Monthly Archives: November 2013

42. Staying hermetically sealed outside Primark.

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Recently a golf pro asked me whether I did any sports psychology. The only advice I could think of was the idea of treating every shot as a ‘hermetically sealed unit’.

‘Oh, you mean, the bubble’, came the reply. I nodded. Someone had obviously thought of my idea first –  Professor Woods, I expect.

On reflection though, I like the phrase ‘hermetically sealed’ better. Imagine being able to extract a single item of behaviour from its context. Imagine taking the item into the lab for a while, looking at it carefully, brainstorming the possibilities. And finally taking the shot, just exactly as you have practiced a thousand times.

Breaking down analogue behaviours into single digits is an attractive way of avoiding the effects of anxiety, or other emotions – like sadness and humiliation – found so frequently on golf courses.

The idea of living in the moment is not new, even though the mindfulness brigade have latched on to it. Sure enough, a brief excursion into google reveals a huge literature on ‘The Power of Now’. Forget about the past, forget about the future.

It’s a 6 foot putt breaking left to right on a downhill slope. Take that putt like Leonardo painted the Mona Lisa’s eyes. Give it everything. Make it perfect.

Golf is of course a flawed analogy for life in general, although for some people, golf is life in general. Golf lends itself to a model where a sequence of discrete events, strokes, make up a sum total. The scoring system is numerical and precise. Even better, there is a handicapping system to compensate the less fortunate. It’s the only game with its own system of social security. It’s like getting a GCSE upgrade on the strength of a Doncaster Postcode.

The same system cannot be applied to more complex behaviours where the scoring system is fuzzy and subjective, for instance, telling a joke, or interacting with someone selling the Big Issue outside Primark. Do we make eye contact? Do we say anything? Do we stop? Do we even buy the paper? What do the NICE guidelines say?

Luckily there is a simple tool to help us live in the moment, one that we have all used. I am referring to the Multiple Choice Questionnaire, or MCQ. If we could think of our day as a series of MCQs, then we could really start to focus on the Now.

MCQs have become the stalwart system for exams. They have several advantages, such as subjecting themselves easily to statistical analysis, but the main advantage is that they can be marked by a machine rather than a teacher after pub closing time.

MCQs are best at testing factual knowledge, but they have been developed to test logical reasoning and other skills. Like crosswords, MCQs have their little quirks and habits that students get to know. For instance if it says ‘Never’ or ‘Always’ then the answer is False. Though some events do occur 100% of the time, such as the sun rising in the East, or England losing penalty shootouts, such events do not trouble the world of exams.

There are other quirks. Some questions have one option that is plainly silly. It’s unclear whether these are designed to reveal a stratum of candidates who are also plainly silly, or because the examiners have been a bit lazy creating proper options:

Q) A 20 yr old female is nervous of being focus of attention in public, so she avoids parties & canteens. Develops palpitations, anxiety, tremors during social engagements. Diagnosis is

One answer only.

    a) Panic disorder

    b) Social Phobia

    c)Anxiety disorder with Panic attacks

    d) Measles

The silly option is usually the last one, supporting the lazy examiner hypothesis.

Instead of the silly option, some examiners prefer a twist of surrealism:

Q)  A 22 yr old male is arrested for sexual harassment of a girl & is found to have tachycardia, dilated pupils, hypertension, sweating, increased psychomotor activity, elated mood , pressure of speech & inflamed nasal mucosa. Diagnosis is

One answer only.

    a) Bipolar disorder type II

    b) Manic phase

    c) Cocaine intoxication

    d) Rock ‘n’ Roll

 

The art of turning our day into an MCQ test, may reveal, sadly, that there are surprisingly few choices we get to make. The biggest one is probably between Macchiato and Flat White. In daily life, the silly and surreal options – trying a fish foot spa or keeping a pet iguana – outnumber the sensible decisions. Such is the ‘choice architecture’ in the modern world. The main trick, like thought – catching in CBT, is to identify a decision point when one occurs. Realise there’s a choice to be made and hit it with an MCQ.

But what about the Big Issue itself? How are people behaving outside Primark? Here are some specimen answers I got from the web:

  • The woman who sells it in our village is a thief. She has been in court more  times than i have had hot dinners. The last time she took her child /  buggy into Peacocks and stole tonnes of clothes, using the buggy

 

  • I give them some money, but I don’t take the magazine. I used to give money to one seller quite regularly, and he was a nice guy but he was really  troubled. I haven’t seen him for a few months so I think his situation  finally got the better of him

 

  • So      what makes you think he’s not genuine? Because he’s a tw*t? tw*ts are  homeless too. In fact, IME, the proportion of tw*ts amongst the homeless is far higher than the general population

 

  • I buy the magazine. It sometimes has some interesting articles and interviews, but that’s not what I buy it for.

 

  • ‘To avoid buying it, i once told a ‘Big Issue’ seller that i got it delivered. The next time i passed him, he punched me’

 

It looks as though the silly and surreal options are both included, but which one is which? Try and stay hermetically sealed while you decide.

41. Finding Tannochbrae, and rolling it out.

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The NHS keeps being re-organised. This week we have the new GP contract and post-Francis, a splurge of nurse recruitment from the EU. The feeling is, the NHS has taken several bullets, and if this was an action thriller, we’d be waiting to see if it’s going to fall down or turns out to be wearing a kevlar vest. There’s a kind of impasse as people wait for the inevitable closure of smaller hospitals, walk-in centres and stagger-in centres, aka A and E.

The worst way of re-organising an organisation is to consult widely, sit down with ‘stakeholders’ and listen to experts. Instead, we need to reach down into the collective consciousness and find the archetypes of medical practice. We need to find the icons and copy them and work backwards from there. For medicine, we need to look no further than historical medical TV drama to find out how things ought to be, and in particular, the 1960’s shows, Dr Finlay’s Casebook, and Dr Kildare. This is what we should be reading:

‘The new general practice contract is more prescriptive and detailed than people expected. It looks as though there are going to be two doctors in each practice – one old and one young. Both must be Scottish. Only one other employee is mandated, an older female ‘housekeeper’, ideally called Janet.

The doctors must not be married. Beyond a telephone they will not use any modern form of communication device. The younger doctor must keep up to date and introduce anything deemed new-fangled. The older doctor must act as mentor and companion to the younger, specialising in wisdom and wry expression.

Although comparatively wealthy, both doctors should espouse a liberal stance and champion the disadvantaged. Both of them should know their way round a microscope. At times they may use a Motor Car to visit patients in their own homes’.

The model for hospital doctors is slightly different. Whereas the two Scottish GPs are brimming with lifestyle advice – such as proper fish filleting technique – the hospital team’s job is ‘to keep people alive, not to tell them how to live’. The hospital also uses a team of two, again an older and a younger man, but this time they are American. Both of them look good with stethoscopes and know their way around machines that go beep.

In all cases, tweed is de rigueur, no suits.

Both in general practice and in hospital, the teams will need to fight against rogue practitioners. In the community this is likely to be a toff, who works single handed, mainly in private practice and drives a Bentley. For some unaccountable reason, he has something of a way with the ladies. In hospital the main enemy is an autocratic character who calls himself The Chief. He’s in the board room far too much and never in the operating theatre. The ladies don’t like him, apart from one sycophantic, sado-masochistic type.

Both teams like a lot of background music, favouring lavish strings arrangements. But whereas the GPs prefer a jaunty tempo, in hospital it’s strictly andante, to match the steady flow of trolleys down corridors, with tubular bells on the offbeat.

Jeremy Hunt, you used to be culture secretary, so you know all this. Finlay and Cameron would never have sat around on clinical commissioning groups or attended team building workshops. Finlay would never have gone on about strategic aims and driving down operating costs by standardising the infrastructure. If Cameron had to say something like, ‘we need to front-load the front-loading’, he would at least deliver the line in a huge theatrical splutter.

The archetypes are a little different for psychiatrists, being found mainly in movies. These have been well documented in papers such Theory and Practice of Movie Psychiatry, by Irving Schneider.* The actor Patrick Stewart turns up in two pivotal roles along these lines, first as the decent-sort consultant Eddie Roebuck in Maybury, and much later on, after several years in space, as the evil Dr Jonas in Conspiracy Theory.

In the latter role he offers a poor model of practice, specialising in finishing off the survivors of a brainwashing assassins program. Though there are no NICE guidelines on brainwashing, and how to handle it when it goes wrong, Jonas probably missed the short medical ethics course at the end of year 5.

It’s likely that the new template for mental health practice will be more like this:

‘The psychiatrists, who are brothers, seem a little fussy and pompous but mean well. To compensate for limitations in his interpersonal skills, one of them runs a local radio show where patients can phone in, so that the whole community can benefit from his wisdom. For background music, it’s strictly jazz.

Jeremy Hunt, these are our heroes, not the Kings Fund, nor NHS England, nor the Nuffield Trust, nor the CQC. As culture secretary you were the one person in the country never to watch UK Gold, but now it’s time to catch up.

*Am J Psychiatry. 1987 Aug;144(8):996-1002)

40. Holding’em, folding’em – or going nuclear.

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A man must know his limitations.

Some days you’re the windshield, some days you’re the bug, according to Mark Knopfler. When tackling a large outfit like a utility company, be assured, everyday you’re the bug. And when tackling the NHS, they are the Louisville Slugger and you are the ball, as Mark would put it.

Sometimes it pays not to fight on too many fronts at the same time – just ask Hitler.

One of the battles not to fight is with a large corporation. Private or public sector, it doesn’t matter, don’t tangle with it unless you have unlimited resources, a firm of lawyers and preferably an enforcer who works through ‘unofficial channels’ e.g. by re-arranging peoples kneecaps. And I don’t mean an orthopaedic registrar.

For example, though I should know better, I am locked in a pointless battle with Ovo Energy, which will only end one way. Every time they read the meter they record the night as day and the day as night, essentially adopting the world view of  a nocturnal creature. They purport to be a green outfit, and I suspect they are trying to be fairer to owls and badgers, who cannot at present benefit from Economy 7.

Large organisations are groups of thousands of people, with massive resources. You are one person with very little time and money, even if Erin Brockovich is your favourite movie.

There are several ways that people get hurt when they interact with large organisations, but the main effect is that of learned helplessness. Even Kim Kardashian can’t get British Airways to accept they have taken items out of her bags. Veteran complainer Clive Zeitman resorted to sending British Airways’ mouldy strawberries to their CEO by courier service*. As a result his daughters were invited to Heathrow to inspect the catering facilities. Personally I’d have suspected they were walking into a trap, like Clive might receive them back, also by courier, but not in one piece.

You might get an apology – but does an apology on behalf of a vast organisation actually mean anything? Customer relations usually frame an apology in a twisted way like ‘We are sorry that you feel unhappy and dissatisfied with our service’. The implication is that your feelings of unhappiness and dissatisfaction are your problem and relate to poor early life experiences.

They might as well add, ‘we hope with adequate therapy you manage to resolve your issues with your over-involved yet emotionally detached  mother.’

You might get carried away and become a single issue fanatic and pub bore. The organisation might even have you designated a ‘vexatious complainer’, which means they acknowledge your letters but don’t otherwise respond to them (no change there then).

And finally, having gone too far, having got personal with some hapless call centre employee, having bogged yourself down in nitpicking details, you are consumed with guilt and remorse and you realise you have turned into a monster. For instance in suggesting that there is really only one essential item in the meter readers’ toolkit of skills.

Worst of all, it might turn out you were wrong all the time. I have checked that meter so many times. I have taken photos of it and mailed them to Ovo. My dream is to get an eminent person – Desmond Tutu would be ideal – to visit the house during the day and observe the meter’s steady advance as I turn on all the appliances, then sign an affidavit as follows: ‘I Desmond Tutu, Archbishop and veteran human rights campaigner, winner of the Nobel peace prize in 1984, solemnly confirm that Reading One is Economy 7.’ How you like them eggs, Mister Ovo? [ovo=egg, gettit?]

Instead of signing, Desmond would probably advise me that the relationship between the strong and the weak, the big and the small, is far more complicated than a simplistic perpetrator / victim scenario. Butterflies should take care not to break the wheels.

As a participant in Capitalism, which is the only game in town, it is better to regard yourself as playing a game rather than conducting asymmetrical warfare. The paradigm of gaming means you choose your opponent wisely and play when it suits you. If you lose, its only a game (sucker).

Why do people hate large organisations so much anyway?  Perhaps there’s a limit to the amount of ‘putting you on hold’ people can take, even with Vivaldi in the background. It is very difficult, even for an able -bodied, able-minded person, to penetrate the ‘choice architecture’ that creates a force field around organisations. How difficult must it be for a person with impaired abilities to deal with ordinary issues like trying to minimise energy costs?

Is there such as thing a Corporate Psychiatrist? I don’t mean a psychiatrist who wears a smart suit, drives an Audi and carries a Blackberry, because there are none. No, I mean someone who can diagnose and treat ailments that affect large companies.

For instance, the power companies suddenly became incredibly unpopular and possibly evil.  Could that be seen as a kind of disease process? I have a friend who works for an energy company, who assures me the industry is not evil, not particularly profitable and not guilty of the various price-rigging allegations that are being promoted in the media. He hasn’t tried to sell me any energy yet, but I accept he might be working a long con.

My theory is that society has a certain quantity of Stigma within it, which is probably a constant total. Now that Stigma cannot legitimately be attached to disability or minorities, it has had to go somewhere, and seemingly it attaches itself to arbitrarily and lazily designated villains-de-jour, such as banks, newspapers or power companies.

If there is hope, it probably does not come in the form of EDF, but I am hoping that nuclear electricity will boil my kettle faster, so I am changing over. We are heading toward judgement day for the meter, as two giant companies slug it out in the cellar. Desmond, you could have stopped this.

https://elt.oup.com/elt/students/englishfile/dyslexicfriendlytexts/ef_int_reading_8a.pdf?cc=us&selLanguage=en

39. Dropping hammers, more carefully, onto mobile devices.

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Do you wake up sometimes, look into the middle distance through the dull overcast November weather- 10 degrees Celsius, wind speed 9mph, 50% chance of rain – and wish that things were just a bit more extreme?

On the one hand, political correctness limits what can be said or done on the traditional left and right of the political spectrum. On the other hand, some religious factions – you know who you are – have ‘gone off on one’ with terrible results. Single-issue campaigning represents a window of opportunity, but even the most popular campaigns, against badger culling and wind farms for instance, tend to lose traction.

Shouldn’t Brian May be more concerned about bringing out a brilliant solo album, people ask? Shouldn’t any form of electricity be gratefully received, taking form, as it can, as light, music and warmth?

As the day goes on, opportunities to do anything extreme are surprisingly limited. True, Ladbrokes seems to be open all hours, but some kind of pheromone operates to keep people out. There is no fragrance called Loser.

One of the easier outlets seems to be Sport. It’s not uncommon to see someone running several miles before breakfast. It’s not unusual to see a cyclist powering his way round the peak district. Most of us would be exhausted just putting on the Lycra. Let alone even consider proper extreme sports, like snowboard chess and water cribbage.

The psychological roots of extremism are probably highly varied. One likely culprit is the mechanism of Denial, where the mind tells Reality, quietly and firmly, to shove off. It’s the mentality that puts a cup cake display on the gym reception counter. (Yes you, Hilton by Doubletree, Chester.) It’s the approach that leads to dropping hammers on mobile phones to test their durability. As though Isaac Newton had never existed.

Most people with Depression or other mental health problems resort to extreme therapy at times. In fact there’s a massive history of ‘heroic remedies’ in medicine, mostly deriving from the (bogus) four humour system, which ran for nearly 2000 years, from Galen to Beyoncé. Favourite approaches included purgatives, bleeding, cupping and cautery. I’m not sure what cupping was and I’m too squeamish to look it up. People still do ear-candling, which sounds similar, and this could lend itself to extreme versions, now that we have petrol.

The military have contributed enormously to extreme thinking. They have highly disciplined physical training programs, but also extravagant headwear, like the Busby. The military tend to suffer from PTSD, which is an extreme type of anxiety disorder, and they favour gung-ho treatment options, like eye movement desensitisation, instead of the gym and cupcake regime preferred by anxious civilians.

Treatments for mental health have of course taken extreme paths at times. Insulin coma and ECT are two obvious examples in terms of physical treatments. There are still psychiatrists who get fanatical with antidepressants. While most people with Depression struggle to get even adequate drug treatment, there is a small group who get battered with mega doses and multiple combinations that would leave the NICE guidelines in tattered shreds and probably smouldering.

Psychological treatments have also got extreme from time to time. For instance Primal Scream Therapy, which led to John Lennon’s worst album. And Flooding therapy, where phobias are treated by facing the feared item full on (one of the few occasions when tame spiders have found useful employment.)

More recently we had so-called ‘Assertive Outreach Teams’, who visited you whether you liked it or not. Like the doomed squad in The Wild Geese (ditto Clear and Present Danger), Assertive Outreach have been abandoned by HQ and stood down, with some still behind enemy lines.

Most people have a little voice in their ear that says, ‘I wouldn’t do that if I were you’. It’s enough to stop ordinary impulses, like pressing Amazon’s very frightening ‘buy with one click’ button, buying anyone’s second album, or biting a green chilli. It would be nice to have a health advisor along similar lines, possibly in the form of a mantra or an app. Luckily, there are warning labels everywhere, like the one that says not to put cigarette ends in your petrol tank.

CBT gives us a framework to collect our thoughts and examine them from different perspectives. CBT will tend to reduce extreme thoughts and move them back towards a sensible perspective. As such one criticism of CBT is that, if implemented on a massive scale, it could bring about a very bland society. Someone will say, not Tony Blair this time, that there are three basic values – moderation, moderation and moderation.

In which case how will resistant depression get treated? And who will seek out and follow up our reluctant service users? Above all, who will test our phones against the laws of physics?