Monthly Archives: September 2013

34. Calling International Rescue. Discreetly.

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After an extensive rebranding exercise, the chief executive is announcing a brilliant new name for the mental health service. ‘We are going to call it…’Emotional Rescue’…’  The applause is more muted than expected and there is muttering. Someone whispers to let him know it was a Rolling Stones album, and not one of the better ones, flirting a little too closely with Disco.

David Miliband has made a similar mistake in agreeing to be head of International Rescue. Doesn’t he realise he or his brother must spend half their time in space, monitoring all the radio frequencies, just in case there is a distress call?

Imagine just popping out into space for a cigarette and while you aren’t watching there is an earthquake or motorway pile up. How let-down would people feel? This never happened to the Tracey brothers –  puppets never need the bathroom.

The notion of being rescued, of someone watching over us, is a favourite one in fiction, popular culture (superheros) and religion (saviours). The gold standard for benign oversight is the catholic concept of the guardian angel. The nuns taught us we had one each.

Could that explain why some people seem very lucky? And might some guardian angels be better than others? Is each one newly created for each human, or are they deployed like the police, in a largely reactive role? Do they have a team leader, like social services, who will be vilified in the celestial media in case of a guardianship faux pas?

Do they confine their advice to moral matters, or would they for instance, stop you from buying shoes a size too small because they were in the sale, or attempting to hit a 3 wood out of a fairway bunker?

Might they have served other people in the past, like Kevin Costner’s character, Frank, in The Bodyguard? Don’t forget, last time Frank had a day off, Reagan was shot.

What a shame the real life Whitney Houston didn’t have such a person looking after her. Celebs seem to get much worse mental health care than ordinary folk. Perhaps it’s because they are surrounded by sycophants and parasites, rather than loyal and heroic servants.

Think about it. Say what you want about the NHS, we would never have gone round and given someone with severe insomnia a propofol injection, as happened to poor Michael Jackson, not even on a weekend shift.

I shudder to think what might have happened if Michael Jackson had been an NHS patient. In the USA a doctor was tried and convicted of involuntary manslaughter. In the NHS there would have been a serious incident inquiry lasting years and finally releasing a 9000 page report, criticising practically everyone involved, with particularly scathing mentions for Martin Bashir for his interviews, and Paul McCartney, for disputing  whether ‘the girl is mine’.

So many missed opportunities to prevent a tragedy. All those cosmetic operations. The accusations about children. That tea party when Bubbles took things too far. The controversial version of ‘They don’t Care about Us’. Where was the inter – agency working? Where was the properly completed Risk Assessment?

Where should celebrities turn when their lives get out of control? If they are lucky enough to be in a government or large corporation, there are people who can look out for them. In particular, people who can manage publicity and pull strings. There are lawyers and personal assistants, special advisors, coaches and trainers. Imagine having someone who comments on your actions very favourably and sends a glowing account to the media. How long would it take you to believe your own publicity? Not long in the case of people already prone to narcissism.

However many people there are in a ‘support network’ there is often no-one there when you really need them. Michael Jackson even had a full time personal physician present in his house, yet still died.

It takes a massive effort to be there for someone 24/7, which is why we invented the guardian angel, and why Trusts use grandiose titles like Crisis Teams to describe one bloke and two phones.

People who have the so-called borderline personality like to test the rescue services, both metaphorically and literally. You find out who your friends are when things go wrong, so why not test them out in advance, like a fire drill, by putting yourself in danger? Is David Miliband listening or not? This should get his attention…

Maybe NHS Trusts should set up special teams to protect celebs from the evil clutches of corporations and private healthcare.

At present, celebs with problems seem routinely directed toward spells in what gets called ‘rehab’. This means being admitted to an expensive private clinic, focussing on detoxification and abstinence programs for addiction.

No-one ever criticises such approaches as misguided or ineffective. When a movie character says, ‘I’m checking you into Rehab right now,’ no-one ever responds, ‘but the outcome after a year is no better than a control group who just see a counsellor’. It’s just not drama.

Residential drug misuse services are seldom provided in the NHS, because the cost benefit analysis for such treatment is very unfavourable. Perhaps showbiz types take a different perspective. They want a proper emotional rescue, not cosy chats, pottery and yoga.

Celebs never seem to get a social worker or CPN or get to attend the allotment project. They never seem to get taken shopping, by health care assistants, or make mosaics from broken car window glass.

There is an increasingly large gap between inpatient services like rehab clinics, and the next rung down, which is an appointment once a week in converted premises above Poundland. There is very little mental health care provided within the night-time economy, just the usual haunts – police station and A and E.

It’s comforting to imagine that an outfit like the A team or International Rescue would come and help you if you hit a downward spiral. That is perhaps why the ambucopter service attracts a lot of charitable support. It’s there when you need it – you hope. But should we have to put money in a pub collecting box to pay for the ambucopter, when we are paying £3.15 for a pint, most of which goes in tax?

Since tax on alcohol amounts to nine billion pounds annually, almost 2% of total revenue, perhaps we really could afford more Emotional Rescue, and even buy the phrase off Mick and Keith.

Just in case the Crisis Team needs more staff at night, i.e. more than one.

Just in case David Miliband is in the space station jacuzzi.

Just in case the nuns were wrong, and your angel can’t really fly.

33. Unfolding tragedy and putting it away nicely.

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The hideous smirk of the wasp monster.

A child’s eyes grow wide as he is handed a massive ice cream with a chocolate flake in it. Only to grow wider still as the handover is fumbled and the ice cream falls to the ground. The ice cream and cornet fall apart and roll in different dusty directions. The moment is too tragic for anyone to bear.

Further down the High Street, a teenager’s Iphone 5 falls from the shallow pockets of his hipster jeans, falling on concrete and smashing the glass front. His social network is shut down and his life is now officially ruined.

Even further along the same road, a girl who has borrowed her sister’s slightly-too-big stiletto shoes  stumbles on a tree root the council have tried to cover over with flexible tarmac, breaking the shoe heel and spraining her ankle. Her big heel days are over and thus she now has no chance of attracting a suitable partner.

Life is just a series of accidents waiting to happen. And noxious events are associated with getting depressed. People who suffer adverse ‘life events’ seem more likely to suffer from a variety of health problems, including depressive episodes. This led researchers to try and measure such events using rating scales. For instance the Holmes and Rahe Scale gave a numerical score to various life changes, divorce for instance scoring 73, getting fired scoring 47.

Interestingly, supposedly positive life events like marriage (50), marital reconciliation (45) and outstanding personal achievement (28) also were associated with Depression.

Later on life events scales were refined by allowing for context, which also made them a bit subjective and unwieldy, compared with a checklist.

Further on it was argued that certain people were predisposed both to exposing themselves to adverse events and getting depressed. So the relationship between adversity and mental health was less causal than it might seem.

Either way, whether we are accident prone or unlucky, surely if Depression is associated with ‘hardship’ it would pay to make people tougher?

In an earlier era of psychology experiment, scientists tested the pain thresholds of various cultural groups. A unit for measuring pain, the dol, was developed, by applying a hot thing to a subject’s skin.

One experiment attempted to calibrate labour pain in dols, by applying the hot thing to the subjects hand, between contractions. That’s a bit of a departure from the sort of birth plan the National Childbirth Trust would recommend .

This tells us mainly that scientists and their subjects were much tougher in the mid twentieth century. But were they also a bit dumber?

Everyone knows about the Milgram experiment in 1963, where people seemed strangely willing to obey an authority figure who told them to give electric shocks to subjects.

The findings went with the grain of sixties liberalism – that we all could be monsters, given the right circumstances. Following this vibe, Milgram merely found what he was looking for, seemingly cooking the method to get the outcome he desired.   Milgram’s work has been debunked*, but nevertheless will live on for all time in a zillion Social Science for Dummies textbooks.

Much like another favourite, the Rosenhan Study, the one where non-ill researchers admitted themselves to  psychiatric hospitals like mystery shoppers and were all found to be psychotic. The results were grossly exaggerated but enjoyed and endlessly propagated by those who would debunk psychiatrists, which is most of us. At least we are always on the lookout for mystery shopper style researchers.

Maybe the world of academic psychology in the 1960s was just a very tough period in history, like the wild west, or the Roman empire. People got up in the morning fully expecting senseless violence and thought nothing much of a little light electrocution before lunch.

So if they had the dol unit in the 1940s, it would probably have been affected by grade inflation over the years, or even completely re-valued, like the French Franc in 1960, where 100 suddenly became 1.

Help is at hand in the form of Resilience Coaching. If we could do to the Holmes Rahe Scale what France did to the Franc, then we will laugh away tragedy as minor inconvenience.

However, from an ergonomic point of view I’d still like to see a complete redesign of both the Iphone and the ice cream. The ice cream should be shaped more like the phone and vice versa.

Heels are more difficult, but I’m thinking if the Niqab gets banned by parliament could challenging shoes get included in the legislation?

*Behind the Shock Machine, the untold story of the notorious Milgram psychology experiments, by Gina Perry.

32. Picking and Mixing with the Mules.

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It’s not cool and it’s not clever.

Aren’t we funny about taking tablets? Some people just refuse to admit they are biological machines run by small computers made of gloop. We are quite happy to have additives in petrol, but not in food, unless you call butter, sugar and salt additives, which you would if they were called by their chemical names.

Nevertheless, when Pain is the issue, most people are fairly quick to give up grinning and bearing it. Suddenly alien molecules are allowed into the body. And in the case of opiates, not just allowed in, but given the full red carpet treatment.

I’ve been speculating a lot about pain this week, thanks to my foolish attempt to test the limits of the sacral disc mechanism. (Is that quite a good name for a progressive rock band?) God was clearly having an off day when he drew this part on the celestial white- board. Perhaps he was going through an ‘organic’ phase, knowing deep down he should be using neoprene and titanium for load bearing surfaces, and proper grommets instead of cartilage.

We can’t change our spinal parts, but we can get painkillers from Wilko.

It’s interesting what pharmaceutical products you can find in a hardware store. All the inconsistencies of the so called war on drugs present themselves along aisles 5 and 6.You can buy two packets of aspirin or paracetamol, but no more, in case you take an overdose. The rule does not seem to apply to Ibuprofen though, and certainly not to other tablets which are not painkillers.Just across the shop you can buy any amount of Evo – Stik, Meths or nail varnish remover, not to mention turpentine. Possessing and inhaling solvents is not illegal and never has been.

Similarly not illegal, some of our patients take what are called ‘legal highs’. The current favourite seems to be ‘Clockwork Orange’ which I am told costs £10.95 a sachet and can be added to tobacco.Most people who tried it seem to have become violently sick, much like the effects of tobacco itself, only exaggerated.I looked at the wording on the packet- poor quality graphic design by the way – which says not to consume it at all, it is a ‘research chemical’. This obviously appeals to a sizable minority of drug users who like to experiment, usually without getting permission from the ethical committee and seldom sticking to robust methodology

.I think I can trust most of our patients not to take it, but what concerned me most was that many of them did not know Clockwork Orange was a book and a film. That’s why we need psychiatrists from my age group, so we can explain the cultural background properly, including how Stanley Kubrick had the film taken off the market for a long period for fear of copy cat violence. Probably the drug will go the same way. Maybe one day it will turn out to be a useful remedy for migraine or piles and stage a comeback

.Meanwhile, for only 36p, thirty times less than Clockwork Orange, you can get 16 Ibuprofen tablets. They are foil wrapped, mint coated and come in a nice carton with tasteful graphic design and a better instruction leaflet than you get with a Sony TV. I’m tempted to photograph the packet lovingly and put it on ebay. Would that make me a drug dealer?

Supposing opiate painkillers like Tramadol or Morphine were on sale in Wilko for a similar modest price – what would happen? Would everyone become an opiate addict within a few weeks? To some extent this is the question that needs to be answered by those who seek to legalise drugs.

One of Thomas Szasz’s better works was: ‘Ceremonial Chemistry: The Ritual Persecution of Drugs, Addicts and Pushers’. One of his arguments was that certain cultures had learned to deal with opiates and used them medicinally and recreationally while still holding down jobs and families.This has probably not happened yet in Rotherham, so we could expect a learning curve if Wilko suddenly turned into a Head Shop. And by learning curve I mean spates of car accidents, marital breakdowns and people getting fired.

What would happen to the NHS if Opiates were freely available? Would we even need the NHS at all if we could get Tramadol from Poundshop, instead of behind Poundshop? Which section would Wilko have to delete to make room for extra tablets? Already it’s quite a nuisance that the gardening section disappears in September to make room for an aisle of Christmas tat.

We could easily lose the pick and mix selection. Light-bulb moment! What about a pick and mix section for drugs? Like we have in the NHS. You read it here first

.All drugs are just molecules, whatever the effects they might have on the human body. Some are poisonous, some are illegal, some are helpful, some are  more or less inert. Some are called over the counter, some are called prescription, some are called controlled. Some are called research chemicals and some are called plant food. Some are just called glue. If the molecule gets a hold over us, it’s a power we have bestowed on it.

There is a kind of market for drugs, artificial to an extent, and distorted by the way compounds are treated by the authorities and tradition, but the likely premier league would consist of the old favourites – opiates like heroin and psycho-stimulants like cocaine.

As far as Depression goes, all these are off limits, being gigantic holes to fall down.Life is a battle against adversity and these substances – unlike Chateauneuf du Pape and Theakston’s Old Peculiar –  are classed as chemical weapons.If Wilko seriously try putting these on sale they can expect a surgical strike from the US air force, or at least a visit from Kofi Annan.

I think he’s more of a Waitrose man to be honest.

 

31. Paying homage to the Empathy Police.

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By all means grab it by the stem and de-root it, but be careful to bend properly at the knees. Above all don’t feel sorry for it.

How did that make you feel?

A question asked by a million news and sports reporters, usually following a tragic or catastrophic moment, such as falling over the first hurdle in the Olympics, having trained for 4 years day and night.

Most people don’t have, or need to have, the kind of vocabulary to describe their feelings on these occasions. The correct British response is to massively understate any emotional effects of such an event, such as saying you were slightly disappointed but otherwise had a very nice day.

A little like Abraham Lincoln’s wife’s theatre review.

Now the idiotic question beloved of crap reporters everywhere, may be asked by surgeons, misguidedly trying to improve their approval ratings: How did you feel when…(you found we had removed the wrong kidney and left two swabs and a sandwich inside you?)

We know that empathy plays a massive part in the quality of relationships. We know it plays a key role in psychotherapy. We also know that some people have very non-empathic personalities, but that doesn’t always stop them from becoming surgeons, or even psychiatrists. It doesn’t even stop them from attempting to run workshops in emotional intelligence.

Can empathy be learned? What’s your instinct on this one? Having attended (at gunpoint, it must be added) occasional ‘workshops’ designed to improve EI, I would say not. If it’s truly a type of intelligence, which is debatable, then it’s pretty unlikely to change much. Otherwise, why call it intelligence? Asking this question during each workshop made me feel unpopular, maybe hated, I wouldn’t know.

Take this sentence from today’s Times newspaper:

‘Its not very difficult to ask the question next time I have a consultation, ‘How did that make you feel?’ which just makes you a better doctor’.

This question is described as a ‘cultural signifier’ to patients that doctors were taking them seriously.

In the same article we learn that last year the number of ‘serious medical blunders’ doubled, so that there were 299 ‘never events’ such as surgery on the wrong body part. These events illustrate the real meaning of carelessness, which is entirely different from feeling you are not being taken seriously.

I know that these remarks are probably misquoted and taken out of context. Perhaps the person quoted, Prof Ben Bridgewater, is the most empathic person you could ever hope to meet.

Nevertheless, I am lost for words to express my feelings about his remarks, save for the usual, though rather dated rejoinder, ‘beam me up Scotty’.

In fact, quite large numbers of doctors are following the bumble bees and are returning to their motherships. They didn’t join up on the basis of competing against colleagues in a league table, nor do they wish to collect tons of bogus documentation to run past the GMC every five years. So we are set to lose a large number of valued part time and older colleagues, much as we lost a whole generation of experienced ‘old- school’ nurses (and some old school-nurses) when PREP started.

When surgeons start facing the Empathy Police I fear many of them will hang up their gowns and wellies.

All this matters this week because I have hurt my back. In what I now know should be called a ‘never event’, I tried to lift something very heavy in the garden, and felt ‘something go’, way down in the lower sacral spine.

In fact I am not looking for any empathy at all on this one. Not even genuineness, warmth, or unconditional positive regard. I’m hoping not to have to fill in any questionnaires or rating scales. I don’t want the transference or counter transference interpreted.

Also, I don’t want to be taken seriously – lets keep it light should we?

In fact, I’d prefer a rather brusque and disdainful approach. After all it was pretty silly doing what I did. I really wasn’t following my own advice at all, which is to limit gardening activity to occasional chemical warfare against insurgent weeds, backed up by sound diplomacy.

So really, a telling off is fine. But what I want to obtain is a reasonable armoury of painkillers and ideally, an encounter with some kind of scanning machine.

And if I’m asked how I feel I will say I am slightly disappointed.