Author Archives: ep2012

57. Selecting the right animal charity, and other questions.

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Another Free School fails OFSTED.

Some people seem to question everything and some seem to question nothing. And then there are those in between. This week EP attempts to address some of your burning issues, so you don’t have to. Why not send in some more for next week?

Q. Is thinking driven by continual questioning?

A. No, it is driven by nicotine, chewing gum and certain types of chocolate.

 Q. Is Mindfulness the new Mom’s apple pie?

A. That’s probably a bit too concrete and  three-dimensional. It is perhaps more the new Angel Delight, or Dream Topping.

Q. My son has built a scale model of Stockport with fingernail cuttings. Should I call the early intervention team?

A. I’m afraid it’s too late. Try entering him for the Turner Prize.

Q. Should I give more money to charity or try Random Acts of Kindness?

A. It’s best giving to a highly specific charity, rather than one where most of the money goes to a bloated bureaucracy in Chelmsford. Some of my favourite charities are animal related, for instance, Pyjamas for Llamas, and Maracas for Alpacas. The latter is based, I think, in Caracas. If you want a random act of kindness, give the lollipop lady a bullfighting outfit. Tell her it’s just a question of reframing.

Q. Most people assume they are healthy unless they have symptoms of an illness. I’m the other way round – I need constant proof that I am well. Should I be worried?

A.This is called the Inverse Health Cognition. It may just mean you’re American. Otherwise, Kindles and Ipads have very long battery life nowadays – these will get you through long periods in doctors’ waiting rooms.

Q. Why do medical students ask questions all the time, instead of the old system, where I ask them questions?

A. Because the signal strength in hospital is too poor for google to work properly. You are the next best thing. Take it as a compliment.

Q. I’m having trouble understanding the changes to the NHS. Can you explain them?

A. It’s a complicated model, based on the old British Empire. It’s a mixture of colonial administration, piracy and gambling. Don’t forget, the British Empire never went away – they just moved the headquarters to Washington.

Q. What can I do about writer’s block

A. What I do is write in the form of Questions and Answers. If that doesn’t work try Lactulose.

Q. Is it true there is no real person called Ted Baker? My beliefs are shattered.

A. Nothing is as it seems. Compared with faking the moon landings, this was a pretty easy deception. Colonel Sanders was real, but he wasn’t a real colonel. The chicken doesn’t come from Kentucky either. Does it even come from chickens? I bought a Giant bicycle, only to find it was the same size as all the other bicycles. Same thing with Tiny Computers. As Peter O’Toole observed in Stuntman, King Kong was really only six feet high. The list goes on…

Q. If World War Three happens, where shall we hold it?

A. The middle east, during the summer, is completely stupid, see World Cup 2022. Conversely, Russia is too cold. It all points to Belgium, if there’s room.

Q. Have you had any more ideas for blockbuster movies?

A. It so happens yes. My latest idea is a sci fi / historical / heist movie: A team led by John Sentamu, Archbishop of York, mounts a daring raid in an attempt to steal the bones of Richard III from Leicester University’s high security archaeology wing, reclaiming them for York. Only to find, when they break into the lab, that the genetics department have actually re-created Richard III himself from traces of DNA. He’s angry. He wants his kingdom back. And the last place he’s going is Yorkshire. That’s all I can give away at this stage, Brad.

56. Making the Co-op a bit more Hendrix.

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An early attempt at the anatomy pop-up book.

Almost every medical problem in some way boils down to a faulty feedback cycle. The simplest examples are endocrine diseases like diabetes, but the model can be applied to cancer cells, where cell division fails to switch off, and immune diseases, where antibodies mistakenly attack a person’s own tissue. A lot of economic or political debate falls into this same category of trying to fine-tune a system. For instance, using higher interest rates to reduce borrowing, or tougher sentences to reduce crime. Sometimes a system breaks down, failing to respond to feedback, like the heating systems on East Midlands Trains, which have fallen victim to the fashion for Hot Yoga.

Today, we learn that the Co-operative Group is ungovernable. That seems like an over-reaction, based on my experiences at the local Co-op supermarket. But when I think about it more carefully, the signs have been there for a while. Firstly, the car parking spaces went from impossibly narrow to Humvee size. Then there were the yellow sticker reductions – from £2.99  to £2.97. Not enough action there to clear a pile of steak pies facing a tight sell-by date. And when the pet food and pet product aisle became longer than the people food section (I accept there’s an overlap), we should have seen the writing on the wall. As well as the actual writing on the wall, which says ‘Laura H is Easy’.

During its flirtation with electricity, Psychology showed an interest in Biofeedback. This was an attempt to exert conscious control over a supposedly unconscious function, like blood pressure or heart rate. To learn this, a person needed a machine that would continually measure and reveal the reading concerned, and a system of relaxation. You can still buy biofeedback machines, but they are competing with tablets like beta blockers that don’t need plugging in. There could be a biofeedback revival once access to Functional MRI gets easier, for instance if you can get one on your android phone. For Apple you’d need the £25 adaptor.

I just got back some feedback on myself, from colleagues and patients, in the form of a so-called 360 degree assessment. We have to do one every five years. It seems like a slow process, but that’s about 20 times more frequent than the Cooperative Society. Alleged ‘crystal methodist’ and adult-content-consumer Paul Flowers, who chaired the co-op bank until last year, apparently did very well in aptitude and psychometric tests prior to his appointment in 2010. I suspect he’d have passed his 360 with flying colours too. Flowers was said for instance to have been excellent at engaging other people’s views. History may yet regard him as a great chairman. If he’d worked in the NHS he’d have been reinstated by now in a different branch at twice the salary.

To make feedback work we need to make the sampling frequency higher and the amplitude lower – a process that cuts in as soon as someone goes ‘off message’. Something more akin to the kind of feedback Jimi Hendrix achieved in his version of Star Spangled Banner. Imagine a system for instance that connects a politician or corporate giant to a brain imaging device. This could display his brain activity as he goes along, either to himself on an autocue, or to the audience, on a powerpoint display. Similar techniques have been applied to audience feedback during political speeches and even movies, using appreciation buttons.

Amazon apparently know which are the best pages in novels, based on how quickly they are read. Imagine what the great novelists could have done with this technology. Maybe it would have stopped characters suddenly dropping dead from a chill, or selling their wife at a market. Or making Laura H, suddenly, ‘difficult’.

It’s said that people who become habitual liars fail to notice whether they are even lying or not and even come to believe their own lies. Yet lie detectors have been around for decades. We already have a host of biological measurements such as EEG and skin conductance. We already have heads up interactive displays such as Google Glass. We already have portable electric shock devices. And somewhere in the world there is probably a large pile of testicle electrodes. Surely it won’t be long before someone connects up these technologies?

55. Saving the early intervention service, till later.

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An uneasy meeting at a fancy dress party.

It’s official. Children cost too much. Childcare costs more than a mortgage. If you have children they might stop you going to work, and they eat a lot too. Shouldn’t people be told this sooner? Worse than that, children don’t come with any kind of guarantee, and more of them seem to be going wrong. If Toyota had made them there’d be a recall. And soon a Commons Committee on young people’s mental health will start its proceedings.

Though there are rumours that mental health problems among teenagers have increased, there has not been a proper survey since 2004, when the world was very different. It’s hard to believe, but they didn’t even have Instagram in those days, let alone Whatsapp. People wore top hats and tail coats and travelled by horse, particularly the women.

There are lots of theoretical reasons why it’s got worse to be a teenager. Legal highs are widely available, the Harry Potter series came to an end, and no-one is far enough beyond suspicion to take over hosting Jim’ll Fix It, unless Desmond Tutu can be persuaded. Large numbers of youngsters have been sent to remote labour camps, or universities as they are now known. Employment opportunities as footballers and TV presenters, the only jobs worth having, have largely dried up.

Sadly, if a generation of teenagers became psychotic or depressed, no-one would really notice. Part of the blame belongs to British psychiatry and its strange tradition of age discrimination. For some reason we have different specialists for young, adult and older people, as though they were totally different forms of life – like eggs, caterpillars and butterflies respectively.

There’s a kind of reason for that, in that young people don’t really get the same kind of mental illnesses as adults. Psychotic conditions are very rare in children, or so we thought. ‘Early intervention’ services were an attempt to plug the gap, at least for older teenagers who seemed to be showing signs of schizophrenia. Early intervention was a laudable aspiration, but didn’t get much beyond that, since there was no litmus test for psychosis. The services were overwhelmed to an extent, by the numbers of children with emotional disorders, such as so-called ‘borderline’ personality; problems that,in a sense, flow from children being treated as commodities instead of people.

To cut a long story short, another tonne of anti-psychotics wended its way to the sewerage system, some of it via people. The early intervention services have been pruned back rather savagely, before they had a chance to flower. Doubtless the Commons Health Committee will come to regret this. In the meantime, services for teenagers are largely restricted to a skateboard area and free condoms at the library, for those who are brave enough.

When the large mental hospitals were closed down, some people warned that community services would be much easier to cut. It’s to do with visibility. Some of the asylum hospitals were the size of aircraft carriers; quite likely some of them had their own Harrier Squadron. They certainly had farms, ballrooms and cricket pitches. Everyone has noticed they’ve gone.

The coalition government has been quite tough on aircraft carriers, and luckily there won’t be one to send to the Crimea. But having a carrier with no aircraft to go on top is a major embarrassment. It’s like a Christmas cake without the marzipan, let alone the little decorative church and snowman. Similarly, having a hospital full of closed wards looks a bit wasteful. But if a care assistant only comes half as often, for half as long, or doesn’t visit at all, no-one really notices.

And if your psychotherapist turns out to have one years training at a community college, rather than the 25 year apprenticeship in Vienna and the multiple doctorates you’d expected, it’s hardly a big deal to anyone. Low tech services have a soft underbelly, as do many of the people who work in them – too much driving about eating petrol station sandwiches.

As the community mental health services are scythed back, we hear only a few muffled squawks from politicians. Nick Clegg (deputy prime minister and Britain’s answer to Al Gore) popped up in January, stating that mental health must be given parity with physical health. ‘We have got to take this out of the shadows’, he said. And we can expect a further survey on teenagers’ mental health, probably conducted by social media. But does the government have any coherent plan for teenagers, or are they considered, as a Bond villain might say, ‘expendable’? After all, they don’t vote and they don’t pay much tax. As a species, humans have a reasonable life expectancy at birth, which is a miracle, considering we ride bicycles, but perhaps this is set to change. It’s a bit ominous that youngsters are now being told that world war one was a useful outing.

With the demise of early intervention teams, there should be a move for adult and child psychiatrists to work together more closely, but I see no signs of this. They just drive a totally different kind of Audi.

During vacations I always got a child psychiatrist to cover my work, which he did brilliantly. I doubt whether I’d fare so well with his patients, unless he wanted half of them put on depot injections, and a tonne of complaint letters from parents. And I’m not sure if they still have sandpits to play in, so I wouldn’t know whether to bring my own bucket and spade.

Maybe a reverse takeover is in order, where children’s services take over and everyone is regarded as a child. This is perhaps the only way that children can get treated equitably. The danger is Ofsted staging a coup and taking over the government. And everyone would have to have a CRB check, just to meet anyone else at all. Treating everyone like children has worked well in lots of countries – you know who you are, nanny states.  Perhaps Nick Clegg could consider this. Otherwise, teenagers, like Hank B Marvin, are just going to have to ‘stay in the shadows’.

54. Looking at parallax, from a slightly different angle.

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Electric horses – the next big thing in personal transportation.

A man talks to a phone-in show on Piccadilly Radio. He says the TV aerials in the next street are of an unusual type and point a different way, not towards the transmitter. Finally he mutters the word, ‘aliens’. The radio host asks him whether he has checked for seed pods under the stairs. The joke is a bit lost on those unfamiliar with ‘Invasion of the Bodysnatchers’. The host finally grows inpatient and cuts off the most interesting guest of the day, before I can get an impression of whether he is psychotic or not.

One of the intriguing questions in public health is how many psychotic people there are hidden away who have no contact with the NHS. Surveys suggest that 1% of people have schizophrenia, which is a much higher number than we see in clinics. Have these surveys over-included a lot of people who, on the face of it, seem deluded, but on closer examination, simply share widely held beliefs about conspiracy?

On a long plane flight this week I read a book by Andy Thomas, called ‘Conspiracies – the facts, the theories, the evidence’. One of many questions that occurred to me, was why had this book suddenly been reduced in price from £6.99 to 99p? It’s hard to believe that Amazon doesn’t form part of the New World Order, the secret power said to be behind many attempts to deceive us. Maybe this book is in itself a diversionary tactic, or a tiny wink of knowingness that Big Brother gives us from time to time.

A surprisingly large number of people believe that Princess Diana was murdered or that the twin towers were brought down by some faction within the USA. In fact a surprising number of people believe both that Diana was murdered and that she is still alive. Chalk that one up to cognitive dissonance theory.

If some or all of these theories turn out to be true, it would definitely change a person’s view of the world, from that of a relatively safe place to a dark, dangerous and threatening one.

The fact that there are so many people who believe in conspiracy, and that certain conspiracies, such as Watergate, turned out to be true, raises a lot of interesting questions for clinicians.

As psychiatrists, we are taught not to get delusions mixed up with religion, politics or superstition. To be called delusional, a belief has to show a clean break in its logical development. Conspiracy theorists work with an alternative chain of logic, rather than a deluded person’s new canvas of meaning. Though many people who are psychotic suffer from persecutory type ideas, it is very rare to confuse a psychotic person with a ‘truth seeker’, as conspiracy theorists are now known, despite some very bizarre truth seeking theories, such as thinking the royal family are lizards.

There is probably very little point in trying to work out why people develop strong beliefs. The answer is ‘all sorts of reasons’. As far as delusional beliefs go, the best answer we have come up with is ‘because of a disease process’. Although delusions are held strongly, most non-delusional belief is held lightly and easily changed in the face of further inquiry. For instance, it is reported that when faced with medical need, many catholics will opt for a termination of pregnancy and that many Jehovah’s witnesses will change their minds in favour of blood transfusion. Most opinion surveys test only the topsoil of belief, and are designed to do so, by whatever vested interest is controlling the survey.

Psychiatrists are not in a hurry to identify beliefs as delusional, and despite what is said about the old Soviet Union etc, it has not been necessary for oppressive regimes to use tame psychiatrists to label dissidents as psychotic. Oppressive regimes are able to lock people up or have them disappear without pretending they are ill.

While psychiatrists don’t seem to be playing much part in locking up dissidents, they may be complicit in some more sophisticated subversions. In particular, psychiatrists play a major role in the drugs pipeline, the one that runs from a chemical works in Hull to your meso-limbic system and mine.

For instance, a steady stream of people come to outpatient clinics ‘wanting the diagnosis’ of bipolar disorder. (See Post 28). The exponential growth in the Bipolar Industry has been well described by David Healy, in his book, Mania: A Short History of Bipolar Disorder. Tellingly, this book has not been reduced by Amazon, so it probably contains some sinister truths we are not supposed to hear.

The key parts of this conspiracy are as follows: No useful new drugs have been developed in mental health for 20 years. Instead, the pharmaceutical industry has chosen to expand the market for drugs already on the market. Hence we saw a complete re-branding of ‘manic depressive disorder’ into ‘bipolar disorder’, massively expanding the diagnostic concept by including so called ‘bipolar II’ and ‘bipolar spectrum disorder’.

The outcome was a massive increase in the numbers of people with miscellaneous temperamental problems being given so called ‘mood stabilisers’, either atypical anti-psychotics or anticonvulsants, both being items from Boots’ ‘fat and sleepy’ aisle.

It took a lot of time and money to do this, and large numbers of psychiatrists collaborated in the process. There is a strange relationship between certain academics and clinicians and the drug companies and by strange relationship I mean free lunch – in Belgium.

In fuddy-duddy Britain, there is now endless conflict between psychiatrists and wannabe bipolar patients, but the signs are that the psychiatrists are surrendering. The customer is always right, especially if he is persistent, sharp-elbowed and well-googled.

We saw the same pattern in children’s mental health services. Once upon a time it was extremely rare to be diagnosed with Hyperactivity in the UK. A child had to be hyperactive all the time, not just between 4pm and KFC time. Even then, the use of psycho-stimulants like Ritalin was rare, and couched in cautionary warnings, like ‘use only as part of a carefully controlled therapy package, including social and family interventions’. Today’s community paediatricians basically fly crop dusting planes over the countryside, spraying Ritalin wherever they see a school.

Does someone have an agenda that includes more and more people taking mind altering drugs? It’s hard to imagine that a proper dictator would like to see cohorts of drunk women staggering round York on Friday nights, or lines of people queuing up for methadone outside Boots every morning. But then its hard to work out why the existing drug laws are not enforced, or why more and more heroin came out of Afghanistan despite the war in that country, or why our ward has a filing cabinet full of confiscated ‘legal highs’. Is it feasible that legal highs cannot be controlled by legislation, when there is legislation that makes Tesco throw away half its food, and legislation that stops me from connecting a gas fire?

Would a genuinely repressive regime be happy for millions of its citizens to take antidepressants, in some misguided hope that they would become more docile or cheerful in times of adversity? Marx is quoted as saying religion is the opiate of the masses, but perhaps the word he actually used was Ritalin.

The culture of propaganda has a lot to do with the rise of conspiracy theory. In the public sector we are routinely spun false statistics and like to pretend we are providing an excellent service. In mental health Trusts we want to pretend we are offering psychotherapy, when really we are offering only a nice chat, checklists and tablets. Its a kind of cover up, but we’re not in Jason Bourne territory. It’s obviously a lot cheaper to fiddle the statistics than to provide real therapists or policemen.

My colleagues are probably sitting tight, waiting for the Bipolar II epidemic to subside. Just like the Ritalin kids, the new wave ‘bipolar twos’ will soon be be stuffing their tablets behind the radiator. At the moment some people view a diagnosis of bipolar disorder as a get-out-jail-free card, in case of a minor indiscretion. These will get devalued if more people use them, instead of throwing doubles or paying £50 . Even now, fewer celebrities are coming forward purporting to have Bipolar II, and they are probably going back to having narcissism instead.

The conspiracy between Big Pharma and eminent psychiatrists will find a new condition supposedly amenable to antipsychotic drugs, such as food intolerance, or somatic symptom disorder. Then the experts and drug reps will be back in their Audis again at another round of conferences.

Sadly, most conspiracies don’t involve lizards or the CIA. Nor even do they involve a secret Mister Big, played by Morgan Freeman . They are just about drumming up trade. How boring is that? The new world order is just business as usual.

53. Eating brunch, with keen social observers.

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A five factor system based on skin conductance, showing that shy and bashful are not the same

Fed up with being an armchair sociologist, at the weekend I did some field work in Camden, in search of Hipsters. Accompanied by expert guides, we went to a comedy club, the Norfolk pub and Food Lab for brunch. From time to time I asked my guides if there were any Hipsters around, and they would discreetly point them out. It’s a lot better than birdwatching or trainspotting, because Hipsters are found in warm places with excellent coffee, rather than flooded wetlands, or Stevenage Station.

In Islington, at brunch time, most restaurants are full and we are turned away a few times. In Food Lab, to get us in, a bloke with a Macbook who has probably been there for hours, has to be moved on. My guide points out a girl near the window in a brown hat, with a boyfriend who looks like Brad Pitt. The girl is a Hipster, but not the boyfriend, I am assured. I remain puzzled.

It’s always been difficult for psychiatrists to categorise types of people. We mainly look for familiar patterns – people who look and behave like patients we have seen before. In Camden though, that’s practically everyone.

For decades, psychologists attempted to measure personality, using various scales and measuring techniques. The most surprisingly successful of these is the so called Myers Brigg Type Inventory, which is widely used by business types, and hardly at all in clinical work. Myers Briggs was not trained in psychology and it shows.

To be fair, psychology is a young science, and plenty of people dabbled in it who’d struggle to flip a burger through 180 degrees. The Myers Brigg system is based on the work of Jung, who was also not trained in psychology (and it shows), and divides people into 16 different types. You will get a four letter code, like ISTJ, at the end of it, which is about as useful as knowing you’re a Gemini. Try telling your hairdresser you’re an ISTJ for instance.

The Myers Brigg inventory struggles when it comes to validity and reliability, just like horoscopes.  And four digit codes are so difficult to remember. I get mine confused with MDMA, which is ecstasy, and NMDA, which is a nerve cell, not to mention CSNY, which is Crosby Stills, Nash and Young.

Briggs Myers’ only work of fiction, the novel Murder Yet to Come, published in 1929, won the National Detective Murder Mystery Contest for that year. It applies her ideas about personality type into a murder mystery and sounds like she foresaw Minority Report.

In parallel with Myers Brigg, we had the ‘16PF’, which also attempted to divide people into 16, and the MMPI, which had no particular core theory of personality, except to establish how similarly you answered questions to a group of 1940s  american psychiatric patients.

By the time MMPI -2 came out, in the eighties, all this statistical pomposity had been swept aside, by the Mister Men books. This established a series of simple, face-valid types, each with good graphics and the behavioural phenotype explained in a brief, amusing narrative. There are at least 49 Mister Men books, with a further 42 in the Little Miss series, giving at least 90 categories.

Unlike the four-capital-letter systems, the Mister Men series could easily replace the ICD-10 diagnostic system. Instead of which the NHS has gone for a clustering system with 21 categories. Don’t they realise that dice only have 6 sides? There are certain numbers that are used for systems like this, we know this from Ancient Babylon. Useful numbers must divide into 60. Just look at Time and Money.

If 90, or even 16, is too many categories to bother with, how about using just 3? Shortly before he died in 1997, Hans Eysenck gave a talk in Sheffield and our clinical tutor hired a coach for colleagues and trainees to go and see him. On the night of his talk there was dense freezing fog and only two of us turned up. We went anyway, arriving very late and missing most of his talk. Worse still, we were welcomed enthusiastically to the front of the hall by the chairman, like being picked on at a comedy gig, and the talk was about support groups for cardiac patients rather than anything controversial, like personality typing.

Eysenck used a two factor system to describe personality, these being Extroversion and Neuroticism. Much later he added a third dimension, called Psychoticism, adding a bit of chimp. Again, popular culture was way ahead of psychology. The beat generation had developed an axis which ran from Cool to Square. This was almost sufficient to describe what a person was like, but it proved necessary to add the dimension of Geekiness, which runs at 90 degrees to Cool-Square, or ‘orthogonally’, as a geek would say.

One of my proudest moments was when I was buying some pipe insulation at Pipeline Center, note the edgy use of US spelling, and the assistant, who was called Clinton, pointed excitedly at my watch and assured me it was the geekiest thing he had ever seen. Scoring Low on Cool, Low on Square even, but high on Geeky. A new dimensional system was born.

Which brings us back to Hipsters, who could almost certainly be defined as people who would never visit Pipeline Centre, unless they were sculptors working with tubes.

Hipsters are mainly cool, but a little bit square in some ways, and quite geeky. The web is full of Venn diagrams explaining all this. It’s been said that Hipsters cannot be categorised, since this would, of itself, make them too mainstream.

If Jung and Myers Brigg had spent more time in Islington and Pipeline Centre, they could have saved themselves a lot of time and trouble. Roger Hargreaves has made them look Silly. Apologies to the guy who was moved on at Food Lab, I’ve just realised you were probably doing field work too, but without guides.

52. Finding yourself and more importantly, your keys.

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A picture with a mental health sort of vibe, suitable for a leaflet, no sensible offer refused.

Two girls walk slowly to school alongside each other, both talking into mobile phones, possibly to each other.

A man in the public library, reading the newspaper, who moves his finger along the lines of print and whispers the words out loud.

An electrician, talking to his assistant, explains what he is doing as he puts in a new fuse box. He deliberately gives himself little electric shocks at times, explaining that this is something you should never do.

A man clutching a can of Special Brew, talking loudly, seemingly to no-one, as he staggers down the high street.

A kid, pretending to be CIA, talks into his sleeve at quiet moments during a history lesson.

I’ve been observing people talking out loud, and – heresy! – I’m just wondering if there shouldn’t be more of it.

Here’s another unpopular view – I always preferred the original release of Blade Runner to the subsequent versions, simply because of the Marlowe style spoken narrative. We’ve had ‘the final cut’, but I hope there will be more versions, for instance, a musical, with tap-dancing robots.

All this stems from the realisation that we are all several people in one. The idea that we are ‘an individual’ is handy for practical purposes, such as issuing passports and driving licences, but manifestly an oversimplification. Discarding for a moment oddities like multiple personality disorder, we spend a lot of our time in different modes of operation.

Dreaming, day-dreaming, fantasising, imagining for instance. Set on autopilot as we drive to work, often not remembering all the mini roundabouts and small mammals we drove over. Or reverting to chimp mode when there is a perceived threat.

In people who suffer from psychosis, this potential for multi mode operation has been called ‘double bookkeeping’. The ancient example is a patient who is deluded that he is the King, but is content to mop the hospital floor as a day job. Real life examples are frequent enough. One of my customers thinks he is the most senior officer in the British Army, but he is happy to work in the snack bar on a voluntary basis.

There is no need to be psychotic to indulge in double bookkeeping. The phrase ‘creative accountancy’ goes back a long way. Look, for instance, at the target culture of the modern regulated public sector, where information is routinely falsified. I even had trouble typing that word, falsified. I wanted to type ‘spun’ or ‘distorted’ or ‘laundered’, such is our reluctance to attribute malicious motivation. To call someone a liar is a serious insult and perjury can carry a jail sentence. Are all these managers and civil servants who cook the books consciously aware that they are lying, or are they using a series of mental mechanisms to justify themselves?

My hypothesis here is that it is easier to lie in a diagram or a document than it is to lie out loud. Speaking out loud seems to engage bits of mental functioning that are more careful and scrutinising. If you lose your keys, if you speak out loud the word ‘keys’, you are more likely to find them. Hearing yourself out loud seems to kick the awareness level one layer higher.

Apparently negotiations go better if you speak in the first person and include some ‘feeling’ words. If you happen to citizen’s arrest a former prime minister, be sure to mention you are disappointed with some of his bombing decisions and surprised that he thinks he can walk freely around Shoreditch, amidst Hipsters.

If you appear in court, and you hear yourself swear to tell the truth, the whole truth and nothing but the truth, you probably will. Talking to yourself is the new talking to someone else.

And that brings us to new technologies, like Siri and Google Now. If you hear yourself say, ‘is there a good japanese noodle bar round here?’ you will immediately realise that you are being silly. You don’t like noodles and you’re in Rotherham. You don’t need the latest phone, or any phone at all, you just speak into your sleeve.

That’s got implications for psychotherapy, and for the church, which has never successfully marketed its Confession product. If the magic ingredient is simply speaking out loud then you don’t really need the therapist or priest. You could dial 111 and explain your problems over the phone – just unplug it first.

51. Feeding Fivepences into the System.

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Durer had a problem drawing the female upper body, which was why he was dropped from the Tomb Raider team.

No-one in the post office queue seems to be talking about Expressed Emotion research. Perhaps that’s because, like the post office queue itself, the concept belongs to the seventies. That’s why I prefer Hermes Mail, where the drop off point is across town, in a corner shop heavily frequented by substance mis-users.

The idea that behaving like a character from Eastenders can bring about psychotic relapse in a family member is devastating. The key ingredients of Expressed Emotion, or EE as we used to call it before the telecoms company stole the name, are supposed to be Critical Comments, Hostility and Emotional Overinvolvement. The same conditions have been achieved on shows that feature hysterical and random harsh judgements, like Strictly or the X Factor.

At the corner shop, a lady in front of me has counted out a large number of copper and silver coins onto the counter and the shopkeeper helps to count them. The customer is an ex punk rocker by the look of her attire, though a quick mental calculation tells me that she was already aged at least 40 in 1978, when punk was at its height, so that her wardrobe consultants may be at fault. Nevertheless, torn tartan trousers are pretty much fine for any occasion, from the Savoy Grill downwards, let alone a trip to the corner shop. There are people in pyjamas behind me in the queue.

The problem seems to be related to the Lottery – she has brought the wrong ticket, or it is not her own ticket, or possibly it is a dry cleaning receipt. She glances back at me conspiratorially and says that she isn’t going to tell the person whose ticket it was supposed to be. I confirm to her that her ethical position is sound, but also that I have no idea what she is talking about.

I observe that everyone in the queue is very calm, despite what seems like a pretty serious delay in proceedings. And I attribute this to a very particular body language on the part of the salesperson. She is a tall Asian lady with an excellent upright posture and a steely gaze.Yet even within the steel, there is a glint that says, ‘make time in your life for an elderly person who cannot cope with the modern world’. This is a low EE shop, I decide, and no-one is relapsing into a psychosis here this morning.

If you like low EE, one of the best shops is called Boyes. It’s hard to explain the ambience. The lighting is soft and the aisles are wide, but in no way confusing. Towards the back of the shop, there are piles of haberdashery and materials, including a large selection of foam blocks. None of the items are brash or tawdry; every item is just the kind of thing you might need one day, if you were turning over a new leaf from a former life as a contract killer.

The public library used to be low EE but things have really changed. In the centre is a ring of PCs which are occupied by students, all of whom are looking at facebook. In the foyer two old blokes are talking loudly about the bets they have placed that day. The atmosphere is tense, because everyone knows the librarian should exert some kind of authority and enforce silence, but this doesn’t happen. And then people arrive to collect free condoms from the help desk, and I wonder how they are filed and coded in the library system. The librarian says they have run out of condoms and apologises profusely. The two customers, who are teenage boys taking the mickey, burst into a fit of giggling . I appreciate the distraction, which allows me to feed handfuls of 5p pieces into the self service machine. So I can rent DVDs and pay fines effectively free, in that I can mobilise coins that were, up till now, beyond use.

EE was one of the most cumbersome tools ever developed by modern mental health researchers. It has fallen out of fashion not just because it is a thing of the seventies, but because it could never be cost effective compared with drug therapy.

It takes a panel of specially trained academics hours to decide if a family is high EE or not. EE can be reduced by special family education programs, the feasibility of which ranks with ‘rolling out’ DIY SOS nationwide.

Otherwise psychotic people shouldn’t spend more than 35 hours a week with their high EE family. That leaves a lot of time to kill. First day centres closed, then Woolworth’s closed, then the library repealed the decibel law. Employment is increasingly high EE, and so is television.

That probably explains why we ‘find ourselves’ in Boyes so much, trying to remember why we wanted foam blocks. And why people trying to avoid a psychotic relapse spend a lot of time in the Hermes queue.

EE is a good name for a business, even if they can’t really provide ‘everything everywhere’. In community mental health care its more a case of Nothing Anywhere, just shops to go in.

Also, its only £3.60 for your parcel, instead of £12.60 with Royal Mail.

50. Taking Canadian Living more seriously.

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First, cement each of the six guitar strings to the guitar. Then, cement the guitar to the James Blunt figure. Now, cement the James Blunt figure to the tank controls…

When I was about 7, I had a book called ‘365 Things to Make and Do in Nature and Science’. To be honest, many of the projects were frustrating, as it was difficult to obtain the necessary parts and materials, some of which were quite exotic. In our town it was very hard to obtain, say, an old altimeter from a WW2 German bomber, or a tin of gunpowder. There was also the obvious problem of leaving one day relatively unstructured during a leap year.

Until now, I have never questioned the idea that Doing Something is a worthy use of time, as compared with Reading Something, or Watching Something. But now, typing with a bandaged thumb from an unfortunate slip of the Stanley Knife, tennis elbow on both sides, from excessive screwdriver and spanner activities, and lower back pain from heavy lifting, I’m forced to ponder whether it’s time to say goodbye to B and Q and that new yellow brick road I was planning.

The Nike slogan, ‘Just do it’, is now 25 years old. People were tougher in the eighties – if coined now,  that slogan would come with a number of provisos and safety warnings, such as adding: ‘once you have checked with your cardiologist’ or  ‘providing you are Corgi Registered’.

Though Nike do not state this overtly, their motto asserts a behaviourist stance on life which I interpret as follows – you are what you do. There is a worthy theory underpinning this outlook, stemming from the psychology of self – perception. From what we find ourselves doing, we infer who we are and what we stand for. I am sitting at a computer, wiping blood off the spacebar, so I am a dedicated writer. If I had a Scotch, a full ashtray and a loaded revolver on the desk I’d be even more dedicated.

Last year, as further evidence of a shift from behaviourism toward ‘cognitivism’, Nike took the ‘just do it’ campaign in a new direction: Possibility.

‘With ‘Possibilities’ we’re taking ‘Just Do It’ to a whole new place, showing people a new way to set goals and think about their own athletic potential’

Thinking about our athletic potential is quite cognitive. If you are taking a penalty shot or serving at tennis, the last thing you want to do is think about possibilities. Probably the one time David Beckham thought about possibilities was the time he shot the ball twenty feet above the crossbar.

Apple’s campaign ‘Think Different’, invented in 1997,  also seemed to pursue a cognitive path. 29 famous ‘thinkers’, such as Albert Einstein, were included in the campaign posters. But if we look more closely at the list, we see that many if not most of the ‘thinkers’ were actually artists or musicians, i.e. people who held tools in their hands, made grooves in vinyl or canvas and left a legacy of artefacts and occasionally accidentally cut their fingers. In fact, none of those featured in the ads were Philosophers, unless you count Kermit the frog.

‘Here’s to the crazy ones’, ran the script,  ‘The misfits. The rebels. The troublemakers. The round pegs in the square holes. The ones who see things differently. They’re not fond of rules. And they have no respect for the status quo’.

The script seems to owe something to Top Gun, where, rather lazily in terms of character development, the hero was named Maverick.

We probably know many such mavericks, but they have never become well known or achieved much, because they thought too much and didn’t do enough. In Britain they would mainly be described as harmless eccentrics. On the other hand, those who made it into the ranks of Think Different were prolific doers. Alfred Hitchcock made over 60 movies for instance; Bob Dylan made over 40 albums.

Maverick couldn’t wait to get catapulted off an aircraft carrier and frighten the MiGs.

I just collected a Depression Leaflet from the doctors while I had my finger looked at.

In the ‘what can be done?’ section there is a bit of practical advice as follows:

‘Vary your normal routine, get out and about if you can, keep occupied if possible, if you can’t sleep, try watching TV or listening to the radio.’

In search of useful things to do I turned to ‘Canadian Living’ magazine. I found an article called ‘Fifty good deeds for fifty days’, which borrows a little from the Random Acts of Kindness movement.

Like ‘365 things to make and do’ however, some of the materials are hard to find. For instance I have no ‘well behaved dog’ to take to visit elderly people, nor any fresh cut flowers to leave at a nursing home. If I happened to buy some pet food at the supermarket to take to the local animal hospital, I’d probably buy something they weren’t allowed, like cream buns.

I’ve come up with these ideas instead, which I’m hoping Canadian Living will publish:

  • Wearing a salvation army jacket and carrying a clipboard, feed parking meters that are about to expire – not for Audi drivers though
  • Get everything out of your food cupboard and throw away any packets with a sell by date before you were born, or 1963, whichever is more recent
  • At Tramshed, in Shoreditch, try and make a citizen’s arrest on Tony Blair.
  • Find a pothole in the road, chalk round it in yellow and report it to Fillthathole.org
  • Place a small whiteboard in your toilet, headed: ‘This toilet was last checked at…’ Then sign with a fictional name and date, such as Attila the Hun, 453 AD.
  • Install Windows 8.1, but first say goodbye to everything you have on your computer, it’ll be like new
  • Phone up Santander Bank at 5.30pm and ask them to answer a short feedback questionnaire, regarding your performance as a customer
  • Phone up the bursar at the University of Leicester and ask for a cash donation towards your holiday in the Bahamas

In other words, don’t just think different – do different. Or differently, if you prefer .

49. Saying no to Mister Kipling.

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My new laboratory

Outside Ladbrokes, it occurs to me that behavioural psychology, one of the greatest discoveries of the twentieth century, has fallen, like that other great Russian invention, the Kalashnikov, into entirely the wrong hands.

Clinicians have neglected behaviourist explanations and treatments for mental health problems, leaving these dark arts to commerce.

Though still called cognitive behaviour therapy, CBT has edged out the behavioural aspects, such as facing feared situations in real life, or reducing unwanted repetitive actions like texting during mealtimes.

The move towards Mindfulness has taken things even further in this direction. Whereas behavioural techniques can be applied successfully to animals, mindfulness cannot. Herein lies the problem. Therapists are most reluctant to regard the human being as an animal, whereas it suits some commercial interests for people to act like plankton.

In fields such as gambling, shopping, advertising and food, simple behavioural strategies have proven to be devastatingly effective. By placing rows of sweeties either side of the checkout in supermarkets, or sending a tinkling food cart slowly but surely up and down planes and trains, we are made to drool. Our sense of scale is disrupted, by selling massive chocolate bars for £1, next to tiny versions for 65p and three-for-two offers. Greater consumption seems to make sense.

Behavioural interventions like graded exposure and exposure response prevention are too dangerously similar to common sense to warrant an exorbitant fee in clinical practice. Whereas a gambling machine or a chocolate bar has no problem reducing you conceptually to the role of laboratory animal.

I’m just dreaming up another screenplay, which is for a re-make of Traffic, but with people addicted to sugar instead of heroin, with fat actors instead of thin.

I’m hoping it’ll get funded before the current moral panic about sugar dies down. The idea is to examine ‘the sugar problem’ from different perspectives, from politicians and big business on the one hand, to the crowds of diabetics camped outside Clinic 16 on the other, via the sticky pavements outside KFC.

Here’s the background theory as I understand it, simplified for the movie:

1. For some reason, the USA has a big corn syrup industry and puts corn in all kinds of food products.

2. Fructose, made from corn, is sweeter than glucose and has less feedback effect on the brain, leading to over-consumption and frequent trips to the Spar shop.

3. People get more tolerant to sugar, increasing their consumption progressively.

4. They may experience craving and withdrawal effects similar to chemically addictive drugs, leading to sugar addiction

5. Sugar tweaks the dopamine and endorphin pathways in the brain. These are shown diagrammatically as massive cables connected to the addiction box, which is sited just behind the nose.

6. Recognising they have an addictive product on their hands, the food industry takes advantage, increasing the sugar concentrations, fructose content and portion size. 500ml becomes the new 330ml. We are asked at food shops if we want to ‘go large’ and we say yes. Shouldn’t there be a consent form for such a far reaching decision?

7. Big Sugar runs a clever diversionary tactic, blaming Big Fat for everything.

8. The insulin manufacturers get richer.

9. Politicians propose a Sugar Tax, forgetting it was an OMD album and they probably still have copyright.

10. Grand Designs features an edible house made of Glacier Mints.

Did the mental health industry play its part in the great sugar rush? At first sight, it looks as though our hands are also sticky. Mainstream psychiatry demonised the use of amphetamines, barbiturates, benzodiazepines and antipsychotics as tranquillisers, while promoting ‘atypical antipsychotics’ that were strongly associated with weight gain. Psychiatrists promoted the concept of addiction and started applying it to things increasingly difficult to compare to heroin, such as chocolate, sex, darts and embroidery. As a result, the concept of addiction has become a metaphor for any repetitive pleasurable behaviour that has a downside.

The mental health industry is buying into the idea that drugs and even foods have power over us and may enslave us if we weaken. In terms of reducing the crowds at clinic 16, will it help to regard sugar as an addiction? More likely it will prove counterproductive to empower sugar by deeming it a chemical of substance. There’s no denying that sugar is a powerful ingredient – the taste for sugar is hard-wired. After all, it’s only competing with three other tastes, two of which are bitter and sour. It’s a taste that children seem to love, but that many grow out of. But in the end it’s just a molecule, not a mystical power. Food and drugs are tools for us to use, not the other way round.

I’m pretty sure, in a double blind trial, I could not tell Coke from Diet Coke. Yet everyone I ask assures me there is a massive difference. There’s an urban myth that sugar intake creates a ‘rush’ or increases energy, even risking overexcitement. Who planted that idea in popular consciousness? Mars, perhaps.

As a debunking exercise, I did a small field trial on the so-called Death By Chocolate. Suffice it to say I survived. Should I have asked for my money back?

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The Death By Chocolate, before the experiment

Maybe the marketing men did not envisage how strongly sugar would catch on, given a combination of chemical and social reinforcement and low pricing. Companies say they have increased portion size and fructose content because people are demanding larger and sweeter products. A kind of forward feedback has occurred, and the moral is, conditioning is a powerful motivator.

How to end this movie then? One idea is to have all the dark psychologists who manipulate our food preferences arrested in a raid on Tate and Lyle? Or an upbeat ending with scientists discovering Baking Canderel? Or a line of addicts at the sugar clinic, receiving treacle in little pots, instead of methadone?

Incidentally, please do not attempt the Death By Chocolate challenge without medical advice. Sometimes these urban myths have a grain of truth in them.

48. Tuning in to the sound of sharpening knives.

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An architect taking a quick personality test

It’s a clear, bright evening in Yorkshire. A man in a Volkswagen Golf stretches both hands behind his head, steering for a while with his knees. He is observed by police safety cameras and later charged with dangerous driving. Not only does he get a year’s ban, 100 hours community service and a fine of £685. In addition he is vilified on the evening news by a sanctimonious policeman. In a moment he has gone from ordinary bloke to public enemy number one. The moral of the story is that any pretence that Yorkshire had to be ‘the Texas of England’ has completely evaporated.

The deeper moral is that sanctimonious people are much more dangerous than careless drivers. It’s not that long ago – the eighties? – that people were put in pillories and stocks and burned as witches. More recently the tabloids have taken over the hunt, bringing down celebrities whenever they can.

I am sure the bible covered this very issue, in the episode about casting stones at the adulterous person. Clearly, hypocrites have always existed. The practice of scapegoating existed in Ancient Greece, where they used to throw a beggar or a disabled person out of town whenever there was a natural disaster. They could have used a goat, like the Israelis, but maybe it suited them better to exclude a person, in terms of reducing the social security budget.

If the storms and floods continue I suspect we will have to blame a football (or cricket) manager and cast him out. It would be all too easy to mention a name or two.

It probably suits the police to pretend they are fighting crime by video. But a casual inspection of the local town centre reveals significant criminal activity. Lots of drivers are using mobile phones, parking on yellow lines, eating sandwiches and smoking cigarettes. All at the same time, in some cases. It wouldn’t take me long, if you made me a crime-fighter, to find people riding bikes without lights, on pavements, or even without hands on the handlebars.

Higher up the criminal food chain, complex laws are also enforced selectively, from drug possession to tax evasion, depending on the whim or policy of the CPS. The EU Commission even has an article in its constitution stating that it will pick and choose what it wants to enforce.

Suffice it to say, there seems to be a lot of luck involved in falling foul of the law, certainly more than your history teacher explained on the Magna Carta field trip.

I suspect the recent legislation banning fox hunting with dogs reflects an acknowledgement that all of us might have a deep rooted and nasty tendency to join a baying mob, which must be guarded against.

Scapegoating is a process found in dysfunctional groups and families. It is viewed as an unhealthy defence mechanism that, nevertheless, serves some purpose in preserving the group’s existence. Scapegoating often seems to occur in group therapy, where it can be interpreted, or even better, treated. With jazz.

Today’s paper reveals that jazz has infiltrated the public sector and has been applied to NHS managers, senior policemen and the department of transport. Alex Steele, musician and founder of ‘Improwise’, states that the NHS, in need of radical change, has called in his jazz quartet several times ‘to help with leadership’.

A police chief is quoted as saying the situation in his organisation was best explored through ‘parallels with the world of jazz’. Comedian Alexei Sayle famously observed that Jazz had no natural enemies or predators, but it seems he was wrong.

The Department of Health ’rounded furiously’ on the jazz workshops, stating that taxpayers will be ‘rightly appalled’.

So, jazz, intended to help groups function better, itself becomes the scapegoat. But Jazz cannot be blamed for careless driving. Hands off the Wheel was grunge, not jazz, and Asleep at the Wheel are Country. From Texas, not Yorkshire.