In this podcast, Professor Houston talks about the psychological impact on those affected by the Aberfan disaster of 1966. The podcast expands on an interview Prof Houston gave to BBC Wales as part of a series of podcasts recently produced about the disaster. It is strongly advised that you listen to podcast 7 of the BBC series prior to listening to this podcast. https://www.bbc.co.uk/sounds/brand/p09z3n7y Further reading: https://www.nhs.uk/conditions/electroencephalogram/ Iain McLean and Martin Johnes, Aberfan: government and disasters (Cardiff: Welsh Academic Press, 2000), especially chapter 5. Morgan, L., Scourfield, J., Williams, D., Jasper, A., & Lewis, G. (2003). The Aberfan disaster: 33-year follow-up of survivors. British Journal of Psychiatry, 182(6), 532-536. doi:10.1192/bjp.182.6.532

Devolved psychiatries - Professor Rab Houston by Professor Rab Houston

Prof John Crichton - Consultant Forensic Psychiatrist and Chair of the Royal College of Psychiatrists in Scotland. What is a forensic psychiatrist? Far from the media stereotypes forensic psychiatrists are not so different to other doctors but working at the most extremes of human experience. Any one of us may have a mental health problem. Very rarely that problem may result in an inability to control ones actions and may lead to direful consequences. Forensic psychiatry is all about helping people recover their lives after such life changing events and by placing the care and treatment of patient at the centre ensuring everyone’s safety.

This is a 50 minute audio file of a talk I delivered at the National Records of Scotland on 7 August 2019, in connection with my hugely successful exhibition that they kindly hosted: ‘Prisoners or Patients? Criminal Insanity in Victorian Scotland’. It explains the records I used and the development of the criminal justice system’s attempts to deal with those who had committed serious offences, but were found to be insane and thus not responsible for their actions. The justice system faced the same problems as today and dealt with ‘prisoner-patients’ or ‘state lunatics’ (as they were known) in a remarkably humane fashion, given the constraints of limited resources, basic medicine, and different social attitudes 150 years ago. The talk explains in depth who the offenders were and what they had done, the processes for admission to, and release from the only such specialist facility in Scotland prior to the opening of The State Hospital at Carstairs in 1948, medical and scientific understandings of insanity, and the social context of Victorian Scotland.

Professor Rory O’Connor, Suicidal Behaviour Research Laboratory, University of Glasgow Suicide and self-harm are major public health concerns with complex aetiologies which encompass a multifaceted array of risk and protective factors. There is growing recognition that we need to move beyond psychiatric categories to further our understanding of the pathways to both. As an individual makes a decision to take their own life, an appreciation of the psychology of the suicidal mind is central to suicide prevention. Another key challenge is that our understanding of the factors that determine behavioural enaction (i.e., which individuals with suicidal thoughts will act on these thoughts) is limited. Although a comprehensive understanding of these determinants of suicidality requires an appreciation of biological, psychological and social perspectives, the focus in this podcast is primarily on the psychosocial determinants of self-harm and suicide. To this end, The Integrated Motivational–Volitional (IMV) Model of Suicidal Behaviour (O’Connor & Kirtley, 2018; O’Connor, 2011) is discussed; it provides a framework in which to understand suicide and self-harm. This tripartite model maps the relationship between background factors and trigger events, and the development of suicidal ideation/intent through to suicidal behaviour. In this podcast, we talk about a range of different topics including: • The epidemiological context. Suicide rates. • The myths around suicide and self-harm • The determinants of suicide and self-harm • The IMV model of suicidal behaviour • The implications for the prevention of suicide References O'Connor, R.C., Kirtley, O.J. (2018). The Integrated Motivational-Volitional Model of Suicidal Behaviour. Philosophical Transactions of the Royal Society B. 373: 20170268. Steve Platt's work on inequalities and suicidal behaviour https://onlinelibrary.wiley.com/doi/abs/10.1002/9781118903223.ch15 www.suicideresearch.info

In this podcast Professor Chris Williams, a researcher and teacher in the area of cognitive behavioural therapy (CBT) introduces CBT as a self-help form of therapy. It gives people the tools help themselves. Although correctly described as a form of psychotherapy, another way of conceptualising CBT is as a form of adult learning. That perspective can help make sense of recent advances in CBT where key CBT principles are communicated via CBT books, classes or websites. The key elements are a CBT structure that then builds on the therapeutic relationship and helps people both understand why they feel as they do, and also learn new skills to make changes. CBT provides a structure of how to make these changes in a planned and evidence-based way. However it also requires and effective and supportive therapeutic relationship to encourage people to keep on track as they plan changes in their lives. It is on this balance of structure and relationship that CBT aims to help achieve change.

Chief Inspector Michael Brown: ‘Police, policing, and mental health in the UK’. Police services all over the world are essential as a de facto mental health service, especially around crisis care. All have struggled with untoward incidents involving the use of force, or deaths following police contact, which have framed – perhaps distorted - discussion. Reviews of these incidents have concluded that police officers are usually working in a context where the professional options available to them are not always adequate and that support after police decision-making is not always available. Reviews have also emphasized the need to improve police training and awareness of mental health, without necessarily specifying what that means and without taking account of contributory problems in healthcare provision by other agencies. Better police training and awareness of the mental health issues they face professionally is essential, but not sufficient. Many of the people the police encounter, where mental health is a factor in the incident, are known to have a history of mental health problems and have often been service users previously. The challenge is twofold – to reduce reliance upon the police service (and criminal justice system, including the prison service) to the extent we can; and to improve the quality of the police response where it is necessary for officers to become involved.

People with learning disability were understood and treated very differently in the past from the present. While attempts were always made to help them, this was against a background of pessimism about their prospects. Much progress has been made in the past half century in positive attitudes towards this group, with closures of the large institutions in which they were often housed and better integration into the community. Nonetheless, challenges remain, including a significantly shorter life expectancy compared with the general population. Dr Fionnuala Williams clarifies misconceptions and enlightens listeners on the definition, causes, and treatments relevant to this diverse population group, where communication is key.

Social workers and care in the community Social workers have a crucial part to play in improving mental health services and mental health outcomes for citizens. They bring a distinctive social and rights-based perspective to their work. Their advanced relationship-based skills, and their focus on personalisation and recovery, can support people to make positive, self-directed change. Social workers are trained to work in partnership with people using services, their families and carers, to optimise involvement and collaborative solutions. Like community psychiatric nurses, social workers also manage some of the most challenging and complex risks for individuals and society, and take decisions with and on behalf of people within complicated legal frameworks, balancing and protecting the rights of different parties. This includes, but is not limited to, their vital role as the core of the Approved Mental Health Professional (AMHP) workforce. Social workers are central to the holistic, individualised treatment available to sufferers from mental disorders, which epitomises the goals of modern healthcare provision. Dr Ruth Allen, Chief Executive, British Association of Social Workers

In the podcast I talk about my research on the biological basis of schizophrenia using brain imaging and my attempts to understand symptoms such as hallucinations in terms of brain based cognitive processes. I describe what schizophrenia is like from the point of view of clinicians and from the point of view of patients. I suggest that the experiences described by patients in history are very similar to those described today. Finally, I discuss treatments. There has been much improvement since the discovery of drug treatments in the 1950s, but we still have not identified the causes of schizophrenia and, for the majority of patients, life remains very hard. Chris Frith is Emeritus professor of Neuropsychology and the Wellcome Centre for Human Neuroimaging at UCL and Honorary Research Fellow at the Institute of Philosophy.

Autism is a neuro-developmental disorder with a prevalence of about one in 100 births. Although we assume that this disorder has always been with us, and Rab Houston and I identified a case from the 18th century, it was not given a label until the 1940s. Hans Asperger, a Viennese pediatrician, and Leo Kanner, an American child psychiatrist, both used the label ‘autistic’ to characterise the condition. It took another thirty years until it was understood that it was not rare, but there was a whole spectrum of autistic conditions, all sharing the core symptoms of impaired social communication and repetitive and restricted behaviours. To explain these symptoms I mention two proposals: the ‘Theory of mind’ account, explaining the communication impairment; the ‘Weak central coherence account’, explaining the focus on detail. Uta Frith is Emeritus Professor of Cognitive Development at UCL’s Institute of Cognitive Neuroscience.

Symptoms of schizophrenia develop in more than 1:200 people, in all cultures, while 2- 4% of the population may experience major depression at some time in their life. Mild and moderate depression are, of course, much more common. Sometimes illnesses run in families and show higher concordance among identical compared to non-identical twins suggesting an important genetic contribution to risk. Molecular genetics now gives us the tools to analyse genetic risk using DNA samples donated by people with schizophrenia, bipolar disorder, depression, autism, attention deficit, obsessive-compulsive disorder, anxiety, anorexia, substance use and post-traumatic stress. These disorders are the focus of ongoing international collaborations performing genome -wide association studies. Results to date are remarkable. Genes have been found that contribute to these illnesses and it is hoped this new knowledge could lead to novel drug targets and new preventative interventions. The use of advanced techniques such as gene editing and improved possibilities for accurate prenatal testing are raising important ethical questions that require informed public discussion and debate.

People in both the developed and the developing world are living longer, and in better health, than in any prior point in history. However, mental health professionals, especially psychologists, need to prepare for this upcoming increase in older persons – whom they will encounter in all areas of practice. There is an urgent need for practitioners to upskill, and students to embrace, key principles from gerontology (the science of aging) to foster greater awareness, understanding, and appreciation of later life experience. The psychological issues faced in clinical practice will evolve along with these demographic changes — for example, intergenerational issues among blended families, anxieties around retirement, and issues particularly pressing for women, such as caregiving, will present themselves more frequently. These issues are important for mental health professionals, concerned with ageing, to recognize and address with sensitivity and respect, with curiosity and a willingness to listen and learn.

Eating Disorders are understandable as a way of coping with uncomfortable feelings. A temporary sense of reward or emotional detachment can occur due to maladaptive eating. The disorders are driven by fears about being unacceptable. Beliefs about people with eating disorders being selfish or overly concerned about beauty, still seem to arise. In reality they tend to have an excessively low opinion of their appearance and are usually kind and generous to a fault. The belief that what is required to cure an eating disorder is to ‘just eat normally’, is still frequently expressed to people with these complex psychological disorders. I also believe the risk of premature death from an eating disorder is commonly exaggerated in public and professional discourse, with potentially unhelpful consequences for treatment. My hope for the future is that overly simplistic theories about and treatment of eating disorders will give way to more complex, integrated, holistic approaches to care.

Bipolar disorder is a complex psychiatric disorder of mood and behaviour that has been recognised for thousands of years. It probably affects about 1 in 50 individuals worldwide and is characterised by episodes of depression alternating with episodes of mania. In this podcast we discuss the presentation, diagnosis and treatment of bipolar disorder. We highlight the strengths and limitations of current diagnostic classifications and we consider the need for a multidisciplinary treatment approach that integrates medications (such as lithium) with psychosocial approaches (such as group psychoeducation). We also consider the intriguing link between bipolar disorder and creativity and we conclude with an optimistic discussion of latest research in the field and how this will ultimately lead to improved diagnosis and new treatments in the future.

In this podcast, Professor Rab Houston speaks to Alexander Baldacchino, Professor of Medicine, Psychiatry and Addictions, University of St Andrews and Clinical Lead and Consultant in Addiction Psychiatry with NHS Fife. This podcast will hopefully provide the right incentive for listeners to understand better the finer details pertinent to the topic of substance misuse disorder and dependence. Listeners will be taken through some of the relevant historical, clinical, epidemiological, humanistic and other cross cutting themes to allow a more positive formulation of what the problems caused or as a consequences of substance misuse can be crystallised without stigmatising the individual or population involved. The interview explores understandings and misunderstandings of substance misuse, and the possibilities for helping misusers against a background of rapid changes in society, medical provision, and the proliferation of substances.

Gerry Hastie trained between 1993-96, when nurse training programmes were changing from being delivered by the Local Health Authority to Higher Education. He has always been a mental health nurse and has worked in care home settings, long term in-patient care settings, acute admissions, addictions and the community. In this podcast he illustrates his personal journey to doing what he does, and what it takes to be a mental health nurse, focusing on values and personal qualities; skills and different remits and the many roles taken on by nurses with patients, their families and colleagues. Nurses are simultaneously therapists, advocates, teachers and researchers who within their own training and skill set but whose work is essential with other professionals. He offers a perspective on what makes nursing unique and how nurses complement the multi-disciplinary team. Finally, Gerry tries to step outside and looks into his profession as an observer and use examples from clinical experience and popular culture to imagine what the public think mental health nurses do.

In the first podcast of our new series, Professor Rab Houston is in conversation with Dr Miles Mack, Past chair of RCGP Scotland and a GP partner in Dingwall, Scotland. General Practice is the backbone of the British NHS and GPs provide a vital role in providing medical health care to patients registered to their practices. They provide continuity of care and a comprehensive approach, both in the first point of care and coordinating ongoing care for long term conditions. This podcast discusses their work in mental health, its relationship to physical well being and how they provide an interface with the hospital and specialist services in the wider health and care services.

I argued in the last podcast that medical theories in colonial Africa had a strong racial element to them, which buttressed colonialism. In this final podcast of my mini-series I’m going to explore how these ideas related to the actual practice of psychiatry in colonial Africa. I broaden my perspective to include not only Malawi, but also Natal and Uganda. I try to nuance some of cruder understandings of colonial psychiatry by suggesting that clinicians could adopt perspectives and treatments that focused on suffering human beings, rather than racial stereotypes. Psychiatry on the ground was different: it always is when interacting with real-life patients. I conclude by looking at the way forward for psychiatry in sub-Saharan Africa. Image: Nurse and patient, Malawi. Copyright Daniel Maissan www.danielmaissan.nl

If you have listened to my series of podcasts on the history of psychiatry in Britain and Ireland you will know that psychiatric relationships are at least partly about power and about the assumptions medical practitioners made concerning those they treated. In the old world, class and sex were important differentiators. In a colonial setting there was an added dimension. Daniel H. Tuke, a British expert on insanity and visiting medical officer at England’s York Retreat, wrote in the Journal of Mental Science for 1857 that ‘the liability to mental disease is greater (other things being equal) in a civilized and thinking people, than in nomadic tribes’. So madness was the price Europeans paid for living in civilization, but transposed to a colonial setting it was the price Africans paid for encountering civilization. Colonial psychiatrists worked to address fundamental issues of social anthropology: How did race affect mind and behaviour? Was it possible to change peoples and cultures? The answer was sadly predictable and the racist ideas I outline provided a rationale for maintaining colonial dependency because they seemed to prove that Africans were unsuited to governing themselves or interacting with the wider world. Their societies had both too many and too few restraints, making them inherently unstable. Image: Juba Central Prison, Sudan, copyright PBS (Robin Hammond, Condemned)( www.witnesschange.org )