At the core  of the NHS is a commitment to provide “choice” as a right. When I first joined the NHS in 1982, patients could be referred by their GP to any NHS hospital. Introduction of the internal market, with its division of purchaser and provider, eroded this system; the provision of choice for medical and surgical problems returns us to roughly what we had before, with patients more involved in the decision about where they receive their care. The Department of Health states that the options available for “choice” will develop over time. This is understandable, especially in the light of the current financial climate. However, the first area where this has become a legal right is elective care: since 1 April 2009, patients have had a right to choose the organization that provides their treatment when they are referred for their first outpatient appointment with a consultant-led team. The legal right applies at present to referrals for elective care services only (that is, ones which are pre-arranged). The Department of Health now appears to discriminate against people who are disabled by their mental disorder, and needing elective care, as “mental health services” are specifically excluded from the legal right for choice of referral. It is true that many referrals for mental health services are emergency or non-elective, but a significant number are not. I have had communications with many people with OCD or BDD (or their families) who are severely disabled, and who want to be referred to our service at the South London and Maudsley Trust because of our reputation and results. I am proud to say we provide cutting edge treatment and patients often seek to travel to our unit when local care has failed. They may be seeking an assessment for out-patient treatment at the Maudsley Hospital or for admission to a residential unit at the Bethlem Royal. However because they may not be able to obtain a referral or funding, it means individuals with mental health disorder and who are disabled are unable by legal right to obtain elective care at a hospital of their choice. Surely the Department of Health is discriminating on grounds of disability and the Equality Act and flouting the NHS Constitution? Either choice should be removed from all medical and surgical patients or also given to patients with a mental disorder?

I wrote about this to the Department of Health last year and was told that people with mental disorder and disability have a right to choose a provider for a consultant led team provided it is not a mental health service. Equally they argue that everyone is excluded from choice in mental health services whether they have a mental health problem or not! However this is nonsense as people with a mental disorder want choice in their mental health provider and people who do not have a long-term mental health disability do not need to be referred to mental health services.

They further argue that because the NHS has developed the Increasing Access to Psychological  Therapies (IAPT), there are effective choices. This is partly true. At a primary care level, there may be more choice but what happens to the people who need to be stepped up to secondary care when they failed treatment or have more complex or severe problems?  Public bodies have a statutory duty to be pro active in promoting equality. The Department of Health is not promoting equality for people who are disabled by their mental disorder and need mental health services. They say they will change this anomaly in time. Please write to your MP and Department of Health and keep up the pressure.

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A quote from me was published in the Observer about our study on labiaplasty. If your planning to have labial surgery, please consider volunteering for our research project here

OCD fears is not of course really about “contaminants” – it’s driven by the beliefs and emotional associations with the objects of contamination. The first step in overcoming OCD is of course to stop treating is an contamination problem  and to treat it as an anxiety problem. This of course has a completely different  set of solutions compared to sanitizers and excessive washing.

I travelled with my family to Mynamar-Burma this summer. It is a fascinating country which I thoroughly recommend a visit. This statue of a woman, Sandhamukhi, at a pagoda in Mynamar caught my eye. I understand that after learning the teaching of the Buddha, in gratitude she cut her breast and offered it to the Buddha. As it is against the teaching of Buddha for monks to accept raw meat, the Buddha declined the offer!

The statue reminded me of “DIY cosmetic surgery” in some of my patients with Body Dysmorphic Disorder. I wrote about it in an article in 2000. An example of the desperate state of patients included a woman preoccupied by the ugliness of  her body who desired liposuction who used a knife to cut her thighs and attempted to squeeze out the fat. More recently I had a patient who had tried to use an iron her face to reduce perceived wrinkles. Katharine Phillips has also written in her book ‘The Broken Mirror” about a man who tried to do his own nose operation with chicken cartilage. I think these cases demonstrate the desperation of some people with BDD and the extent they may go to try to change their body image. Needless to say all the cases that I have seen who performed DIY surgery were dissatisfied with the results and their preoccupation and distress with the body part persisted.

Reference:

Veale, D (2000) Outcome  of cosmetic surgery and DIY surgery in patients with Body Dysmorphic Disorder. Psychiatric Bulletin, 2000; 24: 218-221

The mosaic now hangs over the door to the unit and brightly welcomes new patients to Longfield House. It depicts the journey they will embark on during their treatment, and is a permanent legacy left by past residence for future residence to enjoy. Moving from a ‘caterpillar’ to a ‘butterfly’ is a metaphor for this journey, where they will strive towards freedom from anxiety.

The mosaic is part of the Bethlem Gallery artist-in-residence programme, with artist Natasha Morrison leading the project in partnership with our therapist, Lisa Wheble.

The mosaic took 8 weeks to complete and was worked on by 15 Longfield residents and included hundreds of useful behavioural experiments. The project combined both cognitive behavioural therapy (CBT) and occupational therapy goals.

The process of making the mosaic addressed many exposure and behavioural experiments, including:

• Cutting imperfect tiles
• Placing tiles in the ‘wrong’ places
• Breaking sharp pieces of tiles
• Using reflective mirror tiles
• Imbedding intrusive thoughts in permanent grout
• Tolerating contamination in the form of grout and glue on hands
• Placing objects without checking

I hope it provides inspiration for future group projects that combine both CBT and OT goals. The mosaic will continue provide words of encouragement for all those who live in the Longfield House. The feedback from patients involved with the project was extremely positive, with one saying it helped to unite the residents of Longfield House. Another said they planned to buy a mosaic kit upon leaving to keep practising exposure treatment at home.

Some other examples of patient feedback:

“I found the mosaic project both rewarding and challenging. Placing the mosaic pieces for me personally was difficult due to the fact they were not to be placed symmetrically. It was excellent exposure.”

“Like other OCD patients I have a fear of the permanent. My therapy using the mosaic involved intentionally thinking thoughts as I worked. I would have terrible thoughts, which seemed to me would come true if I stuck the piece in place and left it there. It was as if I was setting my thoughts in stone, with no opportunity to reverse them.”

This project is also an example of how much patients can achieve in spite of their anxieties and fears.

Click here for further information about the  Anxiety Disorders Residential Unit.

I had previously submitted the article to a high impact psychiatric journal but was rejected. Although the Editor said he liked it, he said it had caused some controversy in their office as someone thought it was derogatory to patients. I should add that the installation was developed with the help of patients with OCD and it remains a popular figure in our unit. We have also displayed the Bully at a couple of conferences and had many positive comments.

The OCD Bully is a concept that was in my mind for several years and described in the article. My friend, Steve Caplin, finally helped me to realize it.  Steve Caplin is an award-winning artist and writer. The author of a dozen books including “Dad Stuff”, “How to Cheat in Photoshop” and “Complete and Utter Zebu”, Steve is best known for his illustration work. He creates satirical photomontage illustrations for a range of national and international magazines and newspapers, including The Guardian, The Independent, The Sunday Telegraph, The Sunday Times Magazine, Radio Times, Readers Digest, I’Internazionale, FHM France and many more. Steve Caplin has also been building installations for thirty years, chiefly from found objects and urban detritus. His largest work is a 16-foot working Camera Obscura, located in a garden in Hertfordshire.

Professor Jack Rachman unveiled the installation at the Bethlem Royal. He is one of the world’s leading experts on OCD. He used to work on the unit about 30 years ago but is now semi-retired in Vancouver. The story of the OCD bully has been accepted for publication in the British Medical Journal.

More humanoids?

I would love to commission Steve Caplin to create more humanoids that depict the force behind other mental disorders. Just think if we had another 10 siblings – we could have an exhibition of them in the Tate Modern!  Please contact me if you would like more details as they are not that expensive (only the cost of the materials and his time ). I think they can really convey the misery and distress of a mental disorder.

David