85. Facing the inevitable barrage of organic fruit.

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Body language gets you 90% of the marks.

 

The summer of love officially begins with The Royal College of Psychiatrists annual congress, starting on June 29th at the ICC. If you’re going to Birmingham, be sure to wear some flowers in your hair.

We know we will be picketed and probably ridiculed by groups opposed to psychiatry. A warning has gone out to wear proper ID and beware bogus journalists.

But, just maybe, this time around, instead of fighting off the pickets with laser pointers, pretending they are light sabres, we should just let our critics put us in the stocks, if they still have them in Birmingham – I know they still have the bull ring – and wait to get pelted with fruit. Waitrose organic blueberries would be acceptable.

I’m talking about Truth and Reconciliation again. We have to accept that Psychiatry as we know it is a twentieth century phenomenon, running on empty these last few years. It’s time to face our critics and recognise what we did.

We are accused as follows:

  • Started using bullet points, against the advice of the English teachers
  • Colluded with the drug companies to hype SSRIs and Atypicals so that huge amounts of money were wasted paying for drugs that were no better than older drugs that were dirt cheap.
  • Conspired to medicalise swathes of  human behaviour like normal sadness and over-activity in children, yet failed to offer any useful treatments for these problems.
  • Colluded with management and politicians to shut down all our asylums and most of our inpatient units, knowing full well that they would not be adequately replaced with community services.
  • In the name of public safety diverted most of what resources remained to locking people up in secure units and hanging on to them as long as possible.
  • Colluded with managers to implement electronic records, knowing that these would destroy anyone’s ability to write or find a narrative summary.
  • For the nicest of reasons, presided over a decline in the status of medical staff, ending up with no secretarial support, no office, nowhere to park, no say in how things are run, quitting or retiring early, no-one wanting to take our places and decaffeinated coffee.

If you’re going to Birmingham, be sure to wear some flowers in your hair. Like Belladonna. A crown of thorns is taking it too far.

As Scott McKenzie would put it: ‘There’s a whole generation, with a new explanation’.

I’m looking forward to hearing it, the explanation I mean. See you in the Bull Ring.

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84. Learning lessons from cleverer sorts of creature.

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Dolphins. They don’t do SATS.

Matisse and Chase are action dogs who won Britain’s got Talent. The fact that dogs can be taught to walk across a tightrope should make the education establishment pause briefly over its tall latte. As legions of children are subjected to ever-changing methods of learning and testing, has it never occurred to teachers that all they need is a packet of food pellets and a buzzer? If not, they should try writing the learning objectives and lesson plans for a dolphin show.

The problem seems to be in the notion that learners need to ‘understand’ things.

Once you start down the road of Understanding, sooner or later, you will lose your way. As Spinal Tap observed, it’s a very thin line between clever and stupid.

The road to understanding ends with a Philosophy experiment, like how Schrodinger’s Cat can be alive and dead at the same time. The pursuit of Understanding has killed off skills learning and almost no-one can walk across a tightrope nowadays, not even Matisse if safety rules are respected. Apparently Matisse hasn’t got a great head for heights.

As I understand it – which I don’t need to – operant conditioning happens as follows: People (or dogs) blunder around randomly, certain behaviours get associated with nice or nasty experiences. This, in turn, makes it more or less likely the behaviour will be repeated. Rewarding behaviours with biscuits or fish allows trainers to create showbiz animals. It’s embarrassing to accept that operant conditioning remains the strongest determinant of our behaviour. But there are examples all around us if we look.

In front of me for instance is a jar of eucalyptus honey, which I am putting on my elbows. Although I have sat through countless hours of training in evidence – based medicine and statistics, my experiences with honey are completely homespun, not to say stupid. Like most experiments, it started randomly at a hotel somewhere. A particular constellation of circumstances occurred: sore elbows / time to waste / poor impulse control / spare sachet of honey / no-one looking / short sleeves / suspension of disbelief / random fluctuation of self limiting condition / not liking honey as a food.

Add to that perhaps the knowledge that many great discoveries really did happen by chance.

I am not saying – GMC fitness to practice committee, please note – that you should put honey on your sore places. I don’t think I should be doing it myself to be honest, since it is wrecking my reputation and my wool jumpers. And honey just does not fit into a touch-screen world.

I’m aware I am falling victim to Attribution Error. Being aware of it doesn’t stop it happening though. Placebo can still work, even if the subject is told it is a placebo. Even if there are neon lights flashing the word ‘Placebo’ in front of you and a fifty-strong male voice choir singing the word ‘Placebo’ right behind you. That’s why Understanding just isn’t necessary and might even be dangerous.

Which is also why it may not be quite as necessary to try and explain things as the current versions of User Involvement dictate. Some psychiatrists have got into trouble saying stupid things to patients in an attempts to explain how drugs work. The worst thing you can say, apparently, is ‘chemical imbalance’. It’s OK to say ‘chemical’ I think – though some people struggle with the notion that the brain is made of atoms –  it’s the ‘imbalance’ part that does the damage.

Once you start using words like ‘imbalance’ you can be sure you’re on slippery foundations. Next thing you’ll find you’ve said ‘Time’ or ‘Nature’ or ‘Rest’. Then its only a short step to mumbling something like ‘striving officiously against the inevitable darkness’ and ‘tickets to Switzerland’. If you say the words ‘balance’ or ‘imbalance’ you will hear the examiners screaming with laughter behind their one way mirror.

Psychiatrists might use the word ‘deficiency’ in the context of brain chemistry, but not ‘imbalance’. Not that deficiency (e.g. of serotonin) is a proven cause of depression. But the monoamine theory of depression did guide people’s understanding of the illness for many years. ‘Increasing’ serotonin was the simplistic explanation for how antidepressants might work, particularly those named serotonin re-uptake inhibitors.

There are reams of internet pages given over to an argument between anti-psychiatrists and the psychiatric establishment about whether any psychiatrist has actually used the phrase ‘chemical imbalance’. And indeed as to whether the monoamine theory included notions of balance.

Further reams explore whether it was a term that used to be used but has now been abandoned and the usage covered up, like documents in 1984.

Anti-psychiatrists  argue that psychiatrists concocted the notion of Imbalance with big pharma, in return for free logo pens. One of them scoured the literature to find use of the ‘I-word’ and came up with this example from a 2003 textbook:

Sometimes the explanation is as simplistic as ‘a chemical imbalance,’ while other patients and families may request brain imaging so that they can see the possible psychopathology or genetic analyses to calculate genetic risk’

As far as this paragraph goes, the stupidity of the chemical imbalance part is overshadowed by the rest of it, such as the idea of seeing psychopathology on an image of the brain. Even so, the usage seems to be an example of low-end explanatory waffle, rather than as a deliberate falsehood the board of Eli Lilley dreamed up as they circled their cauldron.

When talking about drugs, or honey, smart people know how to say ‘I don’t know’ But it’s not OK, as Ed Milliband found out at the election, to say ‘who cares?’

Just to reassure you, I am not keeping the medicinal honey anywhere near the food honey, and I have labelled it ‘Medicinal Use Only’ and ‘Not for Internal Use’, just like the Boots chemist would have done in 1965. It works by Osmosis I think, which is quite different from correcting an imbalance.