As Geoff Berner once said "thank you, but no thank you"

Last night John Ware`s BBC radio 4 report on CHANNEL broadcast. It was interesting and important, but his treatment of Dr Mashuq Ally disturbed me. Ware gave the impression that it was a coup for a CHANNEL panel chair to come out of the shadows, but I learnt otherwise in 2013 when he popped along to the Victoria pub to speak openly to the Brummy public at a Birmingham Salon. He also seemed to cast anxieties about Dr Ally`s circumspect response to so called trojan horse allegations. I then discovered an even more curious linked article in Standpoint magazine and felt moved to respond.

As a Birmingham based atheist Jew I would like to respond with the words of Jewish Canadian singer Geoff Berner `thank you, but no thank you`. Jews are a reducing minority in Brum and I increasingly share the worry that it is too acceptable to be callous about the right to life of Jews in the Middle East as a consequence of the suffering of Palestinians.

However on this occasion I think your focus on Waqar Ahmed and Mashuq Ally is at the least unhelpful and at the most misleading. I listened to your radio programme and I am left struggling to understand your concern about Dr Mashuq Ally`s willingness to scrutinise so called trojan horse allegations whilst this is currently taking place in a legal forum. I went to a predominantly white christian Birmingham secondary school and was called a jew boy there too, what does that mean? Racist slurs in Birmingham are something that I commonly heard, this was just one of many. I do not fully understand Waqar Ahmed's potentially clumsy comment about IS, but it hardly seems unforgivable. He is strongly advocating a two state solution and this kind of voice is needed.

In your rush to highlight problematic callousness to Jews including those in Birmingham and the Middle East I would kindly ask you to show greater judgement in your questioning, thank you, but on this occasion, no thank you.

Lets ban everything disgusting! From Psychiatric Hospitals

The profiteers of alcohol, tobacco, fat, sugar & sedentary life disgust me. Regular ritualised smoke breaks look like dangerous sources of encouragement to become dependent on tobacco. Premature deaths of patients in psychiatric hospitals are immensely disturbing. I share aspirations thatpatients will stop lining their lungs with tar and the pockets of profiteerswith pennies.

In fact I would like to eradicate unhealthy food, sleeping during the day, sitting around watching TV, failing to get an education, failing to work, reading tabloids and consuming psychoactive substances. I think all that might create utopian Mental Health Centres of excellence, if we agreed to never offer anyone the opportunity of discharge into the real world. If we disproportionately ban things from our hospitals we detach our services from society.

I was going to look into the references claiming that the vanguard of smoking bans reduced violence, discouraged cannabis use, increased therapy, liberated nurses and improved respiratory functioning. I expected that champions of research and evidence based medicine would only state these grand claims if they were supported by robust peer reviewed large epidemiological studies. Regrettably I couldn’t find any weighty data to offer sound foundations for the flighty idea that banning tobacco can improve the quality of therapeutic interventions and bring peace to violent wards.

More significantly it seems inconsistent to have a Mental Health Act that safeguards people from excessive restrictive practices by psychiatric services only to restrict the freedom to make such a mundane choice that is rarely likely to be sufficiently attributable to the nature or degree of any mental disorder. Don’t ritualise smoke breaks and do offer people something better to do than smoke, but don’t take out your disgust at tobacco peddlers on the 58,000 people detained on the grounds of their mental health.

Next week this will be scrutinised at a Maudsley Debate. Speak now or forever don't inhale.

The honest sad path to cohesion?

Last night I attended an important public talk at the impressive Birmingham City University Curzon Building. A rabbi Margaret Jacobi, a bishop David Urqhuart, a criminologist Imran Awan, a human rights lawyer Prof John Yorke and a politician Baroness Warsi scrutinised what Independent Terrorism Legislation Reviewer David Anderson QC has flagged up as a potential clash between the government`s counter extremism and freedom of religious and political expression. I am adding to this to emphasise that whilst the next paragraph contains some aspects of the long discussion that saddened me, the majority was positive & hopeful. I believe that all the panellists participated in order to pursue cohesion. I have chosen to discuss points of difference in the hope that progress can be made in future discussions. My first draft dissappointed Imran Awan who I respect, but it is reasonable that some disagreements make us sad until better solutions are found.

It was a really healthy debate. I do not think that I endorse some of Salma Yaqoob`s views on Israel/Palestine conflict resolution, but her rhetoric was an impressive and necessary contribution. I was a little disturbed by what sounded like jeering when someone mentioned the think tank Quilliam. They come across as progressive, thoughtful and liberal, but the anger towards them seemed palpable. In fact Maajid Nawaz` latest daily beast blog on Israel/Palestine is so impressive because of its rarity as a balanced publication on the conflict. I also felt uncomfortable when the first question from the audience angrily talked about Zionism and the multi faith panel in my opinion did not show enough solidarity with the Rabbi panellist when she said that she thought Jews have the right to life in Israel/Palestine.

The healthiest impressions that I had were that people in Birmingham could freely criticise the government, express fear for their religions and even satirise the idea that the PREVENT duty asks the optometrist looking in your eyes to counter terrorism in case he spots the wrong kind of glint. I do not say this lightly. We must hold on to these freedoms and any new legislation must have safeguards for future talks like this. 

Baroness Warsi did request corrections when she talked about warning teenagers in her family about the dangers of joining ISIS. In my naivete I thought that such talks would be unnecessary and I was publicly reprimanded for asking if it was hyperbolic rhetoric or an actual event. I apologise Baroness Warsi, I was naive and did not want to offend. However, I think that this gap between us is important to reflect on. Perhaps white british non-Muslim's like me need to listen more to Baroness Warsi. Perhaps these `ISIS talks` by mums are far more important than public servants looking for the wrong glint in a pupil or patient`s eyes. I say this in all seriousness.

Whatever the case Birmingham should be proud that it is holding talks that seek cohesion rather than conflict. I thank the organisers and audience, but I also encourage sadness when cohesion is too strained from my perspective.

My Diagnosis: Medical unwillingness to fulfill the PREVENT duty is regressive and fanciful.

On 1st July 2015 the Counter Terrorism & Security Act created a requirement that UK medics and many other public servants give due consideration of their duty to prevent vulnerable people from being drawn into terrorism. On the 18th of September Sean O’Neill announced in The Times that links between mental health and extremism had been identified. He went on to highlight that National Health Service professionals were now employed full-time to support the PREVENT program.

The American Psychology Association’s failure to clarify opposition to involvement of psychologists in torture, mass detention of pro-democracy dissidents in the USSR, the invention of Dangerous & Severe Personality Disorder UK NHS hospital services in the first decade of the millennium, and the unexpectedly highs numbers of UK citizens detained subject to the 2007 adaptation of the Mental Health Act 1983 called Community Treatment Orders are notable forerunners of occasions when political pressure to protect the public from harm placed the rights and freedoms of patients in jeopardy.

Given that the Prime Minister is calling for a whole society approach to counter extremism we judged that it was healthy to comprehensively debate the potential pitfalls that the new statutory PREVENT duty may throw up for psychiatry. We did this with experts, psychiatrists and ethicists at the Philosophy & Psychiatry Conference at the Royal College of Psychiatrists on the 25^th September 2015. We heard first hand from Maajid Nawaz, Chairman & Co-Founder of Quilliam about the significant traumatic life events and teenage growing pains that drew him to the brink of violent extremism. His narrative was recognizable and included the kind of challenges that could have benefited from primary care services that should reasonably be expected to treat people for common medical conditions such as depression and anxiety.

This raised an important first challenge to fears about PREVENT leading to some form of widespread Soviet style situation where political dissidents are brain washed with CBT on the NHS. Let’s get real, despite complex and fragmentary injections of extra treasury cash specifically to try to Increase Access to Psychological Treatment, most General Practitioners are more likely to find that their patient’s will suffer for months or even years before being able to access these basic treatments. They will not be swooped off by our diminishing police forces.

Dr Alexandru Popescu highlighted the serious dangers of political abuse of psychiatry with reference to personal experiences of Communist attempts at Re-education and other sordid international examples. It was right, proper and necessary that these concerns were raised. However, when it came to the panel debate with Senior Coordinator for Counter Terrorism Policing DAC Helen Ball, Former Independent Reviewer of Terrorism Legislation Lord Carlile of Berriew and Fixated Threat Assessment Clinic Consultant Forensic Psychiatrist Dr Simon Wilson, it became apparent that these legitimate concerns were in little danger of being replicated in the UK. Whilst it is the case that the Mental Health Act 1983 can enable the detention of patients in hospitals for years, it was widely accepted that this is not a new challenge for the medical profession and its independently regulated duties to do no harm and respect autonomy. In fact once again the real issue here is the inadequate number of hospital beds which result in scandalous reports of patients being admitted to hospitals hundreds of miles away from their home in the midst of severe episodes of psychosis.

In contrast to the under developed ethical guidance of the American Psychology Association which led to allegations of complicity in CIA torture, the long established process of diagnosing mental conditions was highlighted as a simple safeguard to medical mission creep into detention of UK political activists. No one present disagreed with the well established wisdom that people who are seriously disturbed with the severe symptoms of psychosis may require compulsory treatment in hospital, even if they did not plan to carry out extremist violence. The issue of the imperfections of diagnostic categories and the controversies of detaining people with personality disorder were raised. However, no one expressed plans to swoop up the one per cent of the UK population who meet diagnostic criteria for antisocial personality disorder under the guise of counter terrorism.

The PREVENT strategy and any consequent interventions from health services may or may not demonstrate empirical success in reducing terrorism in the long term. However, concerns that it will convert UK psychiatric hospitals into Gulags and GP’s into spies are thankfully fantasies. I suspect that this common sense assertion may incense those who Maajid Nawaz has dubbed the regressive left who shoe-horn Anti-Israeli, Anti-US and Anti-Capitalist grievances into any accessible narrative. Capitalism may increase gross global inequalities, the US & the UK may engage in harmful foreign policies and Israel may deserve condemnation for the deaths of Palestinian children. However, none of this makes it wrong for a doctor to fulfill their PREVENT duty when a contemporary Daniel McNaughton comes to their attention and admits that he is a hair’s breadth away from acting on his viable plan to assassinate a senior politician on the grounds of his psychotic symptoms. In fact I would go a step further and suggest that professionals who let their political ideologies override their professional duties place future Daniel McNaughtons and their victims at unjustifiable peril. PREVENT provides an opportunity to work with other agencies to try to manage precarious and complex situations. Is it really so scandalous to suggest that public services should try to escape the confines of working in silos when the stakes are high?

Freedom, Counter Terrorism & Psychiatry

On Friday 25th September 2015 at the Royal College of Psychiatrists a group of psychiatrists, ethicists & delegates will use the third day of the UK Psychiatry & Philosophy Conference to discuss freedom, counter terrorism and psychiatry. We will scrutinise the challenges of Chief Constable Sir Peter Fahy's observation from TheTimes 'that mental health difficulties had been identified as a factor that made people vulnerable to recruitment into organisations linked to terrorism'. On the same front page of that edition of The Times Chief Reporter Sean O'Neill announced that as well as '3000 terror suspects plotting to attack the UK', 'the NHS now has full-time staff attached to the anti-extremism Prevent programme who try to identify signs of extremist behaviour'.

September 25th will begin with writer, broadcaster & journalist Tazeen Ahmad building on her Guardian Live Psychology of Terror discussion by interviewing Co-Founder and Chairman of Quilliam Maajid Nawaz about the psychological factors that contributed to his radicalisation.

There seems to be no illusions about the dangers inherent in medicalising political activism or terrorism. The lessons from the past will be brought to the forefront by psychiatrist, writer and philosopher of religion Dr Alexandru Popescu, and the former Anglican priest in Bucharest Revd James Ramsay. They will utilise their experiences of the impact of Soviet re-education, primarily in Romania. 

The morning will end with a panel discussion with the audience asking how we should respond to six contemporary equivalents of Daniel McNaughton. He was a 19th century 'lone wolf' who killed a senior politician in London under the influence of a psychiatric disorder. His actions triggered the reform of judicial approaches throughout the world. These reforms addressed the criminal accountability of offenders whose psychiatric disorders are judged to impair their capacity to understand the nature or immorality of their criminal act, often referred to as the 'insanity defence'.

The panel will include:

Lord Carlile of Berriew C.B.E., Q.C. Between 2001-2011, he was the Independent Reviewer of Terrorism Legislation; the Independent Reviewer of the Government’s new PREVENT policy and remains the independent reviewer of National Security policy in Northern Ireland.

DAC Helen Ball QPM, Senior National Coordinator for Counter Terrorism. DAC Helen Ball was appointed as Senior National Coordinator for Counter Terrorism Policing in August 2013. This role encompassed line management of the Metropolitan Police Service’s Counter Terrorism Command (SO15).

Dr Herjeet Marway a lecturer in the Department of Philosophy at the University of Birmingham. Her research interests include global ethics, relational autonomy, feminist theory, and race. She has written on female suicide bombers, commodification, commercial surrogacy, and feminist bioethics.

Dr Simon Wilson is a consultant forensic psychiatrist at the North London Forensic Service, working in the area of public figure threat assessment. He is also an honorary senior lecturer at the Institute of Psychiatry, Psychology, & Neuroscience. He trained in psychiatry at the Maudsley Hospital in London, and has interests in criminal justice mental health, psychiatric interfaces, and philosophical aspects of psychiatry. He has an MA in philosophy.


This discussion is timely. In the last week MI5 Chief Andrew Parker appeared on the flagship current affairs Radio 4 Today Programme and advised that the Prime Minister sought a 'whole society' response to counter extremism. Psychiatry & Mental Health Services are just one part of society, and the acts of the National Union of Students face greater media attention, but what is the role for psychiatrists? How can they carry this out whilst retaining high standards of medical ethics including a respect for autonomy and a vow to do no harm?

Preventing tragic acts of terrorism and alleviating suffering associated with psychiatric disorders are both worthy goals that are hard to oppose, but do they combine easilly? Last week, in his Annual Report, the current Terror Watchdog David Anderson QC raised 15 questions that are also relevant to this discussions about achieving those worthy goals when they interesect (as well as any forthcoming new legislation). Key questions that his review raises include:

How does a psychiatric role in countering extremism impact on the political, religious and other fundamental choices, and the mental health, of both their patients, and the wider public?

What are the risks associated with the civil sections of the Mental Health Act 1983 which can enable the lifelong detention of patients to protect the public without a jury?

2nd September 2015

EXTRAORDINARY BIRMINGHAM MEDICAL INSTITUTE MEETING WITH GISELA STUART MP

Birmingham Medical Institute, 36 Harborne Road,

Birmingham, West Midlands B15 3AF

SESSION TIME:19.00-20.30 Wednesday 2nd September

SESSION :Competent to die? The Assisted Dying Bill 2015

EXPERT PANEL:

Gisela Stuart MP

Dr Debbie Talbot, Medical Director, Palliative Care

Dr Sarah Mitchell, GP

Dr Sam Finnikin, GP

Sohini Patel, Medical Student

SESSION INTRODUCTION:

On September 11th 2015 the Private Members Assisted Dying Bill (No 2) sponsored by Rob Marris MP will undergo its second reading in the House of Commons. The proposals of the bill were initially introduced by Lord Falconer. The bill intends to enable competent adults who are terminally ill to choose to be provided with medically supervised assistance to end their own life.

Care Not Killing the campaign for promoting care and opposing euthanasia highlight that there is significant opposition to this bill. They highlight that Prime Minister David Cameron stated in June 2015 that he does not support the assisted dying proposals. He expressed fear that this bill would put pressure on frail, elderly people to take a decision that they might not want to go ahead with.

In contrast the Campaign for Dignity in Dying claim that a 2015 Populus poll measured that 82% of 5000 people support these proposals. They appear to challenge the Prime Ministers fear for the frail and highlight that the Assisted Dying Bill would only apply to adults with mental capacity.

This is a matter raises questions about the role of health care services at the end of life, the value of life in the presence of severe persistent symptoms and what constitutes capacity to make life or decisions.

The 39th Maudsley Debate in 2010 at the Institute of Psychiatry the debate ended with a 50:50 split between does for and against such proposals. Beyond groups wishing to protect what they consider to be a fundamental sanctity of life, concerns were raised about the need to ensure that depressive suicidal symptoms were adequately treated amongst the terminally ill.

Liaison Psychiatrist Matthew Hotopf has raised the question of where the capacity bar can be set for people who express a wish to choose death given potential impact of multiple mental disorders on the capacity of individuals to weigh decisions up. For that matter can our lives be sacrificed as a means to end unbearable experiences, can this ever be an informed decision? As Noel Coward once said we have no guarantee that the afterlife will be any less exasperating than this one, have we?

ADDITIONAL INFORMATION ON SPEAKERS:

Gisela Stuart:  Labour MP for Birmingham Edgbaston since 1997, and health minister under Tony Blair’s government. Re-elected in May 2015.

Dr Sarah Mitchell: GP with an interest in palliative care and NIHR Doctoral Research Fellow at the University of Warwick. She was clinical lead for the Birmingham Cross City and South Central CCG palliative and end of life care strategy in 2014. Since then she was appointed to regional and national roles in palliative care. She is also chair of the West Midlands Paediatric Palliative Care network, and her PhD is in palliative care for children and young people.

Dr Sam Finnikin: A salaried GP at Ley Hill Surgery and an NIHR In-Practice Fellow at the University of Birmingham. He has followed the debate on assisted dying over many years and published a review on the topic for GP trainees.

Sohini Patel: Graduated from Kings College London with a BSc in Medical Ethics and Law and undertaking the 4^th year of the MBBS at the University of Birmingham. She was part of the Central London Docbate team, organising and hosting a debate on medical paternalism.