81. Treating old boilers with respect and dignity.

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Rechargeable goat, at docking station.

 

I once worked at a large asylum type hospital which had several hundred patients. One of them became utterly convinced he had been appointed as a psychiatric registrar and dressed and behaved exactly like a junior doctor, right down to the large radio-paging bleep we used to wear in our top pockets. At the time he was accepted as just another character in the very rich tapestry of eccentric people who inhabited that place, like the man who used to put his head round the door in meetings and say, ‘they’ll get them, won’t they?’

Later on I was sad to learn he had eventually been deemed as a hazard to other service users and transferred to a secure unit. The penalty for impersonating professionals is high in some cases, though anyone can call themselves a therapist, or a professor for that matter.

At present, I’m in a similar pretend role. It’s unofficial you understand, there is no paperwork from Jobcentre Plus, but at present I’m on attachment to a gas engineer. Together we are trying to solve a puzzle. If I was Philip K Dick, I would call this story Fault Code Number Five. We are talking about carbon monoxide to dioxide ratios and looking at little graphs and readings on the multi-meter. I am nodding wisely, pretending I understand.

I’m satisfied that I’m attached to the best guy in the field. He is young, he is Rumanian, he scored top of his year at training school and he reads Balzac and Tolstoy. He is a friend of a friend, so he is reluctant to take any money, but I will find a way of paying him in the end. He seems to accept presents of cheese or wine. He was happy to accept one of my favourite screwdrivers too, on the basis that I had another exactly similar one.

Fixing a boiler is more exactly like fixing a person than either of us realised. Engineers use a mixture of inductive and hypothetico-deductive reasoning, just like doctors. First you identify the problem and the history of the problem.

Then you collect a set of routine information. That allows a good guess at the diagnosis, or possible range of diagnoses.

I noticed how he used the back of his hand to test whether a pipe was warm all down its length, much as a surgeon would check for inflamed tissue. He tells me that these flexible pipes sometimes get blocked and I think, just like blood vessels.

After that it’s a matter of getting more specific information, running tests designed to confirm or eliminate each possibility. According to the manual, fault code number 5 means a problem with the gas valve or the flame recognition device. The engineer dismissed the gas valve option with a mere quizzical look, much as I would dismiss a long shot diagnosis like Porphyria or Syphilis. Flame recognition seemed more likely, so he replaced that part. This is where experience tells. I’d have had no idea that gas valves hardly ever went wrong, whereas burner devices degrade over time.

Everything seemed good for a few days, until we suddenly felt chilly, and there it was again, fault code number 5. Luckily, this fault responds to pressing the re-set button, which is where we see a significant departure from treatment in human beings. Very few of us have a physical button for re-set, though there are electrical devices that can automatically shock the heart as and when required.

Computers used to have a tiny hole allowing you to re-set the device with a paper clip. I’ve always assumed there was a little button just inside the hole, but thinking about it maybe it’s more like Acupuncture. Possibly you can stick pins in various parts of computers to make them work better. Maybe we could stick a knitting needle into the boiler – it is metal cased but it has a soft underbelly – and give it a little twiddle.  I hesitate to suggest this to the engineer. There are safety guidelines against doing this, something to do with getting electrocuted. Besides, there is almost no evidence base for Acupuncture in machinery, just like there isn’t with people either.

I can’t help remembering that my dad used to tap the end of the cathode ray tube with a wooden spatula to get the TV going. This generated a great sense of anticipation for a favourite program, since we had to get the TV warmed up a good 15 minutes in advance. My dad never did a controlled trial of spatula tapping versus just leaving the tube to warm up by itself. He’d have been astonished that this far into the computer era we still have to turn things off and on again to get them to work, yes you Mr Sky HD+ box, if you are listening, which you probably are.

The next stage was to ring the manufacturers in Holland and take further advice. They suggested checking the earth connections and the burner gasket. Also there is software available allowing us to do a diagnostic test via the boiler’s USB port. This bit seems so much better than medicine. The manufacturer of humans provided very limited after sales service, no USB port and no guarantee whatsoever. What’s more, our original instructions are a bit tatty after falling into the Dead Sea.

We got so excited about the diagnostic software but the bubble burst when the manufacturer hinted that it’s output would simply say; fault code number 5, fault code number 5, repeatedly, like Revolution Number 9 from the White Album. (Though 5, instead of 9. Obviously.)

It’s true that Ghost in the Machine was the worst album The Police made, but I’m wondering if intermittent faults might indicate a haunting of some kind. I consider sprinkling it with Holy Water, but again, its against regulations, something to do with electricity and water not liking each other. I can’t imagine the engineer taking it well if I bring in a priest. Let’s stick to the medical model.

Which brings me to the punchline. The so-called medical model is much derided in mental health circles, as though some other model could replace it. In engineering there is no controversy about how to conceptualise the process of fixing. There is no-one advocating Alternative Engineering, Values Based Engineering, Recovery Engineering or other abandonment of reason. When your boiler catches fire no-one sends for an astrologer.

Perhaps that is because people are not machines. Except that we are.

Come to think of it, I still have that wooden spatula…

80. Teaching children about factions.

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To save you a lot of work, beer now comes complete with explanatory notes and rating scales.

 

Once I had the good fortune to visit a restaurant in Chicago, towards the top of a very tall building.

On the next table, a man was ordering a very complicated steak. He wanted it done in a very particular way, no seasoning, very rare, in a mushroom and red wine sauce, but without cream, and so it continued. The waiter, maintaining excellent eye contact and nodding, finally said, politely but firmly, ‘sir, it’s not going to happen’.

From that day, this has been one of my favourite catch phrases. Mainly it’s a line best not said out loud, but sub-vocally, it comes into play all the time. It’s a line that should appear as a subtitle every time a politician is interviewed.

Remember before the election, when David Cameron said that immigration could be reduced to tens of thousands per year? Or when Gordon Brown promised to eliminate child poverty? Or when Robin Cook promised an ethical foreign policy?

Now we are approaching another general election and the unrealistic promises are flowing freely.  Nick Clegg says that suicide can be completely abolished. Thousands of new GPs will be recruited to work in Hull. Every child will learn their multiplication tables. All around us, huge neon signs are flashing, ‘Its not going to happen’.

I’m not sure what kind of steak the customer at the Chicago restaurant finally got. Surveys show that behind the scenes in restaurants, nasty things happen to food going out to awkward customers. And its probably the same in the public services. You might think multidisciplinary teams, behind the scenes, are working harmoniously on your behalf. You might think the very words ‘multi-disciplinary’ are so hallowed that they must be illustrated by monks whenever they are written down and recited in plainsong.

And then you read in the Sunday Times  that ‘a turf war raged for years between midwives and medical staff at a hospital in Lancashire’, leaving as many as 30 innocent people dead. Very likely there are similar wars going on elsewhere, yet to be reported.

None of the thirty victims knew they were in the cross-fire. Most of them were babies. That raises the question – if you happen to stumble into a war between professionals, will you realise what is happening before you’re hit?

In an action thriller the first thing you’d notice would be something like having the hot dog sausage shot out of the bun by a sniper bullet, just as you were about to take a bite. There’d be a horrible red stain on your shirt and it would take a few moments to realise it was just tomato ketchup.

Have you noticed every time there’s an enquiry, the conclusion is always that there has been a breakdown of communication between different agencies? And the recommendations always includes words like joined up and liaison and sharing. Maybe we have all seen too many conspiracy thrillers featuring conflict between LAPD and SWAT. Maybe we need to revise Group Psychology for Dummies, but I have never heard a management consultant or HR person suggest that multidisciplinary working is a recipe for disaster . Criticising multidisciplinary working is like criticising democracy, human rights or wholemeal bread, totally taboo.

If anyone suggested starting a new profession that could do everything you needed, they would be roundly criticised from all sides. Otherwise you could construct a mental health professional for the modern era who was part social worker, part nurse, part policeman and part martial arts champion. The result would be pretty similar to the Eddie Murphy character from The Golden Child, who was a social worker and self styled ‘finder of lost children’. Or if you prefer, the Jason Statham character from Safe, or the Bruce Willis character from Mercury Rising, or a combination of all three.

Though sociologists and historians have covered very nicely the struggles between apothecaries and barber surgeons hundreds of years ago, few people dare to write about inter-professional power struggles in modern health care systems. The reality in mental health services is that only one professional is involved at a time, sometimes not even one. That doesn’t stop us waxing on about the multidisciplinary team just as though it existed.

Golden Child or Mercury Rising and Safe were all unpopular with critics. Each film featured a unitary professional (reformed cage fighter in the case of Safe) standing up against splintered and corrupt agencies in order to protect children and as such were felt to be totally unrealistic. What a shame our child protection heroes are just fantasies.

Today, the Casey report into child abuse in Rotherham is out and all over the newspapers. The agencies clearly didn’t work together properly and are much criticised. So far no-one seems to be criticising the multi-agency model itself. Will Eric Pickles and the national crime agency sort things out? Will children be safe from predators as long as politicians, police and social services all blame each other? Or do we need a new kind of action hero?

Sir, I fear, its not going to happen.

79. Cashing the reality check.

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An anthropologist, studying a hipster, spotted in Dalston.

This week I had a root canal filled. Guess what, it went well, because I was literally wearing rose-tinted glasses. Radio 2 was playing, everyone was jaunty, the banter flowed as freely as the lidocaine. The craic was mighty, as they (don’t really) say in Ireland.

Fans of CBT know that to stay healthy we need constantly to examine the way we look at the world and the future. I used to be afraid of dentistry but now I easily prefer it to hair care, where the craic is poor and there is no anaesthetic. Although dentistry is invasive and scary, the dental experience can still be positive if the atmosphere is right. Similarly, it’s possible to frame our view of the world as a positive one, though it may be necessary to stop watching BBC News Channel, with all due respect to Clive and Martine.

While we are on the subject of Reality, and how not to face it, let’s ask the question: where have all the scientists gone, the ones who didn’t become dentists?

If you’re reading a scientific paper you expect every single assertion to be carefully argued and referenced. Statisticians will have hosed down the results, using streams of numbers to wash away the confusion. Conclusions will be couched in cautious tones. Where a crisp punch-line is needed, instead there’ll be mumbled suggestions for further research. Anything that a scientist says is subjected to peer review by other scientists before it gets published.

There may be no such thing as absolute truth, but scientists probably come the closest to finding it, or at least wanting to find it.

I often wonder what it would be like if we asked scientists to form a government. This is virtually the opposite of the current situation, where, in the UK at least, scientists are barred from politics. Ok, Mrs Thatcher had a chemistry degree, but that’s about it.   Otherwise all our leaders studied PPE or law or history. Apparently there is only one scientist in the house of commons, out of 650 MPs.

Perhaps, more than any other fact, this one epitomises the British Disease. Which is talking a good game instead of playing one. We don’t know how to use a torque wrench – we use a talk wrench instead.

Most of modern history pays homage to Freud somehow or another. His nephew, Edward Bernays, pioneered the field of propaganda. Bernays had grave doubts about the democratic process, preferring a system where the masses are guided by an Enlightened Elite. Propaganda specialists gradually took over politics in the West, culminating in the election of PR man David Cameron as Top Banana. Bernays was influenced by his uncle, to the extent of recognising there was no such thing as objectivity. We all have different ‘takes’ on reality and we fit any new information into our existing preconceptions.

Clashes between worldviews can’t be resolved by a simple look at the facts. What facts? It all depends on how the evidence is collected and sifted. My view is that we need more of a scientific approach to making sense of information, but others may feel differently. How often do you hear people say that they don’t trust scientists?

Remember, for example, esteemed psychiatrist David Nutt being sacked from the Advisory Council on the Misuse of Drugs? For saying that some drugs are more harmful than others. And for saying that politicians distort and devalue research findings. The Home Secretary who sacked him was ex-postman Alan Johnson, now a national treasure. Here’s the narrative then: scientists are too narrow or cranky to see things clearly, that’s why we need politicians to decide how to classify drugs.

Quite who belongs to the Enlightened Elite nowadays is open to question. Maybe it is the shadowy ‘new world order’ and their lackeys in the media. Or maybe it is the ‘liberal consensus’ epitomised by the BBC. Or maybe it’s the Hipsters in Stoke Newington. Writer and film-maker Adam Curtis suggested that the Enlightened Elite are manipulating the news to keep us confused and afraid, a process he recently described as ‘oh dearism’ or non-linear war.

The connection between ‘oh dearism’ and Depression in individuals is not clear, but that hasn’t stopped writers like Joanna Moncrieff from asserting that Depression is just one of the missing arrows from the big Venn diagram of discontent, fear, capitalism and drugs.

I’m not sure why the Enlightened Elite would seek to make us all miserable and afraid when – if they had that kind of influence – they could just as easily make us jolly and bright. They are accused of such intent when they stage feelgood events like the Olympics and Children in Need.

In China, being governed by an enlightened elite is not just admitted, it is celebrated. And most of China’s top government officials are scientists. The president, Xi Jinping, studied chemical engineering at university. The last president, Hu Jintao, was an hydraulic engineer. How about the one before that, Jiang Zemin? Yes, he was an engineer too. Cue ‘machinery of government’ metaphor.

Could it be true that people in China have a better grasp on reality than people in the West, because they know the difference between a torque wrench and a thingybob? Do people in China take a more positive view of the world and the future?

Interestingly, it has been reported that there has been a massive drop in the suicide rate in China between 1999 and 2011, some say by as much as 58%.

China is a country run by scientists, which is not to say that UK would become like China if we rounded up our few remaining scientists and sent them to Westminster to rule over us.

Our scientists are just not used to being respected, listened to, or paid very much. Very few of them are party members, attend socialist summer camps or got seconded to tractor factories during their formative years. Our scientists are just not ready to form a party of government.

There is a solution and it will happen anyway, sooner or later. Why not invite some Chinese scientists to join our government, just like the ‘immortal seven’ (the enlightened elite of the day) invited William of Orange to become special guest king? It’s a controversial strategy, but so was the Battle of the Boyne. (Too soon?)

In December, Prince Charles gave a speech about our attitude to engineering. ‘The skills crisis has reached critical levels’, he stated, ‘particularly in the fields of mechanical engineers, machine setters and engineering professionals, which are among the most difficult posts to recruit’.

Like the house of commons, the royal family has only one scientist, Peter Phillips, who did sports science at Exeter. Shouldn’t he be promoted? And is it too early to get George his first electron microscope?

78. The best solution is probably not the one staring you in the face.

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A typical radio enthusiast’s garden.

The amount of energy required to switch on the right hand turn signal on a Vauxhall Astra is probably less than one calorie. Nevertheless, it is too much of a demand for a lot of drivers in this part of England. Similarly, in the age of power steering, minimal effort is required to turn the steering wheel half a turn so that you can turn right without cutting off the corner. Yet this also, it seems, is a Herculean task.

In case you think this is a ‘grumpy old man’ type piece, it isn’t.

I’m not grumbling about poor apostrophe hygiene or using the phrase ‘going forward’. I’m not grumbling about the poor radio signal in the kitchen or the dog woman from number 23. In fact I’m not grumbling at all, just noting a behavioural pattern.

Daniel Kahneman explained it well in ‘Thinking, fast and slow’, one of the themes being the conscious mind’s reluctance to get involved in simple behaviour: ‘Please don’t bother me’, says the mind, ‘someone 44 floors lower down deals with indicating right and that kind of issue’.

If we had a technical term for limited cognition it would be ‘lazithinkia’. In the same way we can’t blame a lazy eye for pointing in the wrong direction, we can’t really blame the human operating system for its limitations. Car drivers turn right without indicating and cut the corner off because the mind doesn’t want to have to tell the finger to move 3 centimetres if it can possibly help it, and the body seeks to minimise the G Force it has to endure. Lazy is not necessarily a judgemental term, but it does lead to problems.

For instance, its unlikely that a dock leaf really provides an antidote to nettle stings. Certainly there is no evidence base for such a claim, unless you want to include the non-specific rubbing effect of the leaf. But that would be equally true for a piece of halibut or the skin (knocked) off a rice pudding. Rubbing the skin reduces the pain perception via the gate control theory, that’s a fact. Dock leafs and nettles can occasionally be found in close proximity, and a dock might be the first thing you find after a nettle attack. But to assume, firstly that the dock is a specific antidote to the nettle and secondly, generalising wildly, that antidotes are to be found next to the relevant poison, requires the mind to take a very long lunch break indeed.

Even in a pharmacy, the uppers and the downers won’t be on the same shelf. And no amount of Merlot will counteract the effects of Cabernet, even if they are right next to each other in Spar. People used to put butter or lard on burns, little realising that the real solution, cold water, was only a yard further from the cooker.

Looking further afield is a nuisance, but in the age of google there is little excuse for failing to get an overview. Recently I had a strange hankering to buy a radio for the kitchen. Not only that, but to buy it the old fashioned way, by going down to the local electric shop and seeing what they had. I can only explain this behaviour psychoanalytically in terms of psychotic defence mechanisms. Radios are somehow comforting objects and going Retro is some kind of regression to a more primitive stage of existence. Retro radios tuned to Classic FM have contributed mightily to calming people down and reducing opiate consumption.

As you will have predicted, this adventure started out like a dream and ended like a nightmare. I found an LG radio massively reduced in the first shop I went in. I got it home and put it on the fridge. It played all the internet stations off the phone via bluetooth. But that was not what I wanted. I wanted to press a button on the top and have it play the Jeremy Vine show on Radio 2. But that was not to be. Nothing on FM. Nothing on DAB. I called LG and they said try moving it to a different part of the house. I said I wanted it in the kitchen. They said turn it off and on again. Then they suggested turning it off for an hour and turning it back on again. LG have an algorithm for these problems which they work through calmly. The third thing is to try tapping it with a little hammer from a Christmas cracker, reciting magic words, the fourth thing is dropping it from a third storey window.

I took it back to the shop, where it worked perfectly. They gave me another one. Again, it wouldn’t work in my house. I got a refund, no problem. I wrote a review on the LG website – they asked for one – only to have it censored by the LG administrator, just because of the third storey window remark, which, OK, was a bit of an exaggeration.

On this occasion my only punishment for lazithinkia was missing the Jeremy Vine show. It could have been so much worse. If I had only engaged my brain I could have solved this problem in so many ways. I wanted a simple, local solution to a complicated technical problem and that’s not how it works and that’s why we have google.

If I’d gone for a solution-focussed-problem-solving approach it might have been better. But that would have involved quite a bit of cognitive and behavioural work, such as getting a proper aerial or fundamentally challenging the quality of the Vine show. That, in turn would call for monitoring that show carefully, using minute by minute evaluation, like so-called dementia mapping. This would show that, over a prolonged period, the program struggles to beat white noise in controlled trials of listener satisfaction. And white noise was there all the time if only I’d tried the AM band.

Also, being Christmas, right next to the radio was a bottle of Russian Standard, the very thing that people say improves poor radio programs.

77. Imagine there’s no Santa.

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The UK version of Village People.

In Buxton, Derbyshire, Father Higgins is in big trouble this week, for telling the kids that Santa isn’t real. Sections of the media pretended to get upset.

Father Higgins doesn’t like fakes. He thinks we should be judged on what we do rather than what we say. He’d rather see people carrying out charitable works than mumbling prayers over their rosary beads. People say to him, ‘I’m not a religious man but…’ and he interjects ‘neither am I really’. Father Higgins has a tendency to go off message at times, but there is no Bishop in Nottingham in post at present to tell him off. And besides that, he’s of an advanced age, he’s been at Buxton, Derbyshire for decades and he knows very well there’s a drastic shortage of priests in the UK. No Martin Sheen character is going to set forth up river to finish him off like in Apocalypse Now. He’s just not expecting the Spanish Inquisition.

Religions have to be careful about debunking mythology, not just because of the pot -calling – the – kettle proverb. Reality is too harsh to tolerate full on, so we have to create a buffer zone of fantasy around it. Some fantasies are shared, like talking animals, royal families and Santa, while some are highly specific to individuals. Mark Chapman fantasised about killing John Lennon for a long time before carrying out the act. Allegedly, Chapman was a fervent Christian and Beatles fan, and had come to regard Lennon as a kind of false prophet. He was influenced by the character of Holden Caulfield in Catcher in the Rye, who hated phonies, yet was something of a phoney himself. It takes one to know one, or as a psychoanalyst might say, it takes one to project one.

Since Lennon had taken the trouble to call his last album ‘Double Fantasy’ rather than say, ‘Double Truth’,  Chapman’s reaction was harsh, to say the least. He should have paid more attention to another contemporary New York musician, Billy Joel, who wrote ‘Angry Young Man’ as something of an antidote to political protest.

Despite that song, which seemed to punctuate an ‘end of history’ moment for over-righteous indignation, people still queue up to denounce perceived hypocrisy. Just think about the Critical Psychiatry Network, who stay up at nights raging about made-up illnesses and pretend drug therapies. Just think about the people who hate the Band Aid single, just because it sometimes snows in Africa and nearly every African person knows it’s Christmas time.

Could Holden Caulfield find anyone around today that he could believe in?  I suspect he’d have to settle for a pet dog. He’d never find a human being he could tolerate. People are intrinsically irrational and hypocritical and contradictory. It’s the way the mind works, isn’t it Mr Spock? In acknowledgement, we have seen a shifting emphasis in therapy away from ‘rational / emotive’ towards ‘acceptance / commitment’, the acceptance being that humans have messy wiring diagrams. We are all phonies now – get over it.

The problem seems to occur not so much when someone creates a fantasy world around themselves, but when they create the wrong alternative reality. In the news today we hear that pets are getting more likely to attack their owners, supposedly because they are not given enough exercise. People are getting dogs that are much too large to live in ordinary homes. Bonsai dogs have been around for a while, but they are not popular. When you buy a dog you are buying a fantasy companion, not an ergonomically-correct domestic appliance. Not that you would really want an appliance whose main function was generating and randomly distributing hair and faecal material. We have an old Dyson for that job.

Though the media have profited greatly from the expanding market in fantasy, the main losers appear to be those bastions of rationality, maths and science.

A large number of our children don’t understand that 85 is a smaller number than 90. If you ask them, ‘if I buy an orange for 20p and an apple for 15p and I pay with a pound coin, how much change will I get?’, they will answer £1.35. But then we do have a thing called Quantitative Easing, which means they are probably right. And what’s more they can all sing all the songs from Frozen.

 

 

 

 

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.

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.

 

73. Defending the metric system and other systems from people who say they aren’t real.

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Finally, a new logo for the National Health Service.

The first page I look at in the local paper is the obituaries. Call it outcome research if you want, it’s a relief not to see any familiar names. Then I look at what’s happening in the world. I note that the deadline is approaching for the library consultation and resolve to send in my idea that they provide noise-cancelling ear protectors.

Then I read about something called Messy Church, which seems to offer a welcome antidote to Puritanism. I wonder whether a Messy Hospital movement might catch on now that MRSA is dying down. And on the very next page there’s an account of a new plan for the NHS which looks very messy indeed. GPs will be hospitals and hospitals will be GPs, and either of them might pop up anywhere, unrestrained by tired old concepts like buildings. There’s apparently an £8 billion deficit, so I can see why buildings won’t be used. The new NHS, like the shops of the future, will be people in white vans. A spokesperson for NHS England states that they’re ‘going to turn the whole thing on its head’.

I skim over the pages that purport to show old photographs of the town. I suspect that someone with an old model Nokia is taking photos of existing buildings and running them through a sepia filter. I’m sure Gregg’s wasn’t there in 1895 for instance. On the next page the local council has taken out an advertising page, assuring us that it is working not just for today, but tomorrow too. And there’s an intriguing little piece about scratch card quizzes ‘being used to help residents select the best services for health needs’. This is the first piece in the paper that leaves me anxious to know more, but there is no further explanation. Just a photograph of the main sign outside the local hospital, underneath which is the caption ‘scratch card’. Hmm.

And then, just as I was getting into enjoying  the gentle rhythm of news about a small town where nothing ever happens, and feeling thankful that I wasn’t living in Sierra Leone or Syria, the bombshell bursts.

Right there on the letters page, in between ‘plant based diet’ and ‘dump the metric system’, is a piece called ‘treatment frustration’ written by a man called Brian Daniels, ‘national spokesperson, citizen’s commission on human rights’.

Brian’s contribution is to assert that mental illnesses do not exist and psychiatrists are not proper doctors. That’s not quite enough to make me choke on my artisan toast. After all, Thomas Szasz was saying the same thing in the sixties and made fame and fortune with his books such as The Myth of Mental Illness. It’s just the worry that someone from the government or civil service might read today’s paper and experience a lightbulb moment. If mental illness doesn’t exist, and there’s a £8 billion deficit, how much are we wasting on psychiatric services?

Normally, the political stance toward mental health is to wheel out Nick Clegg every 3 months and have him state that mental illness should have parity with physical illness and much more needs to be done. This is something we really appreciate. There is no further action beyond the speech you understand, but at least the speech has been given by the deputy prime minister. But we are approaching an election and it’s just possible that Nick Clegg might be replaced and someone like Brian Daniels will gain power.

One of the right wing’s favourite tricks is to hijack a leftist theme and milk it for its unintended consequences. A recent example is the so called Recovery Movement, but further back we have Deinstitutionalisation, Normalisation and other schools of thought that started with the idea of liberalising mental health services. Being in Recovery means you can get on with your life and stop behaving like an ill person. As far as I can see, people are deemed to be ‘in recovery’ when they are still very ill. This suits an overstretched service desperate to get people off the books.

Unfortunately, denying that there is mental illness leads to denying that people should get any mental health treatment.

Brian Daniels probably thinks he’s had a great new idea.The Messy NHS plan is put forward as a great new idea. There’s a big market for Denial.

The scratch card project is apparently an exercise to help people choose an alternative to A and E departments. I wonder what boxes you can choose in case of an acute psychotic episode? Two aspirins and an early night? Pull yourself together? Go straight to Recovery?

Brian Daniels wouldn’t give you any box at all, since he has abolished mental illness. But you won’t get a choice to abolish the metric system.  It’s in a museum in Paris. You can’t pretend its not real.

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A new style health centre, or possibly just a messy church spilling out onto the road?

72. Falling back on homes under the hammer.

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Hull Trains are quite influenced by the Terminator series.

 

On the breakfast news there is almost always a mental health item. There are two types of mental health news reports: the short one and the long one. On the short one, the presenter merely reads out two statements, one from a survey and one from the health service.

First statement: a survey conducted by a charity reveals that there are no services for the mentally ill north of Milton Keynes and that depressed people in the north are simply rounded up and dropped down coal mines.

Second statement: more people are being treated than ever before due to increased investment in acronyms like IPT and IAPT.

You wait for a moment of analysis or commentary, a denial from someone in the coal industry perhaps, or an acronym buff, but in a blink, its over to the Midi dress. Should it really end at the thickest part of the lower leg?

The longer version of the mental health report is just the short one followed by an interview with a ‘service user’. Typically, the service user seems suspiciously mentally well, despite their long period of suffering and eventual escape from the coal mine. It took years of waiting, but eventually they reached the top of the Mindfulness Therapy waiting list, after which they were cured in a jiffy and made ready for TV.

This week, we just had the short version: One in six people attempted suicide while on the waiting list for psychotherapy, which is more than a year on average. NHS England says that there are more mental health services than ever before and even now new acronyms for services are being coined at their new DOA. (gettit?)

It is such a relief when the news stops and Fred Dibnah’s World of Steam, Steel and Stone finally begins, even though every episode is the same. Then there is a program where people buy a small house at an auction, paint it magnolia and rent it out. After that two people try and decide whether to emigrate to Australia, nearly go and then don’t quite go. Following on, a lovable cockney sorts out some dodgy builders in the style of Jack Regan from The Sweeney. Daytime television can seem massively interesting, but only under certain circumstances.

Normally these programs leave the viewer underwhelmed, but that all changes if you get ill. Once you are debilitated and a little delirious, daytime television takes on a whole different dimension. The level of stimulation the human system requires, or can even tolerate, is greatly reduced in cases of biological malfunction.

The key to successful television seems to be following a formula. Even though we’ve seen it a thousand times, we still love a plot that ticks along like a Swiss clock. To a very alert person, formula means repetition and repetition means boredom. To a stressed or unwell person, formula means familiarity and familiarity means comfort. Entertainment has a long history of formulaic productions, from Punch and Judy through James Bond to Strictly Taxidermy. Every time we are presented with a repeatable pattern, the part of the mind that ticks boxes is comforted.

I once asked an older colleague how people used to treat serious mental illnesses before the invention of antipsychotics. His reply was ‘Institutionalisation’. At the time I took this to be an attempt at irony, especially as institutionalisation had come to be regarded as oppression. Now, I realise he was giving a serious answer. Reducing stimulation and imposing regularity were ways of calming people. Perhaps it is just a coincidence that large asylums closed just as daytime TV began. Or perhaps, television just happened to hit the right level of stimulation to suit chronically ill people. One person’s stultification is another persons action thriller. On the acute ward, I noticed that really ill people hardly watched TV, not even football, but could just about manage old Top Gear repeats on Dave.

Disruption of biological rhythms is almost the hallmark of Depression and the first thing that psychiatrists ask you about. Sleep pattern, diurnal mood variation, bowel habit etc. Disruption of biological rhythms is also the hallmark of twenty-first century society, now that shops and the internet are open all hours, pubs never close and you can watch Dr Who whenever you want. I’m not saying the two are causally related, any more than fridge ownership is causally related to crime statistics (other than ice pick murders).

But possibly Stress is being met with De-Stress, in the form of Repeatable Pattern Seeking Behaviour or RPSB, as it will never be called again (too similar to the RSPB, who are a very powerful lobby). Accordingly I may have to forgive people who own pets or buy lottery tickets as simply stressed people in search of fixed schedules. Perhaps they just have nothing to do – besides panic – between Street Patrol UK and Cash in the Attic.

If you just don’t ‘get’ the Fast and Furious series, now you can understand why the same bits are in every film. Humans like patterns. Much of our brain is a scanning device and every cell has a system of time clocks.

Which is why, even before they had CAT scans, Interferon or Clozapine, Regional Health Authorities had their own carpet designers. One design was blamed for people hallucinating. Another type caused terrible friction wounds to frail people. Our own hospital replaced carpets with ‘abattoir-chic’ red lino. Cue carpet jokes: Where to sweep things now?

Like TV programs, carpet that can look fine – just a bit hectic – when you are fully conscious and alert, may look like a pit of vipers to a delirious person. Wetherspoon’s know this only too well.

Last time I was really sick, I remember thinking The Weakest Link was a brilliant program. But after taking a Zantac it suddenly lost all its appeal. It goes to show, if you are sick, you need to titrate your choice of programming carefully against your drug therapy.

Like hospital carpet design, there probably needs to be special programming for sick people. Or just accept that most television is aimed at people with impairment and should be run by Occupational Therapists. It already has?  DIY SOS, Blue Peter, Celebrity Master Chef, Come dine with me, Extreme Fishing…

TV is the new OT and we even have one on the ward.