Monthly Archives: August 2013

30. Philanthropy, partly by accident.

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Poor Allan!

In an attempt to freshen up the local pub, the new landlord has misguidedly brought in musicians on Saturday nights. I fell victim to this last week, when I had to order some complicated drinks, standing right in front of a Rod Stewart impersonator, who in turn was standing in front of a disproportionately large sound system.

No disrespect to Rod, but he has never been a favourite and I am proud to say I have none of his work in my possession, not even on the 80s compilation album I won in the Secret Santa last year, nor even on old DC90 cassettes in the attic. (Regular readers will anyway know that I have destroyed all these).

The effect of standing in front of a wall of sound is disorientating. Look what happened to Phil Spector, for instance. This is why I didn’t immediately notice the bar lady had made a mistake with the change, in my favour. The four drinks I finally ordered – using mime – came to £12.60. I gave the bar lady a twenty pound note and she gave me £12.60 change. I presume she chose the wrong one of the two numbers on the till display.

I soon realised the mistake, but here was a minor ethical dilemma: since the lady’s boss is working right next to her, will it cause her harm if I point out the error? But then again, should the boss not be aware that his employee might be prone to error under harsh environmental conditions?

I made the refund of £5.20 as discreetly as I could during the intro to Maggie May.

The point is, the cost of being an honest man, this week, is higher than usual, but is still only £5.20.

Most weeks there are no opportunities for honesty or dishonesty, where prices are set on barcodes and payments made electronically. It doesn’t cost much to be honest. And it also doesn’t cost much to be generous.

I once read an article by psychologist Dorothy Rowe, asserting that giving someone a present could be quite an aggressive act. In particular it could represent an intrusion into the person’s life and an obligation on them to return the favour at some point. It’s a little bit like a bribe, in creating a sense of unease for the recipient. Even though we live in the age of sellotape, gifts often have strings attached.

I’ve used this notion as an excuse for not sending Christmas or birthday cards for the last few decades. I have other reasons for this, such as not wanting to support a pointless cards and gift shop industry – maybe I am just uneasy about the name Clinton’s – but the real reason is that it is a laborious task that we could all do without.

On reflection I have to admit this act of scroogism has been misguided. The real cost of being a generous person is actually quite low in the modern world. The opportunities for day to day acts of generosity are limited, boiling down mainly to paying for drinks. And even these acts are often rewarded by reciprocation, or retaliation.

Obviously the situation is more difficult when it comes to charitable giving, or taxation, as this is sometimes called. And there are similar ethical arguments about distorting the power relationships between rich and poor countries.

Dorothy Rowe also said: ‘In mental distress the real problem always arises from some kind of threat or insult to the sense of being a person. This can be hard to uncover, and difficult to ameliorate. It is never amenable to a quick fix’. Both giving and receiving charity is a lot more complicated than it first seems.

But there is a clear win/win with charities, where they will accept a lot of the stuff you don’t need or want, and will even come and take it away. They get richer and you get richer inside. Thank you the British Heart Foundation for taking my stuff and making me a better person.

There is a little bag of nuts and bolts to put it back together, taped to a leg, but there are no strings attached.

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29. Growing cress heads for no particular reason.

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This morning, the council came to collect the 3 bins I leave outside on Tuesday mornings, and I think they have brought another new bin – to dump your Guilt into. So much better to have it safely disposed of rather than giving it to another person. Guilt just doesn’t compost down.

I’m hoping for more metaphorical bins in the future, now that local government has taken over public health. In hospitals we have sharps containers coloured yellow, which is a safe place to put barbed comments.

Today, just as The Times reported that health checks for the over 40s were a complete waste of money, I received a letter from my local surgery asking me to come in for a health check with the practice nurse.

Though I am a supporter of evidence-based medicine, it took me less than a minute to make myself an appointment. I am also a hypochondriac.

To be honest, evidence-based decision making can conflict with common sense. Everyone knows that a stitch in time saves nine. As far as I know, there is no equal and opposite proverb to cancel this one out. My strict adherence to the evidence based approach probably doesn’t go much deeper than the occasional casting of nasturtiums on the alternative sector.

So many decisions we have to make are based on intuition rather than double blind randomised control trials. For instance, choosing what we eat. I start with the null hypothesis as follows: nothing that you eat – within reason – makes any difference to you. There are occasional bits of conflicting evidence, but in general nothing to disprove the hypothesis, which is based on the sound principle that the human body is a chemical factory.

I have yet to see any convincing evidence for the five fruits a day policy, nor the arbitrary alcohol consumption limit of 21 or 28 units per week. Which leaves me with a bit of a dilemma over what to tell the practice nurse about my lifestyle. I don’t want to come across as a fanatic of any kind. Like an NHS Trust, or Everton FC, its safest to be half way up the league table rather than at the top or bottom. But there is no real ‘gold standard test’ for lifestyle to pass or fail, apart from a few aspects of what we consume.

Like everyone, I find it very difficult to explain the increasing numbers of people who suffer with obesity. I watched a recent documentary attributing this to the corn syrup industry, but was not entirely convinced. Maybe it is a virus or other infection we have yet to identify. The concept of ‘food addiction’ has gained some adherents, certain products turning out to be incredibly ‘more-ish’, such as chocolate, pizza and ice cream.

Since obesity has increased rapidly over the last 30 years, we could attribute it to any or all of the social trends of the last few decades, from computer ownership to the decline of progressive rock. Psychiatrists have made their own contribution, in the form of atypical antipsychotics, which have doubtless added to the lard mountain.

My own hypothesis – no, really my own intuition, is that obesity is inversely related to pottering.

Pottering has been defined as: ‘to busy oneself in a desultory though agreeable manner’. Pottering behaviour should be largely unplanned, enjoyable, unhurried and diverse. Crucially, pottering does not derive from a work ethic, but from a natural tendency to interact with one’s environment. It’s roots are probably in thousands of years of hunting and gathering.

The habit of pottering has been hard hit by lifestyle changes toward electronic media and industrialisation, and away from localism, arts, crafts, hobbies, games and sport. Home made food is fast going the way of home made clothes.

What is surprising is the lack of a response, either from mental health services or the pharmaceutical industry, to the obesity epidemic. Surprisingly, there is a lack of evidence about what treatment to offer.

As anyone knows who has been on one of those treadmills with a calorie counter, you have to run about a thousand miles to counteract the effects of one Mars Bar. So its hard to see how increased activity alone could be the answer.

CBT does embrace ‘behavioural activation’ and ‘activity scheduling’ and mental health services do employ a small number of occupational therapists. We could begin to rehabilitate a pottering based lifestyle, but we need badly to find a new word for ‘potter’. It’s just too old-bloke-in-a-shed-based. And we need new pottering clothes, instead of tracky-bottoms and cardigans.

So here’s my five point plan:

Pottering should be re-named Freestyle Active Behaviour – fabbing, for short.

Village Shows to be re-named ‘Fabathons’

Stella McCartney / Adidas to bring out a new fabbing range, using a tweed / kevlar fabric mix.

A new talent show, called Britain’s got Knitting.

A new ‘more modern’ penthalon event, consisting of: repairing a stuck window, making a cake, learning the saxophone, growing cress in old eggshells with a face drawn on them and visiting granny.

(Yours may be different).

So far, none of this is evidence based, but neither, it seems, is going to the health centre for a check-up.

28. Removing labels, without toxic chemical solutions.

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Cows are basically hippies.

Who are those people hiding behind the boiler house, just outside the strict boundary of the Foundation Trust premises? Are they common or garden smokers? Are they A and E attenders, who have finished all the books they brought to read while they wait? Or are they escaped but tagged dementia patients?

If you go near them they shy away, like geese, toward a small clutch of untidily parked Fiats and Volvos. Finally, I realise who they are – they are my colleagues who work in community psychiatry.

They are hiding for a good reason though. People are pursuing them, ‘wanting a diagnosis’. And those people are angry.

The history of mental health tends to characterise psychiatrists as predatory. The accepted wisdom is that psychiatrists are part of the forces of social control. Their traditional prey, according to folklore, is a harmless eccentric or political dissident. Their modus operandi is to label these folk with an invented illness concept in order to render them powerless in the eyes of society and the law, so as to drug them or lock them up or both. Such is the myth of ‘anti-psychiatry’.

People used to fear the psychiatrist like a 70s DJ fears the child protection team. But now the tables are turned. Some people are desperate to get labelled as mentally ill. None of my colleagues know why, but they mutter about the internet, celebrities and the drug companies, not to mention the benefits system.

The world seems to have turned upside down, like Twelfth Night. Not as regards boys playing women on stage whose characters are pretending to be men. Rather, more in terms of poacher turning game-keeper.

The story usually starts this way. A short GP letter ending with the words ‘this man thinks he has bipolar disorder, please do the needful’. A patient with a large bundle of papers downloaded from the net. Stating that the description of bipolar disorder fits him perfectly right down to the last semi colon.

The psychiatrist tries to explain that diagnoses are merely conventions about what to call things, that in the UK at least people are rather conservative about the use of diagnostic labels, that labels in their own right can become dangerous and lead to people thinking of themselves in an unhelpful way, even getting stuck in a sick role and benefits trap.

That he doesn’t really seem to have bipolar disorder, at least according to the absurdly narrow conventional diagnostic system that bow tie wearing people in Geneva have written on our behalf in quill pen on parchment.

Finally the meeting ends under a cloud, unless the psychiatrist gives in and recommends a tablet with Q or Z in its name.

It’s tempting to blame our cousins in the US and /or big pharma. There is money to be made from atypical antipsychotics, but only if a group of people can be convinced they need to take them. I have not tried this (Your Honour), but I’m pretty sure atypical antipsychotics and mood stabilisers have practically no street value.

Last time I went to the US I saw some hilarious direct to public advertising for these substances, where the baritone disclaimer tag – ‘may cause impotence, heart failure, convulsions coma and sudden death, take with caution’ – was longer than the advert itself.

I’m not sure why labels are fashionable now. Labelling theory was all the rage in the 1970s and we were all taught not to label people and put them in pigeon holes. Perhaps it started with designer clothes, where the Nike swoosh added $20 to the value of a $2 tee shirt. People who took labelling theory too literally even got tattoos. When we make a diagnosis, we always play it down – we say it’s just a name people give to this type of problem area.

My proposal is that we use a barcode instead. This is a cheap shot, but I think  one or two of my colleagues would be happy to advise people where to stick it.

27. Saying sorry, properly, to Desmond.

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Everything is permitted.

One of the projects that Blue Peter never attempted was to set up your own Truth and Reconciliation Commission. That’s a pity, because a TRC in your own home would be a lot more useful than, say, a separate dining room or garden shed.

Taking the example of South Africa, it looks as though we need three subcommittees: human rights violations, reparation / rehabilitation and amnesty. The first one looks at what went wrong, the second at what can be done to put things right, and the third invites further business from those who want to confess.

It’s worth making some space around the home for the proper infrastructure. Very few people, even catholics, go to confession in church nowadays, and the shortage of mobile priests has led to a decline in the domestic confessional box market. Modern architects wouldn’t even know how to design a priest hole. Most people consequently don’t get much opportunity to take a long look at their behaviour, with the help of a moral philosopher in antiquated neckwear.

Whereas the confession box requires a twin booth, soundproof module with a tiny curtained window – even Homebase seems to have stopped selling them – a TRC unit can be much more transparent and even Scandinavian-looking, in light wood.

The South African prototype required at least 18 people. The domestic version has to make do with a few co-opted members. Its unlikely you’ll get Desmond Tutu, but a distant relative from Canada, or another country with an impeccable human rights record, might be available. Failing that you can try a community psychiatric nurse, mobile hairdresser or peripatetic guitar teacher.

The agenda is to bring to light all the mistakes you have made and the transgressions you have committed; admit you would have done things differently if you had thought about it a bit more and hadn’t drunk so much; you’ll mend anything that you broke, once you get your giro and if there are replacement parts available; and you’ll accept a reasonable penance suggested by the committee.

Something similar has been developed by therapists, in particular so-called ‘Acceptance and Commitment Therapy’ or ACT. Instead of conducting a battle against negative thoughts, ACT helps people forgive themselves for their human frailties in return for a positive attitude toward the future. It looks like an attractive antidote to all the hypocrisy and  finger – pointing we are seeing nowadays.

It’s a bit like confession, but it has to be said, confession has several advantages. Firstly the church has a ‘walk in centre’ approach to confession, so there is no waiting list. Secondly, anonymity is preserved, unlike Therapy, where you will be shopped if there are public safety considerations. And thirdly, the penalties – typically two ‘Hail Marys’ – are really very minor in comparison with those a domestic TRC will hand out, such as taking everyone out to Prezzo.

In confession you are really pleading guilty to Original Sin, but with ACT it turns out your sins are entirely unoriginal.