Monthly Archives: November 2014

76. Keeping in with the in-crowd, going where the in-crowd go and knowing what the in-crowd know.

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An item from the new ‘dysmorphophobia’ range at John Lewis.

It’s November 25th, a slow news day, so an announcement is made that young people with Depression will be treated with apps. That’s no more true today than last month or last year, but apps are now the way forward, rather than electrofolk workshops.

Every time these announcements are made, which is monthly, for some reason Nick Clegg, deputy prime minister, mentions three things; that mental health remains ‘in the shadows’ – again failing to add the obvious quip ‘like Hank Marvin’, that antidepressant tablets laid end to end would now reach as far as Neptune and that ‘1 in 4 of us’ will suffer mental health problems. The question is, why 1 in 4, rather than all of us?

After all, mental health problems are not sharply defined entities at all. Most of them shade into normality along a spectrum, so that we can draw the line between cases and non-cases anywhere we want, from 0% to 100% of the population. Would anyone – even a politician – ever say that 1 in 4 of us suffer from physical illness, now or during our whole lifetime?

Statisticians like to set the cut-off points for illnesses a certain number of standard deviations away from the mean, giving rates like 32%, 5% or 0.3%, depending on how far north of London you want to start calling it The North. This is why most artificially constructed illnesses have those rates. There’s no need to go from door to door sampling people, if you set an arbitrary cut-off point in the first place. Someone described epidemiology as ‘counting swans on the lawn’, but in reality it is much less complicated than that.

The answer seems to lie in a complex calculation about ‘otherness’.

If we make something look too alien, then it will be categorised with all the other rare diseases with pseudo-Greek or exotic names. That gives it kudos, but it’ll  have to compete for interest against names like Von Recklinghausen’s disease and Blackberry Thumb.

If we make it look too common, then people will say it’s just part of life and why don’t they deal with it like anybody else. But – as presumably dreamed up in PR, since there is no evidence to support a 1 in 4 lifetime incidence figure – if we make it 1 in 4 then we probably don’t have it ourselves, but the bloke two doors down almost certainly has it. Presumably the intention is to create a ‘there, but for the grace of God’, feeling, that would send me two doors down the street with a basket of fruit and a compilation CD of eighties power ballads.

I have serious doubts whether the 1 in 4 strategy will work, either in terms of reducing the stigma attached to the fourth person, detecting cases, or promoting treatment. The precedents for 1 in 4 type disorders are not good, if we think about Obesity, Smoking, Diabetes, Backache, or Alcohol misuse. All of these are both common and stigmatised. In fact I would argue that 1 in 4 disorders are the ones that are the most stigmatised of all, the sufferers inevitably regarded as the authors of their own misfortune.

Like the extras included in a Star Trek landing party, someone with a 1 in 4 disorder knows they are going to die soon, but only because they will make stupid space mistakes, the kind that Scotty or Bones would never make, like handling dilithium crystals without oven gloves or forgetting to charge the cloaking device.

This phenomenon gave rise to the term ‘red shirt’, meaning a fictional character who dies soon after being introduced. 73% of the crew killed in the original star trek series wore red shirts, something lost on the UK audience who mainly watched in monochrome.

Rather than assuming a ‘grace of God’ scenario, we conclude that this would never happen to us. We are main characters in our own minds, not extras.

There is nothing about 1 in 4 that protects against ‘otherness’. Its roughly the proportion of people who vote for one of the main two political parties. It’s roughly the proportion who watched the return of Dirty Den to Eastenders. It’s a number that can get killed in the worst civil conflicts. I in 4 can be a highly divisive ratio.

And it’s just a ratio that no-one wants to be part of, as opposed to say, the three in a thousand who might get Blackberry Thumb.

If mental health problems really affected (as few as) one in four of us, and we were all detected and referred for treatment, even if we only were ill for a short time, that would still overwhelm the mental health system, but it would not overwhelm the massed ranks of smartphones and tablets. Some accounts suggest that as few as 1 in 4 people don’t have devices that could run apps. What a coincidence!

As Bryan Ferry put it, you want to be in with the in crowd and go where the in crowd go. As far as the song went, this meant knowing how to have fun. Fun, like therapy, is very hard to find. But it could mean playing a party app on your Nokia, so you don’t have to actually go to it, which is what social media have done for us. Inevitably, social media will become the new group psychotherapy.

Imagine an in crowd that included 25% of the population. Statisticians wouldn’t trust it and Bryan Ferry wouldn’t join it. On the other hand, it’s a number Nick Clegg’s party, the Liberal Democrats, can only dream about now.

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75. Feeding jokes and riddles into Multivac.

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Because I’m worth it.

 

Obviously I can’t say anything about it, but I’ve been on Jury Service. I’d love to tell you all about the case but I can’t. Suffice it to say, as a spectator experience, this beats soaps and reality shows and probably boxing too.

There are some things I just have to write down. There’s a lot of time hanging round in the jury waiting room, which is about as comfortable as a Ryanair departure gate. Though they do have daytime TV, it keeps being interrupted by the How to Be in a Jury DVD. Luckily one of the ushers is a stand up comedian and keeps popping in to try out material on the captive audience.

For some reason, jokes, like dreams, don’t seem to bed themselves into the memory banks very well. When it’s time to remember a joke to tell, the memory just vanishes. Isaac Asimov based a whole short story, ‘Jokester’, on this premise, concluding that jokes were part of a psychology experiment carried out by aliens.

This time I resolve to write them down straight away.

A man comes into the doctor’s surgery.

‘Doctor, I think I’m a moth’.

‘You really need a psychiatrist rather than a GP’

‘Yes, I know, but your light was on’.

No-one laughed apart from me. That’s a bit worrying, since the jury is one of the very few occasions where a random sample of the population has been assembled. Is my sense of humour, statistically, a bit odd? Everyone seems very normal, at least compared with the people I normally meet. Perhaps they have heard it before, or perhaps its because I like psychiatrist jokes more than the average person. Perhaps I am tuned in to contrasts: here’s an ultra sober setting, a Crown Court where people are being tried for sex crimes and murder. And here’s one of the court officers, dressed in a gown, telling gags. Humour often arises out of adverse situations, but why exactly? Why do people make sick jokes about Princess Diana or Fred West?

The usher announces further delays. We see one of the judges arrive in his Impreza and a flunkey goes out to open his door and hold an umbrella over him as he walks five yards to the court entrance. That would never happen in the NHS, not even for Lord Winston.

A man comes into a doctor’s surgery.

You should know I’ve got a rather unusual congenital problem

Tell me more about it

I was born with five penises

Hmm. That must make it difficult to get your trousers on

Actually, they fit… like a glove.

 

I laughed more than the others again, but I like stand up and even pay to see comedians live, which probably places me in a small minority of the population.

The usher pauses ever so slightly between the words ‘fit’ and ‘like’ in the punchline. For some reason that bit of timing is critical in adding humour, the split second somehow priming the laughter pump, like turbo lag. As he finishes the last line he turns and swoops out of the room in a grand exit.

Jokes and dreams. Why can’t we remember them? Is it a lack of concentration, which stops us filing them away properly, or do they just belong to a different part of the brain from the usual memory, like singing uses a different system from talking? Is there an equivalent of a Save command in the memory system, that somehow doesn’t always get pressed?

There are many psychological theories about joke memory, including a rule that the very best jokes are the most difficult ones to remember. Maybe it’s because jokes are inherently discordant and can’t be processed into patterns. And perhaps humour offers a defence mechanism against discordant experiences, like horrific crimes.

I have a friend who races snails. He takes it very seriously. In fact he has one extremely fast snail that he enters for national competitions. For the snail Olympics, to make it even faster, he decided to improve the snails power to weight ratio by removing its shell. After this, it won its next race easily.

I asked my friend how he felt about it.

He said, great performance, although somehow… just a bit sluggish.

I’d like to think that a sense of humour is an asset in working with people with mental health problems. I used to think it was a moral imperative to state a witty remark if it happened to come into your mind. Nowadays though, especially with regard to some people’s interpretations of political correctness, the smart move is to keep it to yourself. No-one would be allowed regular comedy slots in an NHS department, not even dermatology. Even though you can buy a book called ‘The best ever book of dermatology jokes’ on Amazon.

Here’s a joke I found sent into a forum. You are meant to answer the question: Why does no-one trust a dermatologist? The answer is supposed to be ‘he keeps making rash decisions’. Instead someone has responded, in capitals:

BECAUSE THEY SAY YOU NEED A MOLE REMOVED WHICH CAUSES NO PROBLEMS AND INSTEAD LEAVE AN UGLY AND EVEN BIGGER SCAR

I don’t know why that’s funny, but it is. Discordant notes again I suppose. It doesn’t pay to overanalyse it.

At the end of ‘Jokester’, once it was revealed that jokes were nothing more than part of an experiment, humour was simply ‘turned off”. Was Asimov anticipating the PC movement, or was Jokester just a true story?

74. You can’t face your fears with clogs on.

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Its not fast but it can be furious.

 

Wise decision-making usually involves finding the Sweet Spot. On a golf club, the sweet spot is the area on the face that needs to come into contact with the ball. In life, the sweet spot refers to the best compromise between competing considerations. It might be a Ford Fiesta, it might be Bishops Stortford or it might be Jude Law. It depends on your parameters and your budget.

For travelling upward in buildings, the sweet spot is the escalator. Stairs are too tiring and elevators are claustrophobic, if you have a tendency that way.

How do you measure a fear of elevators? In metres of height, perhaps. Or storeys. How many flights of stairs will it take for you to opt for the little box – I nearly said coffin – instead of the stairs? For me, its about 8. To some extent that depends on the lift itself, how crowded it is, how likely is it to break down, and in the event of a breakdown, how long would it be before rescue? There’d be other factors too, such as whether you had your angina spray handy, your catheter in, what shoes you had on etc.

It pains me to set this down in writing, but I once had a pair of clogs; don’t ask why, it was the eighties. Entirely the wrong choice of footwear, it turned out, for a lift-phobic working in a multi (but less than eight) storey  hospital with slippery stone stairways. There’s almost no way of appearing nonchalant tumbling down a flight of stairs flinging X Rays and blood samples in all directions. Even House couldn’t have done it.

Will clogs ever return? I doubt it – the sweet spot for footwear is Airmax. Not WoodMax.

Or just possibly JesusMax, i.e sandals, if you’re in a hot country.

I just came back from India, which has put quite a few things in perspective. My problem with closed spaces for instance has been entirely sorted out after a few trips on the Delhi metro system.

There’s a theory going about, tested in Scandinavia, that if you removed all the road signs and traffic lights, the traffic would sort itself out quite safely, everyone edging forwards, slowly and gingerly, taking care to avoid other vehicles and pedestrians. The same unfettered system seems to work in Delhi, even though the Scandinavian model is played out on 32X fast forward, as though Benny Hill had become transport commissioner.

In Delhi, the auto-rickshaw hits the sweet spot for personal transportation. It’s cheap, it’s fast enough and if you stop for a moment there’ll be one next to you. There’s a nice breeze. It’s a thrill a minute, too. If I’d had cigarette papers I wouldn’t have been able to insert them into the gaps between the traffic (and I might have fallen foul of the new litter laws, too).

It was worth the trip though, to meet so many fascinating and lovely people, such as writer Murad Ali Baig.

Murad writes about motoring, Indian history, religion and many other subjects*. He’s putting the final touches to a book called ‘The Hijacking of God’, which is a brave enterprise now that there is such turmoil in the religious stock markets.

I found that Murad had been down a similar road to myself in assessing the cost effectiveness of whiskey. The good stuff is better than the ordinary, but not ten times better. I think its a version of the law of diminishing returns. The sweet spot for whiskey is towards the budget end of the market, though not quite Tesco blue stripe. Murad tells me that after 6 weeks of aging, the whiskey has matured. Sure, after 12 years it’s better. But not a hundred times better.

One of Murad’s themes is that religions started reasonably enough with excellent principles like peace and love, but soon fell victim to endless tiers of middle men like priests and mystics.

Soon it becomes clear to an outside observer that the religion is operating largely for the benefit of its own employees, who become relatively rich and powerful. The middle men create a false expertise, creating and interpreting myths and symbols, eventually leading to the Spanish Inquisition, TV evangelists and Robert Langdon.

Though one cannot entirely blame a religious ideology for the antics of its practitioners there are lots of parallels between the hi-jacking of religion and the misdirection of other worthy enterprises, such as charities and health services. Typically the primary goals of these organisations are to sustain themselves rather than achieve their stated aims.

Professions create a closed shop, hogging certain activities to themselves that were previously open to anyone.

I’m not sure where we would find the sweet spot for religion. We visited Jain and Baha’i temples, mosques and cathedrals and they all have plus and minus points. It doesn’t do to get too fussy about religion, but I can’t help thinking there’s a gap in the market. Something that does good weddings and funerals without too many food and clothing restrictions. Something that lasts about 40 minutes per week. Something non-violent, yet which permits hedge-cutting. Perhaps the Religion of Nike, where the only rule is ‘just do it’.

If Murad took a look at Psychology and Psychiatry he’d soon spot the mythology. True, there is no setting fire to lambs. True, there are no dietary restrictions, beyond the heavy use of Ristretto. The only vestments are tweed jackets.

But when it comes to Jargon, Gobbledegook or what UKIP would probably call ‘Mumbo Jumbo’, I feel we have now gone one ahead of the god-squad. There are sweet spots in psychotherapy, but such gems- such as REBT – are often shrouded in mystery.

For our ‘Agoraphobia’ we have ‘Graded Exposure in Vivo’, which means taking the elevator up one floor, or ‘Flooding’, which means getting on the Delhi Metro at Central Secretariat station at 9am on a Monday morning. Immersion in the train is a kind of baptism. Once you’re on there’s no turning back.

Though those trains are the most crowded spaces I have ever experienced, after a short while I felt surprisingly calm. I think it might have been the sudden announcement that the train had facilities for charging your laptop. I’d have given the Nokia a bit of free juice, that’s if I’d been able to move more than half an inch in any direction.

Sometimes your worst fear happens and you just laugh. Thank you Mr Nike for keeping it simple. I just did it.

 

 

*Murad Ali Baig: ’80 questions to understand India’, Tara Press.