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Interview with Lade Smith CBE, President of the RCPsych

 

The Royal College of Psychiatrists is the main professional organisation of psychiatrists in the United Kingdom and is responsible for representing psychiatrists, for psychiatric research and for providing public information about mental health problems. It is responsible for supporting psychiatrists throughout their careers from training through to retirement and in setting and raising standards of psychiatry in the United Kingdom. Dr. Lade Smith CBE, was elected president of the college earlier this year for a 3 year term.



The Royal College of Psychiatrists represents over twenty one thousand psychiatrists and psychiatric trainees in the United Kingdom and internationally. It is a leading organisation worldwide for psychiatrists, and any discussion on the role of and future of psychiatrists must pay heed to the views of its leaders. - I was able to get hold of Shubulade or Lade as she´s always called and we planned a TEAMS interview.


Can you tell us a bit about your background?


I was born in Manchester, England. My parents are Nigerian immigrants, though when they came they had British passports, because at the time Nigeria was still a British colony. So they settled in Manchester, in a rough bit of Manchester, in a very working class area. I went to local state schools. My secondary school wasn´t very good, but I loved it any way, but it was rough. Most people in my school, (you don´t realise it until you leave school), that these people had terribly difficult backgrounds. So there were a lot of people who developed substance use issues, lots of mental health problems, quite a few of them died early, criminality etc. So when I bump into old school mates and ask about people, they might say, „oh so and so died, got killed“, or „did you know what happened to her brother? - he was shot“. „Yeh, there was an armed robbery, he got shot, executed“. So the school I was in, a lot of the children grew up with crime around them. I went to school with the, “Gangsters of Manchester”, so it was quite a rough school.


How did you go from there to where you are today?


Well, just ´cause a school´s rough doesn´t mean to say that there aren´t a lot of clever kids in the school. And you may or may not be influenced by people around you. The point is that in well functioning schools, most people fulfil their potential. In a school that´s not so good, only a few people might achieve their potential. So I have friends I still know from school all those years ago, who have done fine. If they´d been to a better school, they´d have done even better but they´re doing allright, so it´s probably about percentages, more than anything else.


Are your parents educated people?


My dad was educated, he worked as an accountant, my mom no. She´s a clever woman, but she was from a very poor family. She went to school, but had to go to a technical college, she went to a secretarial college. But my dad went to quite a good school, I´ve discovered. Then he came here (to the UK) and did accountancy.


The Royal College of Psychiatrists HQ, 21 Prescot St, London, United Kingdom. Image by RCPsych.
The Royal College of Psychiatrists HQ, 21 Prescot St, London, United Kingdom. Image by RCPsych.

Do you have any brothers and sisters?


I´ve got an older brother, five years older than me, he works for Hackney Council, he should have been a social worker, but he´s not.


Where did you go to university?


I went to Guy´s Hospital Medical School, which was the best medical school in the country at the time. This is long before the internet so it was hard to find out about these things, but it was very famous as a medical school. On the first day we started, there were a hundred people in the year, we were all in a lecture theatre and the lecturer asked, how may are from state comprehensive schools, and about ten people put their hands up, most of the rest were from private schools.


Then you went on to do your training at the Maudsley Hospital?


Yeh, I did some locum jobs and then I went to train at the Maudsley, at the Bethlem & Maudsley Hospitals, it was a very small rotation at the time. This was in 1992.


As a consultant what has your focus been?


I always wanted to be a consultant for the Brixton area. So I´m general adult trained. I wanted to work in an area with people who were marginalised, had difficulties, where there was a lot of morbidity, because I thought I could help there, because there is a real thing about being able to cope with and have resilience to deal with the awfulness of their lives, to be in the room with someone who´s had terrible things happen and hold onto that and hold them through that and to make difficult decisions, in order to help them, that people may or may not like. I thought, I can do that, I can work with the people who are most difficult, who aren´t necessarily very attractive. You are not going to get presents, you´re helping people who are maybe aggressive, violent, I can do that. So that´s what I did for about 5 years. It was tiring, I went on maternity leave, to escape (laughs), I needed a break. When I came back I first went to the Institute (of Psychiatry) to develop MScs, I went to the Forensic teaching unit anddeveloped MScs which are still going today, which is nice. Then I went to work at the Maudsley psychiatric intensive care unit and I thought, „I love this, it´s my favourite thing“. Yes, psychiatric intensive care is definitely the thing, because people come in very very unwell and I´d done a lot of psychotherapy, psychodynamic stuff when training, so I always thought, if you really want to help people get better, you really need a holistic approach, it´s not only about the medication, also their psychological state, the social environment they´re coming from and going back, to, what they eat, how much exercise they do, so all this stuff. And having meaningful daytime activities. Even on the ward, you could see that if people didn´t have anything to do on the ward, it was much more likely that there would be a fight, a serious incident, so whilst I was there we introduced a 7 day a week therapeutic approach. And also, I remember, it got on my nerves so much, you got on the ward and there had been an incident and people would say, so and so did this last night, they had been brewing all day and then there was an outburst. I asked, if they´d been brewing all day from the morning, why did you wait until they kicked off at 5 o´clock to intervene? So we developed this proactive approach, it was co-produced, (we didn´t know the word then), this was in the early 2000´s. We got people to, So, at 10am, someone wouldn’t be feeling great and they felt they needed help to calm down, and if they weren’t able to calm down, even with talking, distraction, time out etc., and were getting increasingly agitated, we would offer them buccal midazolam. They would take this themselves, they would then sit in their room for half an hour or so, then talk to so and so or play a game to distract them. Essentially, we got them to say what helped and then provided it before they “kicked off” so they had control over how their potential aggression was managed. It really helped reduce the violent incidents on the wards because we got them before they got to the stage when it was too late. Then I went to forensic intensive care and now I´m the clinical director for forensic services at SLAM.


I agree with you, I find psychiatric intensive care very interesting. 10 years ago I fought to open a psychiatric intensive care ward here in Iceland and it reduced aggression and violence in adult inpatient services by 50-60%.


There we go!


Moving on to broader things. Looking at the 7 competences of a psychiatrist as outlined by the UEMS. How are they relevant to psychiatrists?


For a modern psychiatrist these are good competencies. I like the way they put necessary competencies, ´cause I think the way we were trained as psychiatrists, the idea was that you were a medical professional, a medic, who has specialist knowledge, interest and competence in providing mental healthcare. You were a part of a team, but there wasn´t this idea that you would have an outward facing position as well. I think now I can say with confidence that we get people better, then we send them right back to the conditions that made them unwell in the first place. Now we know that so many mental health problems have been engendered by the conditions that people come from. The inequality, the trauma they suffered in their youth and so on. To make a difference to these things, particularly inequality in society, that requires a political response actually, it requires a response that is not only about the individual, clinical care that we give. You could be the best doctor in the world, but your patients are going to keep getting ill, unless you change the conditions in which they exist. For that to be made clear, to be made known, we need to be able to influence decision-makers to bring about change. We need to be able to talk their language and we need to be able to understand policy and how to influence policy to make a difference. So I think these competencies, when they talk about the need to influence, it’s the educators, the politicians, social media. That´s more than what we were trained to do in the past. Now we need to be trained to do these things so we can truly advocate for our patients.


When I read your statements for becoming a president, you´re emphasising inclusiveness and equality. I understand now from what you say that these are important values for a psychiatrist. Is there anything you want to elaborate on in regard to that?


Well, it could well be that as health professionals, you could easily believe that by the time a person comes to you and is unwell, the reason they´re unwell is simply that they´ve got a genetic predisposition to mental illness. But all the evidence indicates that even if you have a genetic predisposition to an illness you´re not necessarily going to manifest that problem unless the conditions are ripe for you to manifest that condition. And oftentimes, and certainly when it comes to mental illness, those are the conditions more commonly seen in those who have had impoverished lives. So let´s say you have a familial, genetic predisposition to schizophrenia, you have an uncle who has schizophrenia, now let´s say you have a parent with schizophrenia, your risk is going to be 6%, you´re not necessarily going to develop schizophrenia, but if your mom isn´t well during pregnancy, she doesn´t feed herself well, you don´t grow so well, you´re small for dates. You are more likely to be small for dates if your parents can´t feed you well because they´re poor, so obviously poverty is important there. If you are then growing up in an area with poor healthcare so your access to perinatal care is poorer, when you are born it is not such a good hospital, because it´s a poor area, you get some birth trauma, that increases your risk again. When you´re born, the way in which you are fed and nurtured, can make a difference. We know that if you are nurtured well, you’ll have a better outcome. Let´s say your mom is from a family in which the children were neglected. All she knows about parenting is what she was taught and her parenting wassn´t great, she therefore doesn´t know how to nurture you as well as she could, emotionally or physically. However, if she were given parenting classes, (we know parenting classes make a difference), if she is taught, while you are very young, from a baby, up to 3-4 years of age, if the mother is going to parenting classes and taught how to look after you, how to nurture you emotionally and physically, you will do better in life. And you are probably less likely to manifest the mental health problems that you were predisposed to, certainly your outcomes if you do develop them are likely to be better because you will have had better pre-morbid functioning. In fact, the Royal College of Psychiatrists are about to publish ours Early Years report. It is a really good report which shows that those first five years are crucial and you can intervene in those first 5 years in a way that you can´t later on. That´s why fighting inequality is important, not simply because it´s a nice thing to do and not simply because it´s the right thing to do clinically, but because if you intervene earlier then you can reduce the rate of mental illness in children and young people by up to about 25%. That means that these are people who are more likely to achieve their potential, more likely to reach peak productivity. Remember that unlike physical health problems, 75% of mental health problems arise under the age of 24, 50% under the age of 14, that´s completely unlike physical health problems, which happen in middle-aged and older people. By the time you are middle-aged you´ve already achieved your potential, you´ve achieved your peak productivity but when you´re a child with problems and nothing gets done about it you become an adult with chronic, relapsing problems and you don´t reach peak productivity, you don´t achieve your potential, so it´s not just about what´s good for the individual and for their families but what´s good for society...and what´s good for the country actually.


Lade Smith: "Fighting inequality is important, not simply because it´s a nice thing to do and not simply because it´s the right thing to do clinically, but because if you intervene earlier then you can reduce the rate of mental illness in children and young people by up to about 25%." Image by Unsplash.
Lade Smith: "Fighting inequality is important, not simply because it´s a nice thing to do and not simply because it´s the right thing to do clinically, but because if you intervene earlier then you can reduce the rate of mental illness in children and young people by up to about 25%." Image by Unsplash.

You have worked extensively with the National Collaborating Centre for Mental health. Is that a quality centre?


It is a department of the Royal College of Psychiatrists and the first type of work we did was to write NICE-guidance on mental health. So essentially it is a policy research centre. It started out that way. So you do research, you get experts in lived experience (users) and academic experts and clinical experts in the same room and then write the guidance. We reviewed the guidance over time too, but also our work had developed into providing guidance on what services should look like and developing nationally and internationally recognised guidance. For example, we worked with people in Georgia and in the Middle East who wanted to develop their services and supported them to develop their own guidance. For example, we say, well this is what good quality looks like; this is how you might want to do it; this is what you need to be thinking about in your country based on the evidence from your country. We supported them to think about the universal standards you would expect for any mental health service. A teach a man to fish approach.


We have also done a lot of work around Quality Improvement. Once you have the standards, how do you implement them in reality? So we started developing Quality Improvement collaboratives, lots of different services or organisations come together to learn and develop their services together. We co-ordinate them, everyone is trained in quality improvement techniques, we have the research and quality improvement techniques to help them improve their services incrementally. The other thing we do as well is to develop competence frameworks for individuals and staff so that they know what they need to do to deliver better care.


I envy you in the Nordic countries because you are working in countries where there is probably more cohesion, where there is more agreement that something needs to be done about mental healthcare and then you are allowed to do it. In the UK, we are still at the stage of persuading people that there is a problem and that things are pretty dire and that we need resources to make a difference.

Towards the end I want to ask you, do you think our profession has a future and what will that future be?


It is interesting, how we have this whole anti-psychiatry thing, while there is no such thing as an anti-cardiology movement or anti-cancer movement. Yet the drugs used in cancer therapies have horrendous side-effects, but nobody is saying, oh, you don´t need that, get rid of them, but we have this big anti-psychiatry movement. What I think honestly, is that being a psychiatrist is the best kind of doctor in the world. And that´s because you can look after people´s physical health and understand what is going on there, but also look after their mental health too. Surely that is not only interesting, it is the best type of doctor!


"It is interesting, how we have this whole anti-psychiatry thing, while there is no such thing as an anti-cardiology movement or anti-cancer movement."

Over the years the idea has developed that we shouldn´t talk about mental health problems, it´s just people who are a “bit weak and should pull themselves together” somehow. People are embarrassed that they´ve had a mental illness, a psychotic breakdown, and the last thing they want to do is talk about it ever again. We somehow also have been drawn into that, colluding, when we should be saying, yes, we are psychiatrists and yes, we are working with people when they are at their lowest ebb. As a psychiatrist you work with people and learn from them and they share stuff with us which means our relationships with them are evenmore intimate than the relationships they have with their closest loved ones, because they themselves are at the limits of human existence and we go on that journey with them. We go on that journey with them,we help them with the very worst and have seen them through that and support them to fly away. We should be absolutely open about the fact that we have the privilege to do this and we shouldn´t be ashamed of talking about that and that´s what I´d like to see. I think this is important now more than ever before, because people understand mental healthcare much more than before and want to talk about their mental health problems more than ever before but currently we have problems getting and maintaining a workforce in psychiatry. We have difficulty retaining people and that´s because of the chronic underfunding and under resourcing,at a time when there is more need than ever since the pandemic, which means that workload is overwhelming and people are burning out. But this has coincided with, young people, at least in the UK, are saying that the things most important to them, are climate change and mental health. That´s what they care about. In the UK we spend about 12 billion pounds per year on mental healthcare, but mental illness is estimated to cost the UK about 118 billion pounds per year (and that´s a conservative estimate). We are failing people if we are not attending to mental illness, if we are not prioritising this. And one of the things we have to do, therefore is to raise the profile of psychiatry, so people listen to us. There´s more need than ever.


And back to your question, do I think psychiatry will be around in years to come, - you know what, if it meant that, if there was no more mental illness and that´s why no one needs psychiatrists, then, great, that´s brilliant. But the fact is that there is no reduction in people needing mental healthcare. In fact there´s been a 20% increase in people needing mental healthcare since the pandemic and the cost of living crisis has affected the whole world and particularly certain countries like the UK. The issue is not that there isn´t need. There’s enormous need. I do worry, however, about people moving into the space who aren´t trained, who don´t understand how profound people´s problems are. All mental health problems present with anxiety, it doesn´t matter if it´s schizophrenia or bipolar illness, people feel anxious and you can go online, find someone who´s done a 14 hour course in counselling, and created a fancy web-site. You see them remotely, and you think after 50 minutes you feel a bit better because it makes you feel a little less anxious, because basically anxiety responds to reassurance. But an hour later you still have the same problem, you go and see them the next week and keep going and going. And it´s only later, once you´ve seen someone who is properly trained who´s had years and years of medical and psychiatric training that it’s realised that it´s actually prodromal schizophrenia and you need more than counselling. Counselling is useful but you´d be better off taking this medication, doing this CBT, doing exercise, having a particular diet, meaningful relationships, staying away from recreational substances and so forth. So yes, we are going to still need psychiatrists. Because we are the only ones who fully understand the biopsycho-social connection and can do the whole formulation and really understand the depth, breath and length of the longitudinal history that people have, the risk factors and the reason they are here now. And work out the best treatment now. Psychiatrists are the ones who can understand thecomplexity of people’s lives and frankly, hold the risk and be accountable for it. And understand the best treatment plan. It doesn´t mean to say that we´ll have to do all the treatment because frankly we should be the ones overseeing that actually. People who have been on short counselling courses aren´t going to be able to do that. So society needs psychiatrists more than ever.


Finally, any advice to Nordic and Baltic psychiatrists and their leaders?


I would say, be more Norway! (laughs). I say that because a few weeks ago some Norwegian psychiatrists came to visit the College. Interestingly we have very similar issues, anti-psychiatry;severe mental illness not being properly attended to in the way it needs to be attended to etc etc. But the big difference is; in the UK about 10% of our health budget is spent on mental healthcare, despite the fact that it affects 25% of the population every single year. More people than ever are waiting to get help for mental illness. In Norway 30% of the health budget is spent on mental healthcare. Norway is one of the most successful countries in the whole world. I can´t help but think that these two things are correlated.


There is something else, back to the anti-psychiatry – we do need more research into what works. We know that some things work, medications work, but then people say, whoa, but the side-effects are horrendous. Yes, but just because you have side-effects doesn´t mean we should get rid of the drugs, it means refine the drugs and make them better, that´s what we should be calling for and that’s what we would really like to see. Psychiatrists around the world should say, yes, that´s right, these drugs aren´t good enough, but don´t get rid of them, what we need to do is make them better. □



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