67. Choosing exactly the right cakes, by law.

A guard tried to stop me taking this photo. That’s Sheffield for you.

I’ve picked up a tail on the way to Costa. When I order a Flat White and the enormous jaffa cake, a person behind me in the queue nods, makes notes and ticks boxes. Someone is looking through all my bank statements and receipts. My texts and emails are all copied and filed. My cupboards have all been disturbed. My relatives are being interviewed about my habits and desires. Someone’s been at the pub asking what beer I like.

Am I a character from a John Le Carré novel?

Am I a teacher at an Islamic school?

Or have I just missed my Risperdal tablet today?

Is it a song by the Alan Parsons Project? Somebody out there…

None of the above. In fact all this snooping is to my benefit. I am being assessed to see what are my Best Interests.

Admittedly, to have got to this point, I have to fall within the protection offered by the mental capacity act, which means I must have a disorder of mind or brain. There has to be some doubt over whether I can make decisions properly. I have to spend some of my time being supervised in an institution. And people would probably stop me if I chose to leave.

It applies to nearly everybody then.

Carrying out a ‘Best Interests Assessment’ under the mental capacity act is estimated to take about 25 hours of social work time. Since a Supreme Court ruling in March, tens of thousands of institutionalised people are deemed to be deprived of their liberty and are awaiting assessment under the ‘DOLS’ procedure. One of the cases was called ‘Cheshire West’, which would be a good name for an stage actor. If the assessments are delayed, those deprived of their (Article 5) rights will be lined up for compensation payments. At 5pm every day your phone will ring showing an 0843 number and an automated message will ask whether your right to liberty has been infringed. It’s the new PPI.

What will social services do about the pile of referrals, which if stacked end to end, would stretch from all the way from Purgatory to Hell?:

Manager: How long does it take you to do a best interest assessment?

Social Worker: At least 25 hours.

Manager: From now on, you’ve got 25 minutes, and I’m being generous because it’s your birthday.

Social Worker: There are 56 pages of forms to fill out.

Manager: Then you better get started right away.

Social Worker: We’re supposed to find out all about that person. We wouldn’t want them to get the lemon tart instead of the big jaffa cake.

Manager: Save that cake routine for the Supreme Court, why don’t you? I’m guessing Baroness Hale of Richmond will set fire to your ass and mine too.

Social Worker: Whatever happened to you, chief? You’ve taken down the picture of Shami Chakrabarti too!

Manager: If it’s toasted on one side it’s still toast. Three little letters son: G4S. And now you’ve got 22 minutes left.

It’s easy to blame the supreme court, but all they seem to have said is that someone should look out for people who have lost their mental capacity and have been locked up by the state. No-one expected the Spanish Inquisition, except perhaps Dan Brown.

66. Consuming your own smoke, but coughing a bit.

Evergreens, preparing to march.

The last gas canister is nearly used up on the blow-lamp and the Poundland Firelighters have long since expired. And now it’s raining again. I’m pouring some delicatessen grade canola oil on to a pile of smouldering vegetation and I’m wondering how all this began.

I should have been commenting shrewdly on the mental health news, but I’ve had to let things slip. This is the Day of the Hedge, the story that John Wyndham never dared write. I think it began with an innocent attempt to help someone. A number of weeks back a man suddenly turned up and asked if I wanted my hedge trimming. He looked a bit unofficial, but he had a lightweight aluminium bike and a matching petrol hedge trimmer in a duffle bag. It was a cool look, quite unlike the usual tree surgeons, who wear protective gear and drive Land Rover Defenders. I suspected he was new to the war on hedges. I asked him his name, and where he lived. When he told me, I was pretty sure I’d seen that name in the local paper a few times as a person convicted of petty theft and sent to jail. So what? I also remembered that, in mitigation, he was said to have had a drugs problem. So what? We believe in rehabilitation don’t we?

I negotiated him down to £10 and showed him where to put the hedge cuttings. All this passed off smoothly. Before leaving, he glanced at our long line of dissident conifer trees and offered to take them on. Maybe, I thought.

Some weeks later he turned up to do the hedge and we negotiated a price for a full days work. I felt like the man in the vineyard parable. Part of the deal was to come back and take all the cut vegetation away. Again, this all went smoothly. He trimmed the line of trees and made a huge pile of branches. Next day he was going to come and collect them in a trailer.

A few days passed until he turned up again. Could he have an advance of £20 to buy a new tyre for his trailer? OK I thought. At worst I am only going to be £20 poorer, and I still have his ladder, saw and lopper device.

And that, dear reader, was the last I saw of him, some 3 weeks ago. I can’t say I’m not concerned about him, but the pressing problem is the huge pile of branches outside the back door. I have a slight tendency towards pyromania, but let it be said, I have never set fire to anything major, not even an NHS Trust. If I was admitted to a forensic unit, I’m pretty sure I’d be allowed into the smoking area on my own after a month or two. Fire would not figure strongly on my risk assessment. Nevertheless, there is a tall plume of smoke over my house. I reassure Mrs EP that it is mainly steam and not smoke. I hear the neighbours coughing loudly and I reassure myself they are heavy smokers. My legal advisor tells me there are heavy fines if any nesting birds get made homeless. I prepare a Richard Nixon style deniability defence.

My carbon footprint is growing, but the pile seems as big as ever. For the sixth time, I climb inside the green recycling bin and jump up and down to make just a bit more room for foliage. As I jump, I ponder, and I realise there is a very easy solution.

How many psychiatrists are needed to get rid of a pile of trees? At least four. The first to recognise we are in Denial. The second to find a garden dude in the free local magazine. The third to dial the number. The fourth to mix the martinis. Perhaps an extra one to reassess fire risk.

65. Sleepwalking blindfold, into an amorphous tapestry.

Historians agree that modern times began in 1980, with the invention of Pac-Man.

When did it all go wrong? The answer it seems is 1980. And, to a lesser extent, 1988.

Certainly, quite a few things went wrong in 1980. John Lennon was murdered, the Iran / Iraq war began, Robert Mugabe was installed and worst of all, the post-it note went on sale. In mental health, our particular Chernobyl was an explosion of toxic diagnostic heterogeneity. 1980 saw the invention of the concept ‘major depression’ (MDD). With the publication of the DSM3 diagnostic manual, most emotion-based illnesses was fed into a diagnostic Magimix. This turned out to be very convenient for certain people. One, (sloppy) people who don’t like making diagnoses. Two, the (wicked) inventors and propagators of so-called SSRI antidepressants. Rampant heterogeneity was very inconvenient for anyone who wanted to investigate the possible causes and treatments of Depression. Edward Shorter explains the story much better than I can.*

Certain discrete entities, that should have been studied much more carefully, got lost in the new, amorphous tapestry of MDD. One of these was the notion of ‘biological symptoms’ such as appetite and weight loss, early waking and diurnal mood variation (DMV). The classic ‘melancholic’ patient felt much worse early in the morning. Studies of cortisol and other hormone levels throughout the day showed a changed pattern in most depressed people. Of particular interest was the finding that most depressed patients failed to reduce their cortisol levels even when given a steroid tablet the night before. This led to the ‘dexamethasone suppression test’ and other early attempts to find a definitive lab test for Depression. Old school psychiatrists regarded DMV as a cardinal symptom of melancholia. They separated melancholia from other types of depression with barbed wire, landmines and a no-fly zone.

Today, research into circadian rhythms in organisms and the body clock in humans is a major strand of research in life science. Gene expression studies are the way forward. And this week, even the BBC acknowledged this by holding a ‘Day of the Body Clock’.

Quite what the editors had in mind for the body clock day remains a mystery. Each news program had to slot in a body clock item but the presenters looked bewildered as to why. We heard that sportsmen performed better in the evenings. Some brave schools are shifting their timetable for teenagers later into the day, when they are more likely to be awake, although the teachers are more likely to be asleep. More interestingly, scientists told us that society was guilty of a ‘supreme arrogance’ in trying to over-ride our need to get enough sleep. Prof Russell Foster, at the University of Oxford, said people were getting between one and two hours less sleep a night than 60 years ago. We were warned that ‘Modern life and 24-hour society mean many people are now “living against” their body clocks with damaging consequences for health and wellbeing’. Further support then for the Blur Theory – Modern Life is Rubbish. Sleep, like lunch and the concept of Melancholia, was abolished in the eighties.

Studies continue to reveal that a sub-group of depressed patients show an abnormal expression of clock genes. Several promising types of non – drug therapy for depression were based on trying to adjust the body clock: Sleep Deprivation, Phase Advance and Bright Light therapy. Unlike SSRI antidpressants, these are treatments that cost hardly anything and can easily be implemented at home. Also unlike SSRIs, these are treatments that no-one ever tries. The post-it note and Robert Mugabe are here to stay, but Shorter is correct to say that MDD must go: ‘melancholia and non-melancholic depression are quite separate illnesses’. I’m having the bumper stickers printed now.

The idea that deliberately reducing sleep can act as an antidepressant seems counter-intuitive. But it’s possible that the insomnia in depression is the body’s attempt to defend itself against low mood. Which means that society as a whole may be trying to stave off existential despair by staying up late.

*Edward Shorter, 2014, The 25th anniversary of the launch of prozac gives pause for thought: where did we go wrong? BJPsych, 204, 331-2.

64. Improving posture, for sitting ducks.

Pfizer’s new team arrive, looking benign at first.

If you buy something in Waitrose you are given a green plastic token. On the way out you must make a choice between three charities by placing your token in the respective glass jar. To be honest, Waitrose have handed you a burden of responsibility you could well do without. Imagine what would happen if an ethical committee ever popped into Waitrose – they’d be stuck there for hours. Luckily, most people can resolve ethical dilemmas by throwing a set of mental dice, much like answering the last few multiple choice questions as the examiner is coming towards you collecting the papers. If you don’t have this kind of moral adaptability; if you’re a person who never uses the word ‘whatever’, you might turn into a whistle-blower.

In a quiet news week NHS whistle-blower stories are a good way of filling up Page 8 in The Times. The new head of NHS England, Simon Stevens, wants to reassure whistle-blowers that they can speak out safely. He has even had the shark tank removed from under his office floor.

If you want to be a whistle-blower – and remember your careers teacher said not to – it’s important to brush up on your movies. Start with ‘Serpico’, noting that it begins with the whistle-blower being shot and rushed to hospital. Serpico contains all the essential components for exposing poor practice , apart from the getting shot in the face aspect. Firstly, the character must be something of a Bohemian, with excellent hair and a Honda Superhawk. Secondly, the organisation that needs exposing has to be corrupt, through and through. In a conspiracy thriller it’s a given that corruption goes ‘all the way to the Mayor’s Office’. Never trust and confide in the mentor-like figure, played by an avuncular character actor, like Cliff Robertson. And thirdly, there has to be an audience that cares about the information revealed – proper journalists and a Congressional Committee. If your situation doesn’t have the Serpico ingredients no-one will take any notice and you will be marched out of the building, transferred to Runcorn, shot in the face, or all three.

The whistle-blower likes to be seen as a strong, principled and altruistic person who stands up against a corrupt system. Firstly, they exhaust the proper channels, then, finding everyone is in on the cover up, they take it outside the organisation, to the papers. In most cases, the whistle-blower is suspended from duty and very slowly discredited by the employer. Mostly they seem to lose their eventual employment tribunal and people assume that a lot of them are cranks. If they had paid attention to ‘The Insider’, they’d have been wise to all these shenanigans. For revealing that tobacco was surprisingly bad for you, Russell Crowe’s tobacco executive character was subjected to all sorts of dirty tricks by the company.

Whistle-blowers seem to get stuck in the system, sometimes for years. Some of them get stuck in embassies or Russia. Few of them get compensation or vindicated in front of a congressional hearing or portrayed as heroes.

Stories about deficiencies in the public services have lost a lot of their shock value. And employers have become more sophisticated in their powers of discrediting people. Whistle-blowers are often accused of non PC activities, such as being religious, arrogant, or failing to attend the fire lectures. That’s mavericks for you.

Essentially, whistle-blowing is not the British way of doing things, which is to muddle through and make the best of a bad situation. However, that changed a little since the ascendency of ‘management’ in public sector organisations. Managers made the mistake of believing they were running small private companies, when really they were administrators. All the major decisions, and all of the risk, is taken by central government. Yet managers have been successful in calling themselves Boards, styling themselves on private industry and paying themselves accordingly.

Local Trusts expected staff to be loyal to the Trust, but in reality they are only loyal to the NHS as a whole. This mismatch in loyalty plays out as follows: local manager as Sheriff of Nottingham, employee as Robin Hood, Simon Stevens as King Richard, David Nicholson (previous NHS chief) as King John.

The biggest problem for whistle-blowers is a sea change in public perceptions of organisations. No-one is surprised to find there is bullying or abuse within large institutions such as Oakwood Prison, or BBC’s Front Row program. Expectations are lowering and the shock threshold is rising. Medical whistle-blowing stories are losing their impact. I suspect that the conspiracy thriller genre has been so influential that everyone now assumes that large organisations are corrupt propaganda machines. The only exception really is Waitrose. Feed the words ‘waitrose’ and ‘whistle-blowing’ into google and nothing happens – apart from one dark moment in 1997, when Waitrose were accused of organising duck shoots for their staff. According to a leading member of the National Anti-Hunt Campaign, ‘Up to three times a week at the Leckford Abbas Estate near Stockbridge, Hants, parties of drunken John Lewis staff blast away at the pheasants, along with ducks, grouse, pigeons, squirrels and anything else that moves.’ These accusations were soundly refuted, which is reassuring. I don’t think the Anti Hunt Campaign get many green tokens down there, even now.

63. Being a do be, not a don’t be.

Voyeurism can be a problem for creatures that mate outdoors.

British psychiatry is a bullet-riddled corpse lying in the gutter, but people are still stopping by, from time to time, to give it another kicking.

It’s in a similar condition to other twentieth century institutions, like organised religion, nuclear power and the Co-op. They are zombies, but they are still staggering forwards, muttering incoherently.

The bullets come from many directions. No new drugs, no new therapies, massive cuts in hospital and community services. Very few medical graduates are coming forward to work in the speciality.

Attacking British psychiatry in 2014 is equivalent to laying into Workington F.C. for finishing bottom of the Conference League (North).

This time, the would-be assassins are a group called the Council for Evidence Based Psychiatry (CEP), who are attempting an anti-psychiatry re-launch, this time under an ‘evidence-based-medicine’ banner. Some of their argument turns on the (lack of) benefits and dangers of antidepressant drugs.

None of this criticism is new, and like all negative campaigns, this one will fall victim to the ‘negative halo effect’ that surrounds mental health information. It’s guaranteed to make people hop channels. The media won’t be interested unless one of the following crops up: colourful brain scan, or samurai sword.

Like progressive rock, anti-psychiatry belongs to a former era. CEP might just as well attack any other long demised evil empire, such as the Soviet Union or the Barons, or Marlborough Man. They could still be yelling ‘Judas’ at Bob Dylan for ‘going electric’ in 1966. They are probably still worried about the fuel tanks on the Ford Pinto.

To be fair, there is a lot to be critical about in modern psychiatry. Many of the points made by CEP are manifestly true, much as the programs ‘grumpy old men / women’ make accurate observations about modern life. It’s easy to criticise and there’s so much to be critical about. But what is the aim? To rant and rave, or to get more resources for non-drug treatments? To do that, the battle has to be fought in the context of public attitudes towards mental health problems.

Back in the middle of the last century, some very creative and brave researchers attempted to find out what ‘ordinary people’ knew and felt about mental illness. There were a number of milestone studies, such as those by Shirley Star in Chicago, Cumming and Cumming in Canada, and Gatherer and Reid in England.

These studies found that people tended to stereotype the mentally unwell person as dangerous and unpredictable. They were slow and reluctant to consider someone to be mentally ill, but once they did, they tended to avoid that person. The aim of these researchers was to reduce stigma by designing public education programs. Sadly, no-one is paying attention to what they found out, which basically, was: 1. ‘stay positive’ and 2. don’t attempt to pretend that mental illness does not exist – people are hard-wired to believe that it does.

Attempts to alter people’s attitudes toward mental illness failed because of the negative halo effect. In the case of the Cummings, they were eventually forced to leave town, hence the name of their book, ‘Closed Ranks’.

The researchers attributed this to an attempt to advance the notion that mental illness was something that could happen to anyone. People just wouldn’t accept that.

Interestingly, now it is the psychiatrists and nurses who are closing ranks. The worry is that what remains of the mental health industry will turn in on itself, similar to police departments, such as the West Midlands Serious Crime Squad or LAPD after Rodney King.

One sign of this is the Royal College of Pyschiatrists’ accusing itself of institutional racism, following in the footsteps (smaller size, obviously) of the Metropolitan Police. Another sign is the defensive sort of response service users get from NHS Trusts in response to queries. There are odd attempts at ‘whistle-blowing’, but in the NHS, that’s basically a one-way ticket to the Ecuadorian Embassy.

Closing ranks is not the answer, nor is smashing the system. Everyone knows that Psychiatry is the Cinderella specialty. The neglect, in all its forms, including poor quality treatments, is down to negative public attitudes. The Turning Away, as Floydians would put it. The solution, so obviously, is better media coverage.

Here’s an example of a positive strategy: in Liverpool, The Readers Organisation has been pursuing positive mental health by setting up Reading Groups for people with Depression*.

Results have been very promising, although the evidence base would doubtless fail to satisfy the CEP. Probably they will start to identify victims of literature instead: ‘Hi, I’m Charlie. I’ve been catatonic since I read Silas Marner’.

It’s already been shown that reading challenging literature causes bits of brain to light up in bright colours. Surely its time for a controlled trial of Wordsworth versus Prozac?

Although ‘ECT versus Titus Andronicus’ was turned down by the Ethical Committee.

*An investigation into the therapeutic benefits of

reading in relation to depression and well-being: http://www.thereader.org.uk/media/72227/Therapeutic_benefits_of_reading_final_report_March_2011.pdf

62. Displaying the pottery fish, with pride.

My alarm clock rings to tell me it’s behavioural activation time, also known as Nike Therapy, which means just do something and think about it later, if ever.

My eventual aim is to re-write the classic publication ‘365 things to make and do’ in an updated style to suit these post-ironic times. Also, I’d like to add a 366th project before 2016, which is the next leap year.

Today’s project is to shred a few copies of the NICE guidelines for Depression, mix them with PVA and turn them into hats.

As I shred, I realise that these guidelines do mention the term ‘behavioural activation’ but don’t explain how to do it. They say nothing about arts, crafts, music or hats. Which is surprising, given that there is a long tradition of arts and music therapy in mental health.

My hypothesis is that people need to do something with their hands to feel properly human. Manual work, crafts and organised sport have declined, leaving the hands as mere vestiges of devices that once could dig or sew or fire an arrow. Most people still prefer a mouse to a touch screen, when there is a choice. Many people still prefer a manual gearbox, even though automatics are now superior in all respects.

I have another project coming along which is more complicated. This involves taking photos of bits of stained glass windows, printing them in different sizes, using all the different, clichéd image filters in Pixelmator (such as the ‘ennui’ tool), tearing them up and sticking them onto a collage, which in itself looks like a stained glass window.

For some reason I’m having trouble (as though it was the printer’s fault rather than incompetence on my part) getting them printed at the right size, so they are coming out like postage stamps instead of A4.

If I had to give this activity an hourly rating for mood improvement, I’d have to rank it slightly below checking the lawn for cat faeces, collecting it on a special trowel and flinging it over the garden fence onto the railway line. But it might improve.

Either the picture is going to be postcard size, saving a lot of PVA, or I’m going to have to ask a teenager how to resize the images. Or perhaps find an art therapist, just to check whether this whole activity is artistic or not.

There are no art or music therapists in my local area and come to think of it, none in the hospital where I work. This demise of arts and crafts based therapies has been insidious and largely unreported. This seems like a pity, and I wonder who’s to blame.

Somewhere or other, the mental health establishment has got the idea that ‘therapy’ has to involve a bus journey across town to speak to a person in an office for about an hour once a week for about 20 weeks. True, these activities are evidence-based to an extent. It’s just that the evidence has been collected along narrow strands of enquiry, being derived mainly from a ‘clinic’ context.

No-one has bothered to see whether listening to good music or watching football or making rhubarb crumble can treat Depression effectively. And imagine the practical difficulties in conducting such studies.

Therapies where numerical ratings are intrinsic, such as computerised CBT, have the advantage in terms of generating evidence of improvement. They have largely taken over from other modalities, leaving a long queue of psychoanalysts at Jobcentre Plus.

There’s perhaps a lesson to be learned from Interpersonal Psychotherapy, (IPT). This therapy was invented by Klerman, Weissman and colleagues in the eighties. It’s a standardised approach with a proper instruction manual, which makes it amenable to testing. In particular, it was tested against drug therapy – in those days mainly tricyclic antidepressants.

Its designers were highly scientific individuals with an excellent grasp of the various different ‘models’ of Depression: biological, family, cognitive, psychoanalytic, feminist etc. They knew how to fund and conduct controlled trials and publish the evidence properly. And thus IPT is one of the two types of therapy that NICE bother to endorse.

Compare that approach with a study by Mike Crawford in 2012, purporting to show that weekly attendance at a group arts project had no benefit for patients. I quote:

‘Members of activities groups were offered activities that did not involve the use of art or craft materials’.

My italics, meaning ‘why on earth not?’ It’s not the full Blue Peter, not without the sticky-back plastic.

This is what the new version of ‘365 Things’ should try and achieve – a standardised arts and crafts therapy manual. So we can finally show that meaningful activity is good for people. Each task should be spelled out clearly, like in Marguerite Patten’s 1000 favourite recipes.

And include proper materials like policy documents, shredders, glue and paint. For a long time the surest way to upset an occupational therapist was to mention basket weaving. Now, I say it’s about time for a raffia revival. And it’s time to display the pottery fish, if you’re lucky enough to have one.

Detail from Queen of Heaven, by M Healey, 1933, St Brendan’s Cathedral, Loughrea

61. Punching above your weight, with Britney.

Robot Archie is a comic strip character waiting for a revival. He was amazingly strong and intelligent, but he had one career limiting weakness – he had a control panel that was clearly visible to others. This made him vulnerable to assailants creeping up behind him and pressing the clearly labelled off switch. Nevertheless, having labelled buttons, or even dials to control aspects of oneself would be a huge asset for humans.

Imagine setting your mood state or attitudes with a mode switch, like the ‘Dynamic’ button on Toshiba televisions, which gives an altered visual experience similar to hallucinogens.

One control we really need, besides air con, is a self-confidence dial. Most people set their level a bit too high, much like the heating on trains. The average person is over-optimistic about life in general. Psychologists have identified a cognitive bias towards overestimating things like how intelligent and attractive we are, whether our predictions will come true and how long it takes to get served at Costa. It has been argued that all trade works on this basis, where both parties in a deal overestimate the value of the item they are exchanging.

One peculiar exception to this rule seems to be life expectancy – people, including experts like actuaries, are underestimating how long they will live, which is a major nuisance for the pension funds. Another exception is people suffering from Depression, who tend towards pessimism, as well as a negative evaluation of past events.

Setting the confidence level a bit high is viewed as a defence mechanism against life’s upsets and affronts. But there are certain situations where it’s an issue, such as medical training. It is well recognised that the worst type of doctor is the overconfident one. The sort of person who thinks ‘see one, do one, teach one’ should read the other way round. The sort of person who says loudly, ‘bypass grafting – how hard can it really be?’ on his way into the operating theatre. Trainers recognise that the overconfident doctor is the most difficult one to put right. It looks as though overconfidence or even arrogance is relatively impermeable to feedback, which is perhaps why it’s such a good defence against self-loathing.

Another aspect of the overconfidence debate is whether doctors should give a completely accurate account of the likely benefits of treatment, or apply a little positive spin. Surveys have shown that service users appreciate an upbeat attitude, as well as honesty.

Modern life has removed some of the old certainties, such as how long we will live, or whether the older professions are the best careers. The employment market has too many graduates and not enough artisans. Large companies like Tesco and Microsoft, which we assumed would carry on for hundreds of years, like the Roman empire, seem to be on the decline. This has led to a situation where people change career more frequently. Many candidates for jobs think of themselves as overqualified. And the orthodoxy within firms is not to hire the overqualified person on the basis that they will become disgruntled quickly.

That leaves a serious self-calibration problem, in the absence of a human dashboard. To an extent, CBT (Rational Emotive Behaviour Therapy in particular) is an attempt to assign the correct emotional value to aspects of oneself. Otherwise it’s clear that people are just all over the place when it comes to self-evaluation.

Take a look at these small ads for instance, which illustrate some form of extreme cognitive bias – the disorder usually known as ‘Ron Hopeful syndrome’:

Elderly gentleman, heavy smoker, slightly racist, seeks supermodel for company, trips to garden centre, kinky sex and possibly more.

Nissan Micra, 1997, beige, some damage to interior due to poorly cat, looking to exchange for holiday villa in Cornwall or Devon. No time wasters.

Senior scientist wanted, PhD or post doc, nanotechnologist preferred, fluent Russian desirable, for general warehouse duties.

Wanted: chief executive officer for large healthcare organisation, should have English Language GCSE or equivalent, shovel and forklift training provided

General Medical Council seeks lay member. Performance artist preferred, e.g George Formby impersonator; street theatre, statue man, juggling etc desirable. Ukelele provided.

Crime fighting robot from 1960s available for general do-gooding and big society fieldwork, unpredictable at times. Good with dogs.

Historical footnote – contrary to my first impression, a little research shows that Robot Archie has already made a number of career comebacks. According to Wikipedia:

‘In Zenith, he was a burned out 1960’s acid casualty (renaming himself Acid Archie). Archie is apparently killed by Ruby Fox in Phase IV when she short circuits him whilst he is trying to rip off her head. Archie also appears in zzzenith.com in the special Prog 2001 edition of 2000AD. Zenith explains that rust in the brain-pan has caused Archie’s personality to change from anarchist Acid-House aficionado into a vigilante, hunting down sex offenders with a lethal vigour. He is last seen in the story escaping on a bus in a false beard after sexually assaulting pop star Britney Spears’.

It’s also possible that he gained weight with age so that he wasn’t able to reach his own controls any more, located as they are in the middle of his back. As a literal ‘locus of control’ problem, this was probably what gave Julian Rotter the idea in the first place.

To some extent, he never learned to push his own buttons properly. Like most fictional robots, his downfall was caused by getting too human to control himself.

60. Finding more cultured friends.

Bonnie and Clyde – eggs can be killers.

Pretty soon, the most coveted dinner party guests will be microbiologists. If you know any, you should cultivate them. Germs are coming back into fashion.

A lot of people have problems accepting that humans don’t contain any rare or precious elements, except metaphorically, like pearls of wisdom. No gold inside us, no platinum, no diamonds. No titanium, amber or crystals. Mostly water and cheap stuff, like carbon, nitrogen, sulphur and rust.

But there’s worse to come – a large part of us is not human at all – we are nine tenths made of bacteria – at least in terms of the number of cells. The gut ‘microbiotica’ is our largest organ, and possibly our most intelligent one. If the human body is run by a board of directors, the brain might be chairman, but the largest stakeholder is the colon. Definitely not a silent partner. Scientists have shown that the communication network between the gut and brain is a superhighway, the vagus nerve being the M1-near-Luton of all nerve pathways. Many neurotransmitters exist in the gut as well as the brain, and many of them were found in the gut first, such as cholecystokinin, a peptide hormone.

For decades, people were brought up to believe germs were the bad guys. After all, millions of people used to die of infectious diseases like cholera and tuberculosis, and these diseases are still prevalent in much of the world. Although such diseases are controlled mainly by public health measures rather than antibiotics, there is an awareness that resistant organisms are threatening to launch another era of infectious diseases. Already, there have been massive problems controlling outrageous punk – rocker organisms like clostridium difficile (the clue’s in the name).

I’m going to just introduce the phrase ‘faecal transplant’ and get it over with. But that’s how clostridium difficile can be treated. And that’s why there’s a website called ‘the power of poop’. The cure for bad bacteria is good bacteria. I don’t want to upset any readers who are germ phobic, though I expect they are already spraying dettol over the touchscreen and putting on a new pair of Marigolds. A small number of germs have got the others a bad name, just like badgers. We are going to have to stop killing them and start hugging them more. We will see a revolution in the yogurt industry similar to the real ale phenomenon of the seventies. Instead of Ski type products that have been sterilised and given an absurdly-soon sell by date, we will have yogurt with a bit of fizz to it with a ‘best after 2016’ label.

It’s been a while since I treated someone with a germ phobia, but I have a lasting memory of standing next to someone in their home, both of us with our hands pressed against the slimy surface of a kitchen sink, keeping them there for 20 minutes, time for anxiety levels to die down, doing some hands-on behavioural therapy. On this occasion I realised why Cognitive Behaviour Therapy was taking over – because it could provide a massive short cut. Rather than change the actual behaviour, why not look at the thinking behind the behaviour instead? This lady thought that even one germ could kill you. So, hands still pressed into the slime, we talked a bit about the germ theory of disease. People tend to assume that germs cause diseases by infecting people. This is only partly true, in that we have a powerful immune system, so that even the most aggressive organisms will not cause illness in everyone, or even a majority of people. There has to be a chink in the immunological armour, plus a sizable number of germs in the infective boarding party. This concept is called the minimum infective dose, which is usually millions of bacteria. One germ is hardly ever enough to cause an infection. In fact, landing on a human body is one of the worst things that can happen to a germ. It’s equivalent to being the first person up the ladder in an attempt to storm a castle. There are many kinds of immune response, equivalent to boiling oil. So that’s what I told her. It’s true that people can still catch cholera or tetanus, but statistically the chances of catching anything lethal from a sink in Edgbaston is national-lottery-level low (south of Hagley Road, anyway).

The problem for today though, is how to take a rational position on personal hygiene. Last week, at the seaside, I saw a child drop the ice cream out of a cornet onto the beach, only to be retrieved and replaced on the cornet and given back to the child without even a wipe. The child appeared to accept this without reaction or comment. Was the parent doing the child a favour in terms of building up immunity, or recklessly courting a nasty infection? Luckily, most germs will not get through the multiple defences of the upper GI tract, like the concentrated hydrochloric acid in the stomach. That seems to be a problem for so called macrobiotic remedies, which often fail to reach the minimal infective dose. Food outlets are stringently controlled for hygiene. In our cafe shop for instance, the volunteers had to put on plastic gloves between touching the food and the money, which slowed them down enormously, particularly if they had impaired fine movement.

This week however there has been renewed interest in raw milk, even suggesting that it may have health benefits long term. Yet, googling ‘raw milk’ suggests that it’s one of the most dangerous groceries, up there with eggs, peanuts and cantaloupes, in the food-borne infection league. All this makes it difficult to know what to tell germ phobics, in terms of psycho-education. Recently a microbiologist told me not to eat potatoes that have gone a little bit soft or started sprouting. Apparently, they can contain very dangerous toxins. I confess, I never suspected the humble potato could be a mass murderer, though I was not surprised about cantaloupes, whatever they are.

People’s attitudes and behaviours around food hygiene seem to vary tremendously. Some of it comes down to ‘locus of control’ issues, and general perceptions of environmental threat. In the absence of a testable consensus on hygiene, we might just have to go back to old school marigolds-off behavioural therapy. If it turns out, as seems likely*, that ‘good bacteria’ can treat a range of diseases, possibly including Depression, some very careful marketing is going to be needed. For instance, the corporate colour scheme should definitely not be brown. It’s just a gut instinct.

* Dinan TG and Cryan JF, 2013, Melancholic Microbes: a link between gut bacteria and depression. Neurogastroenterol Motil, 25, 713-719

59. Cutting costs to the bone and a few corners.

Behind the scenes at Boots.

While we’re on the subject of newspapers (see 58) I’m wondering if the Sunday Times shouldn’t go on the top shelf at the newsagents, along with Total Carp and Darts Illustrated (Swimwear Edition). I’m seriously wondering if its worth queuing up behind the lottery victims, paying £2.50, just to have your world view tarnished and warped.
What is happening at the Sunday Times? Has the influence of Jeremy Clarkson begun to infect the other journalists, who have failed to realise that Clarkson’s work is ironic?
World war three will probably be a fight between thin people and the obese. I wouldn’t put money on the thin people – yes they can run faster, but they can be squashed more easily and might not survive a nuclear winter. In a bid to kickstart the war, Rod Liddle wrote a vicious attack on obese people, entitled: ‘Chew on this insult, lardbucket. It’s for your own good’.
Elsewhere in the paper we learn from Prince Andrew that failure is good for you. I wonder if he’s fully understood what his therapist told him.
And, if that’s not gratuitous enough for you, Camilla Cavendish writes an article this week entitled: ‘Dr Useless says he’s busy. Fine, I’ll be off to the pharmacist then’.That’s a bit more serious, in that Camilla Cavendish is on the board of the Care Quality Commission, and usually wears a serious writing hat to comment on health services, such as contributing an influential report advocating standard training for health care assistants.
The gist of the article is that doctors are very hard to get to see, ‘just to get antibiotics’. It takes weeks to get an appointment. Whereas you can just walk into the pharmacy shop and see a very nice man in a labcoat who will give you whatever you want straight away.
Does this article suggest there is a significant lobby in favour of reducing the role of GPs in favour of pharmacy shops? Private companies have been rather slow to muscle in on the general practice market. Tesco and Morrisons often have pharmacies, but never seem to offer medical specialists, not even dermatologists.
But more recently, Tesco and Morrisons have been struggling even to run the grocery section properly. Instead of supermarkets taking over health care, it’s more likely that the GP will start selling fruit and vegetables.
If one takes the view that a slimmed down health service will confine itself to drug therapies and leave the chat to the private sector, supermarket pharmacies might become the first port of call for the health shopper.
Like Trad Jazz and CBT, pharmacists have no natural predator – no-one has a bad word to say for them. That view could change, if they take on a more central role in primary care. Pharmacy shops are businesses that make their money from selling tablets and potions. Are they likely to offer a free consultation with a professional person and advise you just to wait and see? Or will they sell you some tablets? Will they give you Paracetamol for 16p or Panadol for 89p? I think you know the answer.
While some commentators are predicting that pharmacy shops will take over from GPs, I say: why not cut out the middleman altogether? And that is where Poundland comes in.
Luckily, mental health is a field where the very cheapest tablets are as good as the luxury products. The NHS doesn’t want to spend money on mental health, and isn’t going to. Luckily, it needn’t cost you a fortune either.
Don’t tell the Royal College I said this, but a reasonably sensible person with access to google and the Poundland Pharmacy, should it ever exist, could get a months supply of an effective antidepressant or antipsychotic for 99p. You could get some free counselling from a local religious organisation or the Samaritans and have enough left over for your bus fare and a flat white. I also wonder why Poundland can’t start a Sunday newspaper that’s a bit nicer to fat people and doctors.

58. Just asking: what would Englebert do?

Robin Hood: should have stayed out of Nottingham

Byron: should have stayed in Nottingham

Is it possible to develop a phobia of a specific town or city? If so, what is the correct term for an acute fear of Nottingham?

Don’t forget, a phobia, by definition, has to be irrational. However, there are plenty of genuine reasons to be afraid of Nottingham, in particular the possibility of making an unwanted left turn onto the Trams only zone, punished by a £30 fine and a humiliating picture of yourself, grinning foolishly, in your car, on a tramway.

We all know there is only one way of treating a phobia, and it’s not multivitamin tablets or fish oil. Determine what the fear is, then – as Nike would have it – just do it. Which is why I find myself in Cafe Nero, near Nottingham station, shaking and hyperventilating and palpitating, as I type my negative thoughts into the Nokia: If I run as fast as I can, I will still be in Nottingham for half an hour before I reach the edge. It feels like being on a submarine or space station, without an escape pod, other than East Midlands Trains. I look round, but I can’t see a defibrillator handy, nor anyone who looks trained in immediate life support. For a moment I wonder if caffeine might really have a discernible effect on the nervous system – I’d always assumed this was a myth.

And then, right in front of me, I notice there is a discarded copy of the Daily Mail health supplement. Which is when I get distracted from my behaviour therapy program and morbid thoughts about sudden-adult-death-in-Nero-syndrome. Until Michael Gove puts more basic medical science onto the school curriculum, we have to make do with the health pages in newspapers to find out how our bodies work. As I read through, I learn the following:

Under the headline, ‘The allergy delusion’, it is reported that many people who think they have allergies, or have even been diagnosed with allergies, are not really allergic. There’s a long story about someone whose GP has told them they had dairy and gluten sensitivity, only to find out from a proper doctor, with a labcoat and microscope, that they had Crohn’s disease the whole time.

Next, I learn that International Singing Superstar, Englebert Humperdinck, (ISSEH for short) suffered from asthma which completely went away after four sessions of acupuncture. Without acupuncture, ISSEH would never have been able to achieve 25th place in the Eurovision song contest. ISSEH’s mother was told she had just a few weeks to live, but following acupuncture, lived on for years.

There are many other fascinating stories. A Psoriasis sufferer had been cured completely by Cognitive Behaviour Therapy. It can be dangerous to suppress a sneeze. Vitamin D is unlikely to do any good for most people. Central heating makes you fat. Lifting weights can harm your eyesight. Migraine can be managed by a magnetic machine about the size and weight of a house brick. It has a handle at either end and is applied to the skull.

I learn that it could be bad for you to keep pressing the snooze button on your alarm clock. Snoozing only makes you more tired. By rights, the button should be called ‘procrastination’, but there isn’t room to write the proper word.

Medicine as reported in newspapers represents an entirely different, yet parallel speciality. In the Hospital of Newspaper Medicine there are several floors devoted to alternative medicine. There is a huge department of Bogus Nutrition. These patients all appear to be slim young females in gym outfits. The mental health floor is convinced that CBT and Mindfulness can cure any condition. The upper floors are filled by keyhole surgeons and computer controlled robots. The medical wing is full of machines the size of house bricks that go beep. Again, all the patients are slim young females in gym outfits.

Yet in the basement of this hospital there is a well resourced Debunkology Department, where last years miracle drugs are revealed to be the stuff of nightmare. Last year Statins were supposed to make us all live till 120. Everyone should take them.This year the Guardian tells us that Statins have become ‘a monster that no-one can kill’.

I think I’m beginning the get the hang of Newspaper Medicine. News has a kind of cycle with a fast turnover – build things up, knock them down. It’s the same treatment as celebrities and football managers. By comparison, Dr Google and Dr Wiki seem like paragons of truth. Something seems to happen to journalists that makes them bitter and twisted. I’m guessing it’s the fact that any old person with a computer and $20 for a website can be a writer nowadays, even an escaped psychiatrist. Newspapers seem to suffer from excess bile, which is probably why they go yellow after a few days.

What would they make of someone who had become phobic to a whole city? My guess is one quick article about Total City Allergy Syndrome, with a tip from ISSEH suggesting acupuncture got him over the problem he had going to South Wigston. Only to be followed by a rapid debunking exercise making it clear that City Allergy Syndrome is a delusion or possibly a benefits fraud.

Along the lines of the Tintern Abbey joke lets try this one:

Patient: Doctor, I have an irrational fear of a large industrial city in the East Midlands.

Doctor: It’s Nottophobia.

Patient: Yes it is a phobia.

No? I’m sure Stuart Lee could make it work.

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