More Experts and Their Expertise

My blog post ‘Experts In Suicide Prevention??’ describes a conundrum that exists in north Wales – a history of people based in the mental health services up here who claim expertise in ‘suicide prevention’ yet who have worked for many years in a region with an astronomical suicide rate (and in a very dysfunctional mental health service). Yet the expertise claimed in suicide prevention is not the only glaring inconsistency evident in the mental health services in north Wales.

My attention was first drawn to some possible very questionable claims of ‘expertise’ and associated ‘research’ many years ago in the Hergest Unit. (Please see blog post ‘The Hergest Unit’ for an account of the many problems at the Hergest Unit.) Back in the early/mid 1990s, every week in the ‘seminar room’ at the Hergest Unit an interesting performance took place. The psychiatrists and some of the associated staff would congregate for ‘seminars’ and ‘journal club’, at which they claimed to be sharing their research expertise with each other. Now unlike most people who were patients in the north Wales mental health system at that time, I had previously been involved in biomedical research, so I knew what researchers and research seminars looked like. And they didn’t look like this. Yes, the ‘seminars’ and ‘journal club’ held at the Hergest Unit were sponsored by pharmaceutical companies, so everyone had a free nosh, but there weren’t many serious researchers in evidence. But there was a motley crew of neglectful and abusive practitioners – even Dr Dafydd Alun Jones occasionally turned up for a free lunch (literally). As far as I could see, there were only two members of staff from the Hergest Unit who were regulars at those seminars who were genuinely involved in research and that was Dr David Healy and another psychiatrist who left the Hergest Unit soon after this, Dr Phil Thomas. Yet the Hergest Unit at that time used to enthusiastically claim that it was a buzzing hive of research activity – into eg. mindfulness, SAD (seasonal affective disorder), drug interactions and various psychological therapies.

I remember the Hergest Unit’s foray into Seasonal Affective Disorder. There was interest in whether exposure to a certain type of artificial light provided to the patient by them sitting in front of a ‘lightbox’ for a certain period of time daily would lift some types of depression. I understand that someone had theorised that there were certain villages in north Wales that were built in the shadow of mountains and received relatively small quantities of daylight and that this was a possible explanation for rates of depression in those villages. A lightbox appeared in a side room in the Hergest Unit and very soon scores of patients – including me – were asked if we’d like to try out the lightbox. So we did. But no-one told us how long we should expose ourselves to the lightbox for or how regularly we should do it. (I also suspect that for the lightbox to have had any effect if the theory was correct, that patients would have had to sit in a particular orientation to the lightbox to ensure that they were properly exposed to the light.) We just used to wander into the room and sit in front of the lightbox for a bit. And then our friends would come and join us as well, because they wanted to talk to us. So a common scene was an assortment of people, all with different diagnoses, sitting around the lightbox having a chat and indeed a fag. Maybe there were randomised clinical trials done with the lightbox – but I never encountered them and I didn’t know any patients who were ever party to any results/advice gained from such trials. Yet an article appeared in a local paper reporting on the pioneering work being done at the Hergest Unit with the lightbox – it named a certain junior doctor as leading the research. The next week in the newspaper an apology appeared with a correction – explaining that the junior doctor named wasn’t actually leading the research. So presumably someone more senior had had a hissy fit and sat on him. After a few months the lightbox was removed and never reappeared and we heard no more about the research.

However farcical the lightbox was, it was at least harmless and was useful in that it provided a focal point enabling the patients to gather and socialise. As the Hergest Unit later descended into utter madness, I started hearing tales of another form of expertise there that seemed to be doing some people quite a lot of damage. By the late 1990s, it was clear that the Hergest Unit was unravelling – staff were in conflict with each other, good staff were leaving, facilities and services were being successively withdrawn, complaints were soaring and patients were dying. At about this time it became noticeable that an awful lot of patients were being diagnosed with ‘borderline personality disorder’, although they had often received different diagnoses previously (and usually received yet different diagnoses again if they subsequently sought help outside of north Wales). I was having less contact with the mental health services by then, but I still stayed in regular contact with many patients and continued to hear some very worrying anecdotes.

Time and again, patients told me that they had been diagnosed with ‘borderline personality disorder’ and were having ‘DBT’. The DBT in question referred to Dialectical Behaviour Therapy, a type of therapy developed in America by Marsha Linehan, specifically for borderline personality disorder. DBT is a consistent, intense, highly structured therapy with very specific conditions and parameters, which also involves a degree of telephone support from the therapist. (As the popularity of, and interest in, DBT exploded, Linehan herself expressed concern regarding practitioners who claimed to be carrying out DBT when they were not and was frank that this would be ineffective or even harmful.) From what I was being told, it seemed that not only were the patients who claimed to receiving DBT not benefiting from it, but I doubted very much whether they were in fact getting DBT – the mental health services in Gwynedd by this time were such a shambles that they would have been incapable of providing the sort of support that DBT involves. Some patients moved out of the region to access mental health treatment – others continued to self-harm and even die. Things had very obviously become very grim in the mental health services. Then one day whilst I was doing my PhD, imagine my surprise when I was searching through some journal articles and I found an article written by a clinical psychologist (whom I knew) from Bangor who was involved in treating Hergest Unit patients – this article was reporting on a trial of ‘adapted DBT’ carried out with patients in Gwynedd. And according to this article, the trial was a roaring success. As with the lightbox, I was never able to locate anyone who had benefited from such a trial or from the dissemination of knowledge from such a trial – all I knew of by that time were many highly distressed patients, many of whom had complained, some who had died and a mental health service in meltdown.

I was able to gather more information regarding the ‘DBT’ being carried out around Bangor in the following years. I knew of one Hergest Unit patient who was told that they were going to be given DBT – so they ordered a book by Marsha Linehan on DBT because they hoped that it would help them engage with the therapy. I was later told that ‘I read the book and what they were doing was nothing like DBT’. Soon after this, I was told an even more worrying story from yet someone else who was told that they were going to be receiving DBT, this time from ‘therapist’ Maggie Fookes, a member of the notoriously dreadful Arfon Community Mental Health Team (please see my blog post ‘The Arfon Community Mental Health Team’), who were later alleged to have been removed from their posts after neglecting patients. The young woman who told me this story had a serious problem with Maggie Fookes, because she claimed that Fookes was obsessed with the notion that the young woman had been sexually abused, which the young woman absolutely maintained was not true (this was not the first time that I had heard about this problem from people on the receiving end of the mental health services in Gwynedd). It seems that the ‘therapy sessions’ involved Maggie Fookes repeatedly confronting her, stating that she had to ‘disclose’ ‘what had happened’. I was told that the grand finale culminated in a therapy session that involved Fookes locking the door of the therapy room and screaming at the young woman ‘I know that something happened, tell me what it was’. Whatever was going on, it certainly didn’t sound like DBT. (This young woman was one of many who eventually left north Wales in order to access competent mental health services.)

Interestingly enough, I know of a practitioner in north Wales who was interested in being trained in DBT. They went to the initial meeting for interested people – and found that Maggie Fookes was going to be the leading light in this group. They did not go to any more meetings because they told me that with Fookes involved, they felt that this was probably going to result in a horror.

The irony is that among all this grandiose huffing and puffing at the time about the ‘expertise’ present in the mental health services in Gwynedd, there was one person in the Hergest Unit who really did know her stuff, in this case in the field of CBT (this was before CBT was promoted as a cure-all by policymakers). That was the nurse who used to run the very popular day centre at the Hergest Unit. She had done her training at a hospital in England that had led the way in psychotherapy and she had received a first rate training in CBT and was enormously helpful to many patients. I never ever heard any of the self-appointed ‘experts’ in the Hergest Unit even mention her expertise in CBT, although one senior nurse (who was later part of the exodus from the Hergest Unit as it went downhill) one day said to me that ‘no-one realises how good she is’. The day centre that she ran was closed down….

There will be further blog posts soon with more information regarding the ‘research’ and ‘psychological therapies’ in the north Wales mental health services…