotherapy for schizophrenia. Schizophrenia Bulletin 2013, 39, 17-21).

But there is another trial that was not included for obvious reasons but in which nidotherapy might have played an important part.  This was the UK700 trial of intensive versus standard case management published in the Lancet in 1999.  In this study four hospital groups were involved, one of which was St Mary’s and St Charles Hospital in west London.

The primary outcome of the trial was the number of days spent in psychiatric hospitals over a two year period after randomisation.  The expectation in advance of the study was that intensive case management (with 10-15 patients per case manager) would lead to fewer admissions than standard case management (30-35 patients per case manager), as more frequent follow-up and supervision anticipated fewer admissions.  Bu the results contradicted this ; intensive case management led to a mean of 73.5 days spent in hospital compared with 73.1 days in those allocated to standard case management (Burns et al, Lancet 1999; 353, 2185-9). Although this was unexpected a similar earlier study had shown that applying more stringent follow-up criteria (care programme approach) led to more admissions (Tyrer et al, Randomised controlled study of close monitoring of vulnerable psychiatric patients. Lancet 1995; 345: 756-9).

But examination of the data from the different sites did show differences.  At three of the four sites there were more days in hospital in the intensive care group compared with standard (St George’s Hospital – 10.5 days, Manchester – 19.5 days, Kings College Hospital – 0.9 days), but at the St Mary’s site there was a big difference in favour of intensive case management (65.7 days for intensive case management and 90.9 days for standard management).  In combined studies like this you are not allowed to cherry pick results afterwards, so nobody commented on this finding, but the fact remains that if the 201 patients at the St Mary’s/St Charles site had been analysed alone there would have been a significant finding in favour of intensive case management.

But why the difference compared with other sites?   The staff we had on the project had all worked together and been trained in the principles of nidotherapy, even though at that time the exact content of the intervention had not been properly formulated. So you could argue, but not with an intense level of conviction, that the significant difference at S Mary’s/St Charles was the consequence of intensive case management plus nidotherapy  versus standard case management.  This conclusion was to some extent supported by a later trial showing that nidotherapy plus assertive case management led to a 63% reduction in psychiatric hospital admissions with cost savings compared with assertive case management alone (Ranger et al Cost-effectiveness of nidotherapy for comorbid personality disorder and severe mental illness: randomized controlled trial. Epidemiologia e Psichiatria Sociale, 18, 128-36).

So whether there are two or three trials of nidotherapy published I will leave for you to decide. But the data are beginning to stack up and cannot be ignored or brushed away too easily.

Wednesday 20th May. Here is the list of organisations that list nidotherapy,  either as one of their central tenets, part of their services or just encapsulated in their philosophy:

Cardinal Clinic, Oakley Green, Windsor

Recovery Village, Palm Beach, Florida, USA and at Umatilla, Florida, USA

Charlottetown Nidotherapy Group, Prince Edward Island, Canada

Mahatma Gandhi institute for Comprehensive Mental Health Care, Guntur, Andhra Pradesh, India

Horton Rehabilitation Services, Horton, Surrey, the very latest addition.  This will be one of the venues for the Nidotherapy 2021 Workshop as we have international visitors again for this meeting.  There will be more on this subject at a later date, and of course we can make no definite plans at this stage.

Thursday, 21st May. One of the important aspects of treatment in nidotherapy is to take all statements made by people in treatment as seriously as those made by a good friend. So in deciding on environmental changes remember not to dismiss too readily. Herman (this is his real name but he does not mind its disclosure) was a man with an apparent psychosis who believed that, after he was forced to leave his home, he was being placed in substandard accommodation out of personal spite. We helped to get a new flat and at first he was very satisfied. He also had a garden and we had a great time changing the colour of his hydrangea flowers from red to blue by adding acid fertiliser to the feed.

But after a bit he became dissatisfied, mainly about the noise in the house next door. He said he was frequently woke in the middle of the night by heavy objects being moved across the floor. ‘Almost always its at 1 o’clock in the morning, just when I’ve got off to sleep’. We found this hard to believe – ‘another of his paranoid delusions’ was the common response – but on investigation we found out he was correct. The house next door was occupied by the business associates of Billy Bragg, the well-known singer song-writer and left wing activist. Billy is a prolific artist and in the song-writing industry you are always under time pressure. A large photocopier and the equipment was often being moved around in the early hours of the morning and this is what made Herman wake up in annoyance. Fortunately the Bragg Ensemble were able to operate more quietly after we expressed our concerns and we were able to report back to Herman that he was correct after all.

And this was the start of Herman’s renaissance. Within two years he had joined the cast of The Teaching of Edward, an operetta based on the experience of Edward Elgar as the bandmaster at the Worcester County Asylum in 1879. Elgar has been playing for the staff at the asylum, as indeed all good bandmasters did at that time, but the patients, led by Herman as their ‘union organiser’, persuade Edward to play for them as well and force him to do so, despite all his reservations, in a noisy chorus:

‘And if the lines don’t seem like a music theme but dialogue from a madcap scene,  

Please don’t mind as you will find, that we will follow right behind, 

Just – take it as it goes

We’ll make sure it flows

From the tops of our heads

To the tips of our toes

This – is the path we’ve chose

Take us where the music goes’

Take us where – the – music – goes

And that is precisely what Herman did, for over 20 performances. So in nidotherapy when you do not jump to conclusions and keep a completely open mind, you never know what might happen.

Friday 22nd March. ‘One division of mental health conditions that the general population has picked up on is the apparent distinction between mood disorders and personality disorders. Those of us who, like me, have suffered from the effects of bipolar disorder like to congratulate ourselves on the purity and constancy at least of our personalities. The illness, we say to ourselves, is like the weather. It comes from outside of who we are. We might be made alarmingly enthusiastic, exuberant, grandiose and overconfident when in the grip of elevated moods, or grumpy, silent, morose and pessimistic when depression descends on us like a leaden cloud, but inside we are ourselves, all right and tight. Personality disorders, that is what the boogeyman suffers from, they are dark and dangerous territory. To be told one suffers from such threatens our sense of self and the very ownership of who we are. ‘

Who wrote this? You may have guessed, Stephen Fry. It is part of the foreword to Taming the Beast Within: Shredding the Stereotypes of Personality Disorder, 2018. Stephen, with a great interest, but no actual training, in mental health has nailed it in one. We do not like to have our personalities messed about by others; they are part of us and if you say I am personality disordered you are attacking the core of my being. This is the main reason why most people with personality disorders do not want treatment. Only those with ‘borderline’ personality disorder ask for it repeatedly, and this is one of the reasons why my colleague, Roger Mulder in Christchurch, New Zealand, and I, argue that it is not a personality disorder at all (look out for a book exposing all the kernel of personality disorder without the chaff, to be published shortly).

So not long ago we assessed people with personality disorder using a scale to find out their views on treatment. This was carried out in a tertiary psychiatric service – one which one of the members said was ‘the last chance saloon’ . We found that only one in three was Type S (treatment seeking); the others were all treatment resisting (Type R)(Tyrer P, Mitchard, S., Methuen, C. & Ranger, M.  (2003). Treatment-rejecting and treatment-seeking personality disorders: Type R and Type S. Journal of Personality Disorders, 17,  265-270). Even in the group who were the most severely personality disordered, people being assessed in the Dangerous and Severe Personality Disordered (DSPD) Programme in England between 1999 and 2005, only 57% rated their personalities as Type S, even though they were on an agreed programme to try to alter their personalities (Tyrer P, et al, (2009). Assessment of dangerous and severe personality disorder:  lessons from a randomised controlled trial linked to qualitative analysis. Forensic Psychology and Psychiatry, 20, 132-146). And it will come as no surprise that in a normal population a study carried out by one of our Trustees found only 13% had Type S personalities (Gardiner C, et al (2010). Associations of Type R (treatment resisting ) and Type S (treatment seeking) personalities in medical students and their clinical implications. Personality and Mental Health,  4, 59-63. 

So you can see why the diagnosis, or ‘label’ if you wish to be more critical, is so despised by some. Perhaps this is the origin of stigma. ‘If you tread on my personality you tread on my soul’.

Saturday 23rd May.  Critics of the term ‘personality disorder’ often refer to the instability of the diagnosis as a reason for dispensing with it. ‘Personality is enduring so how can it disappear. QED, Personality disorder does not exist. It is just a term of criticism.’  The problem in accepting this argument is that it contradicts science, or if you want to be more specific, empirical science. Investigators, with no particular bias or preconceived ideas, have shown over and over again that personality disorder, measured in its hundred different ways, is unstable over time.  In some it persists for years, in others it fluctuates, in others it disappears altogether. We need to find the reasons for these differences, but one key one, linked to nidotherapy, is environment.   If someone with personality disorder, no matter how severe or apparently pervasive, chooses, or happens to be placed in, the right environment for their particular disorder, harmony can be created. There is a fit between the person and the environment that is specific and may be unique. This is why we refer to nidotherapy as ‘reverse Darwinism’.  It is not a particularly clever or apt term, but instead of all competing for the same place in the sun – survival of the fittest – nidotherapy competes for the most different places under the sun – survival of the adapted.  The myriads of different physical, social and personal environments that exist in this planet allow all of us to have this choice.  The problem is how to choose, and this is where nidotherapy comes in.

Sunday, 24th May.   The treatment of personality disorder is unduly complicated, super-specialised and ridiculous.  It has increasingly generated a complex self-serving mix of psychodynamic interpretation, didactic teaching and expert worship that has not helped practice.    

It is also unnecessarily long. The evidence that longer term treatment is required is very flimsy.  When the NICE guideline for personality disorder was going through the relevant data between 2007 and 2009 there were many studies published showing the benefit of courses of psychological treatments varying between three months and one year. In our recommendation at the end of this analysis we concluded that ‘brief psychotherapeutic interventions of less than 3 months’ should not be given for the condition.  But the only significant trial (480 patients) that had tested out such a brief intervention was one for which I was chief investigator, the POPMACT trial (Prevention of Parasuicide by Manual Assisted Cognitive Behaviour Therapy). The CBT given showed only marginal benefit for CBT although it was cost-effective (10% cheaper than standard care)(Byford et al (2003), Psychological Medicine33, 977-986), but those with borderline personality disorder responded Iess well and cost more (Tyrer et al, 2004, Journal of Personality Disorders, 18, 102-116). 

But the treatment given in this trial concentrated only on preventing self-harm. It was not focused on personality disorder.   Of course you can say the two conditions overlap but there are differences that should not be ignored. So the field was wide open for other studies of short-term treatment and I am glad to say that these are now being published. And the results are encouraging. In Canada a stepped care approach showed that most patients could be treated successfully in a three month programme (Laporte et al (2018), Personality and Mental Health, 12, 252-264) and a similar study in the UK using Structured Psychological Support showed similar benefit (Crawford et al (2020) BJPsych Open, 6, e25).

What these treatments do is to take away the unnecessary fluff attached to previous treatments. Shaved down, Structured Psychological Support involves some of the elements of nidotherapy.  It is ‘a person-centred approach that allows therapists to determine the exact number, frequency and duration of sessions based on clinical judgement and patient preference. During the first two sessions therapists assessed the patient’s mental health, personality difficulties and existing understanding of their problems and coping strategies in order to formulate a treatment plan, including a crisis plan.’  

So this is a collaborative exercise, not a top-down model from the heights of Olympus.  It needs to be known more widely. Without it we will continue to have long waiting times, great frustration and, for far too many, denial of treatment.  Read Joel Paris in the latest early view of Personality and Mental Health, Access to psychotherapy for patients with personality disorders, 9th May, 2020) for the clarion call to better access.

Monday 25th May.  Today is International Personality Difficulty Day.  Why not?  There was a Care Day on 21st February, an International Nurses Day on 12th May, and World Mental Health Day will be held on 10th October, as it is every year. The main purpose of these named days is to draw attention of the public to subjects that need greater awareness, and what could need more attention than personality difficulty. At least 2.5 billion people in the world have personality difficulty, more than any other physical or mental disorder, as further study of the new ICD-11 classification will show. Personality difficulty is best summarised as intermittent interpersonal social dysfunction. This is necessarily polysyllabic in order to fit into four words but it can be shortened to ‘environmental antipathy’.  People with personality difficulty only show  the problems of poor social interaction in specific situations such as formal meetings, visits to strange settings, crowds, public speaking, communal eating, competitions, large family gatherings, forced social interactions, hierarchical events (where everyone has to know their place), and assessment interviews.  This covers a large range and most people with personality difficulty are able to manipulate their lives in such a way as to avoid these negative interactions.  But sometimes they cannot, and every year in the United Kingdom there are reports of otherwise respectable neighbours squabbling over subjects such as the height of a garden to such an extent that homicide occurs. The forced interaction of neighbours is very difficult to avoid, and can quickly escalate.

Personality difficulty is generally mild in its effects but there is no reason why International Personality Difficulty Day cannot include all others with personality problems of any severity. I always introduce my discussions with people having any of these with a comment like ‘this suggests you may have some personality difficulty in…..’ as I find this does not offend or annoy, and can readily lead to a constructive discussion. So all those who have the capacity to lead good lives, enjoy liberty and pursue happiness, but fail to do so as completely as they would like because of the brakes imposed by their personality difficulties should be celebrated on this day. They deserve respect, encouragement, and, dare I say it, praise, for their efforts. There is no reason why their struggles should not be acknowledged every year on 25th May, when the darling buds of hope are still awaiting the opportunity to open to their full splendour.

Tuesday, 26th May. William Sargant is not a familiar name to most reading Mental Health Unblocked.  But 60 years ago he was one of the most prominent psychiatrists in the United Kingdom. I first came across him when deciding which medical school to go to after completing my first degree at Cambridge University. My mother, starting a psychology career at the time, insisted I must go to St Thomas’s Hospital as ‘William Sargant is there and he’s the most optimistic psychiatrist in the country’. Indeed he was, but encountering him both as a medical student and in my first psychiatric post as his House Physician (the only one in the country entirely devoted to psychiatry), I learnt that optimism had its drawbacks. Like Donald Trump, he would never admit to failure, and so if one prefrontal leucotomy failed to relieve symptoms he was quite happy to recommend a second or third.  But because of his inveterate optimism, he was popular with most of his staff, including the Nightingale nurses of the hospital, and indeed most of his patients.  One of them I saw 40 years later, long after she had her third leucotomy. She was still completely convinced that ‘Will’ as she called him, with these operations had saved her from a life of constant misery.

But William Sargant was definitely a polariser, a true Marmite character. It was difficult not to choose between either loving or loathing him. What some regarded as therapeutic determination to do everything possible to help a patient, others saw as reckless adventurism, using treatments that had no basis of evidence other than his own clinical experience. He regarded all psychotherapy as limited in efficacy unless it was attuned to Pavlovian conditioning, and was convinced the way forward for psychiatry was to embrace physical treatments, singly, together, or in any other combination, until the patient was better, or at least said he or she was better. But Sargant had a cop-out.  He only claimed success in people who had goodpreviouspersonality. I run these words together as he always said them very hurriedly as though they were one word. But I never saw him assess a personality in a way that was commensurate with practice at the time, so I concluded, possibly infairly, that it was an escape route to explain failure.

But personally I found him easy to work with. You could argue with him and win your point, provided it was not a major one, and I have always felt I learnt more from teachers who went beyond their brief instead of sticking rigidly within it. And although I do not like Marmite on toast or bread, I just love it when I can put a full teaspoon in a cup of very hot water and sip it till I reach the tiny bit of the brown sediment at the bottom, where it tickles my palate with a salty tang. That was the legacy of William Sargant, an old salt who sometimes got into rocky seas.

Wednesday 27th May.

I have been helping Swedish academia recently as an external referee. I was hoping that it might lead eventually to an invitation to join the Nobel Scientific Committee for Physiology and Medicine. I envisaged the letter on crisp Nobel notepaper: ‘We feel that it would now be important to have a psychiatrist on our Committee as mental science has been under-represented in our discussions.’ But of course I will never receive such a letter. Quite apart from the many other disqualifying reasons I am not a member of the Nobel Assembly at Karolinska Institutet nor the Swedish Academy and it is they who choose.

The only psychiatrists to receive the Nobel Prize for Medicine were Julius Wagner-Jauregg and Egan Moniz. Wagner-Jauregg, an Austrian psychiatrist, received his prize for the development of pyrotherapy, the deliberate infection of patients with syphilitic dementia with malaria to create a high fever, and Moniz for the invention of leucotomy. In retrospect these were not major advances, some would call them retreats, and even at the time they were awarded they were pretty small fry. Wagner -Jauregg was a Nazi sympathiser and President of the Austrian League for Racial Regeneration and Heredity. He recommended the forced sterilisation of people considered to be constitutionally inferior. Jeffery Lieberman, in his book, Shrinks: The Untold Story of Psychiatry, now told, considers that the Italian psychiatrists Cerletti and Bini were more deserving contenders as they introduced ECT.

It seems to be particularly difficult for psychiatrists to be ever in the running for a Nobel Prize as they rarely make cut and dried new discoveries. Many feel that Tim Beck is deserving of such an honour for his discovery of cognitive behaviour therapy but despite the impact of this treatment being a thousand times greater than Wagner-Jauregg’s and Moniz’s discoveries this is unlikely to be considered groundbreaking enough for him to become a Nobel Laureate. Perhaps the nearest contender is Sir Alec Jeffreys, of the University of Leicester, possible in tandem with Jeffery Glassberg (who later devoted his time to preserving butterflies (not in pickle but in the open air)), for discovering DNA finger-printing. This has done more for forensic psychiatry and psychology that the thousands of barristers and forensic experts have ever achieved and if Arthur Conan Doyle was alive today Sherlock Holmes would have carried a mobile DNA fingerprinting kit with him everywhere (in Dr Watson’s medicine chest of course).

So I suspect we will have to wait a long time for another psychiatrist to win the Nobel Prize for Physiology and Medicine. But serendipidity owes allegiance to no discipline, and it may place itself munificently on a psychiatrist who least expects it.

Thursday 28th May.  A postscript on Nobel Prize winners. I have only met two of them. One, J D Watson, was one of the three winners of The Nobel prize in Physiology and Medicine in 1962, for discovering the structure of DNA. Rosalind Franklin, who had done the key work on X-ray diffraction should have been included too but she died in 1958 from ovarian cancer. Watson supported her for the Nobel Prize in Chemistry posthumously but failed.  I met James Watson in 2014 at Cold Spring Harbor Laboratory during an international meeting on borderline personality disorder.  I quite liked him. You knew exactly where you were with him. He was not especially impressed with the meeting and said do in earthy language. I challenged him over this, but he said that, being brought up in Chicago, he could never forget the language of his past and was proud of it. He was particularly bothered over what he called ‘this obsession with borderline personality disorder’. ‘Why can’t they look at the others, what’s so fxxxing interesting about borderline?’ 

The other Nobel Prize winner was John Nash, winner of the Nobel Prize for Economics in 1994, long after his famous discovery, linked to game theory.  In between he had developed paranoid schizophrenia and divorced his wife, Alicia. But she was an amazing woman, as despite being divorced, she recognised the original non-schizophrenic John would not have divorced her, so she stuck by him and brought up their son on his own and kept in touch with him. His university, Princeton, also helped by allowing him to still come into the library and get involved with students. After 40 years divorced she remarried him in 2001.

When I met the family, John was remarkably well, by contrast with his son, who had also developed schizophrenia and was very keen on talking about his medication. I suggested to Alicia that John’s improvement might be related to her constant support and encouragement and suggested it might be an example of nidotherapy at work.  But when I asked her straight she was quite clear. ‘It was the Nobel Prize that got him better; that was the key’.   I could not but agree, but I still think there was an element of nidotherapy somewhere.