Monthly Archives: January 2009

The Dementia Care Strategy

In my blog I’m going to write about dementia, this is because that was my main speciality in practice, and because I have a module launching in a couple of weeks that focuses on dementia and so it is uppermost in my mind.

Leonardo DaVinci
Old Man with Water Studies: Leonardo DaVinci

Last year I was thrilled (yes, I really was but didn’t let it show) that the Government was planning to release a Dementia Care Strategy and got quite excited that suddenly my ‘poor relation’ interest was going to be top of the news and lead to better funding and public attention, and also give me lots of new material to boost lessons and discussions in class. It was like as a child waiting for a particular present which isn’t exactly promised, but you feel there’s a good chance it will turn up. As you may know, the Strategy wasn’t published before Christmas, perhaps the Government had other things to deal with, but from my perspective, and others in the field and those who have Dementia, and their families, it was a disappointment.

We do know roughly what the Strategy might contain, because there’s been a draft, and the themes are likely to be raising public awareness, early recognition and improved care. One of the things the strategy was criticised for was a certain vagueness about any money to support the recommendations. Now I’m getting anxious that not only I won’t get the present, but that if I do it won’t have any batteries.

This is just a little corner of the world, and it’s not just about being a spoilt brat when there are so many other pressing concerns – older people, at risk of dementia, or who already have it, don’t usually have high expectations, but maybe this time it will be their turn (and with them all the nurses and other staff involved in their support) to beam with pleasure when they unwrap the parcel. We’ll have to wait and see.

A case for appropriate treatment?

Since the “Treatability Clause was removed from the Mental Health Act in 2007 and the phrase ” Appropriate treatment must be available” replaced it we have to consider what is “appropriate treatment”? 

For example can detention alone be appropriate treatment?

In the case of   R(Home Secretary) v MHRT (2004) this matter was ruled on.

It concerned a person alleged to have a psychopathic disorder. Both the medical team and the court felt that in the community he was extremely dangerous. The question was, was he treatable? He was deriving no benefit from treatment programmes. However, it was felt that he could cope in the structured hospital environment.

The Court held that this was enough. The Tribunal accepted that hospital could prevent deterioration by his continuing in custody. Having accepted that factual proposition it was bound to conclude that the condition was susceptible to treatment as it would prevent deterioration of the symptoms of mental disorder were he suffering from a mental disorder

What can we foresee as the implications of such a legal precedent? How will this type of detention impact on our wards? At what point can the detained person hope for discharge?If it is detention alone that prevents the worsening of a disorder will the person ever be fit for discharge?

I would love to hear your views on this case. If there is enough interest I will post another legal and ethical poser soon.




Listening to Voices

We have just finished teaching the Hearing Voices Module for post registration nurses, which can be taken as part of the ‘top-up’ to a degree qualification, or as a stand-alone course.  We felt privileged to have a very keen cohort of students made up of CPNs, OTs, staff nurses, and support workers, many of whom have considerable experience in working in mental health. 


The course is centred on Romme and Escher’s way of working with people who hear voices, Making Sense of Voices (2000).  In their early work Romme and Escher highlighted the considerable number of people who hear voices who never come into contact with mental health services.  They posited that voice-hearing in itself is not problematic.  In their work with people who are distressed by hearing voices Romme and Escher attempt explore whether there are any links between the personality of the voice and the content of what is heard; and incidents of trauma in the life of the voice-hearer.  They developed the Maastricht Interview Schedule to help voice-hearers to make these sorts of connections. 


The Maastricht Interview Schedule is not an inventory or rating scale, but rather a series of pointers for the helper and the voice-hearer to use together at a pace which suits the voice-hearer.  The questions need to be asked with care and sensitivity as they explore the nature of the experience, the personal history of voice-hearing and the childhood experiences of the voice-hearer.  At first glance it looks like a daunting piece of work to undertake, however we were very pleased to see each of the students begin to use the Maastricht Interview Schedule in their day to day work with clients. 


Students on the course shared how they felt, as they were beginning to work in this way – either with individuals or in setting up voice-hearing groups.  Students gained confidence, and could see how powerful this way of working could be in their own practice.  We heard that service-users said they felt they were being given the opportunity to talk about their experiences in a way that had not been possible before.  The ‘normalising’ of the experience of voice-hearing seemed to be very helpful for many of the clients; and the formulation of a construct to help to explain the origin and meaning of the voices was felt to be very important in redressing the balance of power in the relationship between the voice-hearer and their voices. 


We are hoping that part of our role, which includes an honorary contract with the mental health trust, will be to support those who have attended the course to implement this way of working wherever possible.  I look forward to seeing this way of working used more widely.