92. Doing without experts, or even people who wear spectacles.

1431342713376

The CEO presents his new organisational structure, shown here as a Venn diagram.

A cat is out of its bag. Not Kevin, the actual cat – he can’t get through Kevlar sacking – but metaphorically speaking.

There’s a book out called ‘Where there is no psychiatrist’. Though the phrase ‘developing world’ occurs somewhere in the description, and the front cover depicts a place where people carry water in stone jars on their heads, so probably not Mexborough, in actual fact this manual is meant for Britain itself. There is no psychiatrist in your town or mine. That fellow with the beard is just a hipster. That guy with the carefully-crafted-designer-vagrancy look you admired so much is just a vagrant. Though some people are pretending otherwise, for better or for worse, mental health is going DIY.

There are exactly ten reasons for this:

Very few new doctors are choosing psychiatry as a speciality
A lot of psychiatrists are retiring to open artisan cheese shops
Psychiatrists who don’t use a medical model are more expensive than social workers
Psychiatrists who use a medical model aren’t cool enough at parties
Psychiatrists have to wear a T shirt that says ‘in case of disaster I am to blame’
People have noticed that the NICE guidelines for mental illnesses are the same ones for every single disorder
Illegal drug dealers have got more and better new drugs than we have in the NHS
Maplin have got more and better electrical treatments than we have in the NHS
The GMC now require you to cut down the mightiest tree in the forest, with a herring, in order to get revalidated
Conspiracy theorists have stolen all our best delusions

Now that we have youtube to show us how to do every task, the main constraints on DIY are statutory regulations rather than not knowing how to do things. But where there are severe penalties for unauthorised gas fitting, there is no penalty at all for pretending to be a mindfulness therapist, or for lighting candles in people’s ears.

Surely, before we start selling prozac and zyprexa in Poundland, before we legalise ketamine, before we hang special magnets from our earlobes, there should be youtube videos on how to interpret evidence and follow logic? No mate – this is England. No-one likes an expert round here.

91. Monster Munch – it’s silly not to.

crab

‘The crabs stayed with me until the day I simply decided that they bored me and that I just wouldn’t pay attention to them’ – Jean Paul Sartre.

I don’t like crisps that much, but at the market you can buy 10 bags of Monster Munch, marginally outdated, ‘flamin’ hot’ flavour, twenty per cent extra in each bag, for £1. Or for £2 you can buy a whole box (of 20). Or, for £2 you can get 48 bags of Marmite flavour. That’s unreal isn’t it?

Psychiatrists have dabbled with unreal experiences and created a few technical terms to describe them.

Depersonalization means a sense of unreality within the self. Derealization is a similar experience but refers to a sense of unreality outside of oneself, in the environment. Such experiences have been largely neglected, perhaps because no specific drug therapy is indicated, though an unusual coloured pill – ochre? – is surely needed.

Neither word really does justice to a situation where unlikely events seem to happen,so I propose we co-opt* a new word, Surrealization.

I propose we use this term to describe experiencing events so unlikely you tell yourself, ‘no surely, this can’t be happening’. Situations where you might have tried pinching yourself to check you weren’t dreaming, if you hadn’t seen Inception.

Surrealization is not an anxiety disorder. Unlike ‘Deja Vu’ (due a remake?) it is not a sign of complex partial epilepsy. Nor have I been sprinkling ‘Special K’ on my Special K. I think it’s just the world getting more peculiar. I can’t prove this yet, but I’m starting to keep tabs on the modern world, using a Surrealization Diary, in the best traditions of cognitive therapy. Here are some recent entries:

I don’t like opera that much, but I find myself at a performance of Carmen in Sheffield. The cast includes a donkey and a white stallion and there has to be an awful possibility of the animals misbehaving on stage. Backstage they probably have a ton of sugar lumps for reinforcement purposes.

I begin to hear short bursts of high-pitched noise and at first I assume the radio-microphones on stage are picking up feedback from local cab operators. Then I realise there is an older gentleman sitting right next to me, starting to fiddle with his two hearing aids, which is where the noise is coming from.

The whistling noises get more frequent and louder. But after a while my neighbour takes out both hearing aids and puts them in his pocket, looks relieved and closes his eyes. But the noise continues and gets louder and more screechy. People start to look round and shuffle in their seats, but I realise he is now completely unaware of the aids ‘going turbo’ in his pockets. I try and catch his eye and signal, I point towards the hearing aids and put my finger over my lips, but he takes no notice.

Clearly we are on the edge of an awful scene, until suddenly, the man’s equally elderly female partner shakes him and shouts in his ear: ‘Take the fucking batteries out Ian, take the fucking batteries out’, which, after quite a lot of scrabbling, he manages to do. I write the acronym TTFBO in my diary.

I don’t like literary occasions that much, but this is a good one. I’m standing in a field in Lincolnshire, next to a very busy main road, at a tree planting party, listening to a small female person reading out a chapter of Winnie the Pooh. She speaks movingly but very quietly and her words are lost between the northerly gale and the massive lorries on the road behind her.

I don’t like Health Secretaries that much, but I am reading about Jeremy Hunt’s plans for dementia. Mr Hunt said seven-day services will improve for dementia patients in hospitals, with patients in high dependency care seen and reviewed by a consultant twice a day, every day of the week, by 2020. What the consultant will do when he meets each patient is not explained. We all hope and pray there will be effective treatments for dementia one day, but until then the consultant will be stuck with discussing the cricket score twice daily.

As Bernie Taupin might put it, if he ever met Jeremy: ‘but, then again, no’.

Now I’m at a blood-doning session, standing waiting in the foyer of a community centre with the other donors, waiting for the staff to finish their break. No doubt it makes sense for the staff to have a break between sessions, but it’s a bit weird to keep everyone in the hallway while the staff have their tea and biscuits. They are chatting loudly and I hear one of them explain to another how to pull a sickie by pretending to have diarrhoea. Mrs EP is with me and it is her 50th doning session and she is pumped up expecting the gold badge. But she has filled her forms in with a gel pen and she is told off. Gel pens have joined the long list of things blood donors should be careful about.

I don’t like health screening that much, but at Specsavers there is often a voucher you can get for a free eye test. Sometimes the voucher is on the back of the pay and display car park ticket. If not, under a bit of pressure, the assistant will produce an eye test voucher from under the counter, in a free spectacle case. Today there is a free voucher online, so it’s silly not to have your eyes tested, isn’t it? This is probably the best value in all of health care. It includes a careful examination of the retina by a properly trained person who can see right into your soul with a special lamp. When I ask for my prescription the assistant says I can’t have it because the copier is not working. I offer to write down a copy for myself or just take a photo with my phone. No, she says, data protection. Stupidly, I begin a short discussion about some of the urban myths surrounding information governance. Luckily they don’t have bouncers at opticians, so I leave without my prescription, but uninjured at least.

Now in my diary I am recording an attempt to get to Springfield Hospital from Tooting Bec tube,using Google Maps, missing the entrance and walking all the way round the block. My phone, though I haven’t asked it, tells me I have walked 3 miles and it congratulates me.

Back to the government then, who have been rolling out a short series of surreal announcements under the loose working title in my diary: ‘It’s not going to happen’. On 10 January the prime minister announced he’d be transforming housing estates. On 7th Feb he announced the transformation of prisons. And in March he announced that the NHS will be helping to plan a number of Healthy New Towns.

Quite likely, Surrealization is a reaction to this kind of Orwellian propaganda and luckily there is a specific therapy in the form of observational comedy and political satire.

A word of warning: if you suffer with Surrealization, it’s not safe to say so out loud. You will be stigmatized as awkward, cynical, negative, old or grumpy. And you will quickly be told to TTFBO.

*Co-opt because the term has a limited meaning in the arts, such as creating drama out of dream material. That’s not a problem as a lot of technical words in psychology have a day job, such as Obsession, and many of them moonlight as fragrances too.

90. Spoiling the ship for a ha’p’orth of warhead.

cipramil

Keeping the doctor away: one apple and three bottles of Cipramil.

2016 is turning out to be the year of the internal saboteur, but the abbreviation I.S. is already taken. Examples are all around us of people deliberately choosing to inhibit their functioning.

In this town, people are dying their own hair green and getting misspelled tattoos like ‘No Regerts’. New buildings are getting fewer parking spaces than needed, not enough to discourage people from using cars, but just enough to inconvenience everyone. The Royal Bank of Scotland has told us to sell everything and put the cash in the freezer disguised as a chicken korma.

On a national level our politicians are fighting amongst themselves in each party. Jeremy Corbyn is suggesting running the Trident subs without the nukes on board. There’s a doctors’ strike that no-one can fully understand. And, in an unbelievable U turn, the chief medical officer says alcohol is really bad for you after all.

And if this wasn’t bad enough, David Bowie has died.

Psychoanalysts were good at explaining this kind of thing, examining the metaphorical bullets that people fired into their metaphorical feet, but they are gone, replaced by computerised CBT and web-based expressive writing.

There’s a theme to this: Medical Nemesis, which was the name of a book by Ivan Illich. Ivan’s idea was that doctors had medicalised significant areas of normal life and were set to colonise all human experience, by deeming everything to be Medical. Illich felt there was an inevitability to this process, much as he felt Communism would conquer the world, domino by domino. He also pointed out that a large amount of medical activity was counter-productive, so that the net effect of modern health care was marginal and in due course would become detrimental on balance.

Medical Nemesis was published in 1975, which was the year I went to medical school and David Bowie released Young Americans. Eerily and probably coincidentally, the rise and fall of Psychiatry as a successful enterprise has run in parallel with Bowie’s career. Studying the two timelines, the Bowie discography versus the history of psychiatry, there is a broadly positive correlation, with a slow decline after 1983. I expected to see something significant in 1990, to coincide with the launch of Clozapine, but there is only Tin Machine. No model is perfect.

The theme to our current medical nemesis is this: the counterproductive effects of medicine have been escalated so that they now outweigh the positive effects. After a brief period of medical effectiveness – basically the few weeks that followed shutting down the cholera pump on Broad Street – we are back to doing harm to people.

It’s a bit complicated to say why, but we’re talking about the net effect. There is no doubt that some medical activities are helpful, such as removing marzipan and toy animals that children have accidentally stuck in their ears. But a lot of the old certainties, like spraying the countryside with antibiotics, are over.

Even in 1975, we were taught that the increasing life expectancy that occurred in the twentieth century was mainly due to improvements in hygiene and public health, rather than laser surgery and machines that went beep. Now it is possible that life expectancy is set to reduce. It is already reducing for those who are now in later life, particularly women.

Some of the factors that have inhibited the usefulness of medicine came from outside the profession, such as the food and alcohol industries. Some have come from health industry predators, such as management consultants. Mostly however, the bullets fired into the soft underbelly of medicine have been fired by doctors themselves. For those who like acronyms, the health industry has fallen victim to the 3 P’s, namely: Pomposity, Pretension and Ponderousness. These are the outward signs that medicine has gone where it doesn’t belong, ‘medicine gorn mad’ as Dr Allenby would have said.

Focussing on Mental Health for a moment, we are living through a very unhappy period. Round about the time that Illich wrote Medical Nemesis and Bowie became the thin white Duke, the treatment of mental illness was hitting a purple patch. Psychiatrists still worked out of large mental hospitals with hundreds of beds. About a third of the beds were occupied by patients with poor-outcome psychosis, the ones we pretend now don’t exist. Another third were allocated to elderly patients with dementia. Hospitals had wards that could deal with acutely disturbed psychotic patients, without bundling them into a van and sending them to a private hospital two hundred miles away. But most of the patients were already in the community and there were satellite clinics and community nurses in most towns. Drug therapy, with the exception of Clozapine, had already peaked, using typical antipsychotics and tricyclic antidepressants. Medical training still revolved around the ‘firm’ model, each firm belonging to a Consultant. Trainees learned all the German words for mental phenomena and sat a proper exam with essays and a long case. There was no purchaser provider split. Hospitals were administered, not managed, by a triumvirate of administrator, nurse and doctor.

Can it be possible, 40 years later, with all the endeavour that has gone into research, reorganisation and regulation, all the millions of hours people have spent in committee meetings and working parties, all the billions of pounds spent on management consultants, that our services have actually deteriorated?

Making such an assertion, one is quickly accused of being a grumpy old man or woman. Suffice it to say that not everything a senior or experienced person says should be discounted automatically (just most of it).

There are many examples however of monumental enterprises that fail. The best known are IT projects like ‘Connecting for Health’ which was wound up in 2013, having spent more than £14 billion. The audit office concluded that ‘it was not demonstrated that the financial value of the benefits exceeds the cost of the Programme’. A scenario right out of Illich’s book.

Not only does medicine go where it doesn’t belong. Often it abandons areas where it does belong. For example, ECT. Without wishing to denigrate ECT, the evidence base for its usefulness is quite limited. Suffice it to say it probably works for certain types of acute psychotic condition, mainly the ones that it’s not used for. A lack of evidence that ECT was effective at all did not stop the Royal College setting up a complex system of training and accreditation, called ECTAS. It’s guidelines, along with those written by NICE, were stringent enough to put most ECT units out of business, much to the delight of those opposed to ECT, which is practically everyone.

Now, newer types of electrical and magnetic stimulation are coming out of the closet which are not evidence based or regulated or subject to the protective effects of the mental health act. For better or worse, ECT was regulated to death, but my tip is to hang on to those electrodes for now, pending the development of ‘swimming with electric eels’ holidays.

If Illich’s theory was correct, we would arrive at a point where medicine – in terms of its beneficial effect on society – is taking exactly 100 steps backwards for every 100 it takes forwards. What is unclear is whether we have entered the recession yet. How will we know when the oil tanker of medicine has reached a standstill relative to the sea bed?

A possible indication of such a low point would be, say, identifying a medical condition that has recently been invented, by annexing an aspect of normal life. A condition that has escalated dramatically, filling thousands of outpatient clinics. A condition that can’t be treated effectively by health services. A condition where treatments are poorly evidenced and have clear harmful effects, like stunting growth. You know where I’m heading: by 2003, nearly 8% of American children were diagnosed ADHD. By 2011 this figure is said to have reached 11%, with a large increase in girls diagnosed with the disorder. As with life expectancy, and as Bowie would have noted, girls are the new boys.

In the metaphorical history of psychiatry then, ADHD falls into the long dark period, somewhere between Reality and The Next Day.

89. Ralph, no.

value

Wanted: philosopher.

The highway code was not written by psychologists. So there is very little recognition of the role of the ‘automatic’ brain in terms of handling most driving duties. The code would have us believe that thinking comes before acting, but this is rarely the case day to day. Driving might start out as thoughtful when people first learn, but it soon becomes a habit.

By the time the driving test is over, the autopilot takes over for the next 70 years of carefree motoring. But all the time we see little bits of degeneration, such as cutting corners, running over kerbs when parking and dyslexic indicator work, on occasions where mental functioning goes a bit windows vista.

In general, once the code is learned the mantra goes like this: First, behave; second, think; third, feel. And this would be a good mantra for living your life, if only there was a code of behaviour that was properly itemised, bullet-pointed and illustrated.

But there is no such clear code, only things like custom and manners. Like letting the person with one item in the basket go on ahead in Lidl. But what about the person behind him, and the next person? What about the person with two items? Such dilemmas are meat and potatoes for the ethics panel.

Religious texts are not specific enough. Try searching ‘what car would Jesus drive?’ for instance. Though it has been argued that Jesus and the apostles were in one Accord, it’s not wise to interpret scripture so literally.

Am I the only person to feel our Ethicists are letting us down?

Come on, Moral Maze, your show is so tired. It’s crying out for a road-show format. Let’s get the ethicists out on to the streets and help solve real life moral dilemmas. Help us deal with issues like parking meters and beggars.

In Dublin City Centre there are severe parking restrictions. It is necessary to pay by phone using either a text message, phone call or website. It turns out that all three options are impossible if you don’t have an Irish mobile phone number. Neither do the machines seem to accept coins. Worse than this, there are clear signs of wheel clamping in progress. Like rows of clamped cars covered in moss.

Also in Dublin, there are quite a few beggars. Most adopt passive body language, sitting on the pavement, leaning against a wall, with a polystyrene cup held in both hands, tilted upwards. I didn’t see any money in any of the cups and people seemed to ignore the beggars like they do in every city. I have no idea how many beggars were ‘genuine’ as opposed to being run by gangs.

As I understand it, people are reluctant to give to beggars, not because the helping agencies have advised us not to, but rather because many of them are felt to be running a con. If it is a con though, why adopt a near-catatonic pose, rather than say, stand up, maintain eye contact, talk to people, all strategies that seem to increase donations?

In Dublin, it would be nice to give more money to the parking people and the beggars, but you can’t. Not without a lot more information.

Ethical experiments feed in the background information drip by drip, but on the streets no-one hands out a contextual vignette, not even a placard.

One approach that seems to work is to hand around notes containing a short account of why a donation is requested. Hand out notes politely round a bar or restaurant, giving people half a minute to digest the information, then quietly go round with a paper cup, getting out just before the staff throw you out. Something like: ‘my Volkswagen uses more fuel than I expected and I need an extra bit to pick my children up from the chemotherapy day unit. Just £1.09 will buy a litre of diesel. Please be generous and God bless’

I wondered if this type of beggar used to be teachers and still love to hand out and collect papers. Or possibly psychology students, trying to pay their exorbitant tuition fees.

But can you be sure they are not genuine? Are you really going to ask the names and addresses and ages of their children, where they go to school and why they’ve been left at the chemotherapy unit all day, as your Safeguarding Training says you should? Or will you just give them a few of your Rupees or Turkish coins you keep for such occasions?

On TV last week was a long piece suggesting that large numbers of students were selling sex to ‘sugar daddies’ to help them through college. For some reason this was blamed on the movie Frozen, on the basis that girls were trained to become princesses rather than agents of their own destiny.

http://news.sky.com/story/1576077/sugar-babies-students-selling-sex

Sugardaddy websites make statements like this one:

‘Wondered what the sugardaddy life is like? Well, he won’t be ignoring you whilst watching the football for a start. For a sugardaddy, he has made his investment and his focus will be on you. So whilst the lads are down the pub, your older, richer man may take you to Cannes in his private jet for dinner or to a luxury spa for some couple treatments. Either way, it is guaranteed your man will know how to take care of you and it will be better than ever before’

Anyway, I’m not sure whether the breakfast TV panel considered this issue carefully enough and I hope the Oxford Centre for Practical Ethics will give us a better opinion on whether it’s OK or not. At first glance, the carbon footprint looks excessive, having to eat in Cannes all the time.

Doctors are taught medical ethics according to four basic principles: doing good, not doing harm, personal autonomy and justice. The rule is: look at these four aspects and balance them up as you like, adding a twist of lemon, to justify exactly what you were going to do anyway.

Doctors have a tendency towards utilitarianism and have no trouble hypothetically shooting down a hijacked airliner that is about to crash into a football stadium (depending a little on which stadium, who is playing and the scoreline). But we struggle with dilemmas where the outcomes are uncertain.

Like this one for instance, I came across in Sheffield City Centre this week.

To set the scene, try arriving at 4.20 at one of the main car parks close to City Hall, and work out how much to pay and display. 50p gets you 30 minutes, but after 4.30 it’s only £2 to stay until 8am next day. I’ll give you a moment to think about that.

There seemed to be three options: hang around for ten minutes and pay £2; pay 50p and come back within half an hour and pay £2 more; or try paying £2.50 and seeing what happens. The machine does not give change. Over to you, panel.

Option 1 strikes me as lacklustre. It’s for people who think 10 minutes passes quickly, which means older citizens and people with distorted time perception due to cannabis use.

Option 2 is a little bit inconvenient , but could work, especially if you bought some fish from the shop nearby, the one where tangled lobsters cavort in the front window display. But do you really want to leave live seafood in your car, quite possibly roaming about and scuttling under the seats?

Option 3 on the other hand is a little bit bold, it’s one for the poker player. It’s quite possible that something happens at 4.30 that re-sets the whole system of time, so that the universe ceases to exist, or even worse, you could lose £2.

It takes me about three minutes to decide – ironically this delay in itself has tilted the balance in favour of Option 1, now only 7 minutes is at stake.

I go for option 3 on the basis that it is a scientific experiment and it will cost £2 to conduct or maybe less. Options 1 and 2 are for potheads and anancasts and option 3 is for square jawed people with firm handshakes and a steady gaze. This is my contribution to the science budget for today.

I pay £2.50 and hit the green button. Let the chips fall where they may.

I look at the ticket and it says ‘Expires 1853’.

That’s a bad outcome. For that to work I’d have to come back before 1853 and pay another £2. That’s just not going to happen and I decide to take a risk, either that no-one is checking or if they do, I’ll write a crawling letter to the parking appeals department explaining the situation and begging for mercy.

I know what you’re thinking. If I believe this kind of problem is worth even considering for a minute in a world where terrible things are happening, like massacres and planes falling out of the sky, then surely I’m crying out for Ralph McTell to take me by the hand and lead me through the streets of London and show me something that will make me change my mind.

Just as I think that, I realise that a female person has approached from behind and is talking to me. And this is when I really needed Ralph McTell to put me right. Either that or The Handbook of Practical Ethics.

I turn to listen to the lady. I am not working, but the psychiatrist within me has the meter running. She is well spoken and nicely dressed, low to mid thirties in age. She does not seem affected by substances and her talk is normal in form and content. She tells me she feels terrible approaching strangers, but she has just been to the police station having lost both her handbag and mobile phone in a shop. The police, to her surprise, have been extremely unsympathetic and not offered any help. She tells me she is a Business Studies student at Hallam University. She goes on to say she needs to collect £26.40 that evening so she can buy a bus ticket home to Birmingham.

She seems plausible, but as she continues, a few things don’t seem to quite add up. She is carrying a notebook, which she shows me, but only one page has writing on it. She has written the bus times and price and a few other notes, very neatly, but in rather childish script. Handed out to her by her gang – boss handler, sitting in his gang – boss Mercedes just round the corner, a dark thought says.

I’m thinking: it’s not the way people usually write notes, which is more of a doodle format. Plus, why would a business studies student be starting her studies in mid November. And why would you approach people in a car park, rather than say, the students’ union?

And I remember reading about studies featuring psychology students, posing as nicely spoken people who have lost their wallets, approaching strangers at London stations for help and usually met with very positive and generous reactions. I wondered if this person might be repeating this or a similar study and deeper down I wondered if I was being recorded or filmed. Subsequently I found that Youtube features lots of Rich Beggar social experiments, like the man with a new red Mercedes who solicits 50c for a parking meter.

But there was still a chance she could be genuine, and not a con artist, researcher, addict or beggar.

I decided to give her a small amount of money, £5, based entirely illogically on the odds of her story being true, 20% give or take. Most people I’ve talked to think that was overgenerous. Wiser heads tell me this was an obvious scam.

Furthermore, ethical decisions can’t be made on the basis of percentages of likelihood. Paying £5 was generous if the lady was begging and ungenerous if she was for real. Generally we are advised not to give money to beggars and certainly not to give money to con-artists. There is an ethical basis to this in as far as giving money is not helpful, may do harm and is unjust.

I’m pretty sure I’ve failed the ethics module this time. ‘Didn’t think it through properly’ is scrawled all over the paper in the red biro of morality.

There is a code that says don’t give to beggars, but there is no code for dealing with unexpected events such as people in pub car parks offering to sell you fish or firewood. To protect against scams I suggest one simple principle. Only two groups of people bother – legitimately- to dress impeccably nowadays: car salesmen and funeral directors.

If you are approached by an unaccountably well dressed person and that person is neither of these, then walk away. McTell’s tyranny must end.

87. You know I hate to ask, but are friends electric?

A patent magneto electric machine. USB C adaptor is $40 extra.

In August, I took an Australian visitor to Lincoln Castle for a good slice of History. Everywhere there were flamboyant characters in Victorian outfits and I soon realised Lincoln was hosting a steampunk festival and we were getting more History than just the Magna Carta.

Officially called The Asylum Festival, the event centred on The Lawn hospital, near Lincoln Castle, an early nineteenth century building which, until 1985, served as a mental hospital.

In this case, and in general, it’s easy to argue that steampunk is filling not just a building but also a cultural void at the Lawn vacated by psychiatry, at least in terms of celebrating the Gothic.

According to wikipedia, Steampunk refers to a subgenre of science fiction and sometimes fantasy that incorporates technology and aesthetic designs inspired by 19th-century steam-powered machinery.

Contrast with Psychiatry, which refers to a subgenre of medicine and sometimes fantasy that incorporates technology and aesthetic designs inspired by 19th century electrical-powered machinery.

Another attempted definition of Steampunk is ‘modern technology—iPads, computers, robotics, air travel—powered by steam and set in the 1800’s’.

Again, contrast with psychiatry, which is all about old ideas (mental energy, chemical deficiencies, mindfulness etc) set in a concrete building on a business park modelled on George Smiley’s HQ.

The point is, Steampunk celebrates the art of anachronism, whereas psychiatry regards it with a mixture of hatred and denial.

The Lawn was opened in 1819, which was before the reign of Queen Victoria, but most of the British Asylum hospitals were built during the Victorian period. Many of them were gothic in style, making them a suitable venue for wearing top hats and tinted goggles, riding round on penny farthings and racing steam robots.

Nowadays, psychiatry is shy about its Victorian heritage. The contribution of Freud and his colleagues is celebrated only in terms of a sprinkling of multiple choice questions. Freud’s early work would now be called Neuroscience and we know that he was intrigued by nerve tissue and would have taken a much more Electric road, if only he’d had access to multipacks of AAA batteries or a USB charger.

Freud knew that the brain was electrically powered – indeed this discovery went back to the end of the eighteenth century. He attributed symptoms like hysterical paralysis to mental energy short-circuiting down the wrong pathways.

Since the Victorian era of psychiatric treatment, electricity popped up as a treatment option at frequent intervals. Nowadays there are many people working on various kinds of electrical brain stimulation, such as deep brain stimulation, transcranial direct current brain stimulation (tDCS), magnetic stimulation and the original and genuine product, ECT.

This is not, you understand, the official penchant of British psychiatry, which by convention pretends to emphasise social and psychological approaches. You’re supposed to listen actively for at least five minutes before getting the talk round to tablets and quite a bit longer before mentioning the E word. That’s just a convention. I wouldn’t call it hypocritical, more, let’s say ‘dual mode’.

People say they want to be listened to more than anything else, but that stance also can be a little dual-modish. Quite a number of patients are in search of physical treatments of one kind or another and want to seek medical advice before buying batteries and sponges from B and Q.

Talking yes, counselling certainly, making a few changes to your life, I guess so, but hey, just tossing an idea out there, how about electricity?

Sadly, the custodians of ECT, psychiatrists and their colleagues in mental health trusts, have completely failed to market their product at all. The number of people prescribed ECT has declined dramatically over the years. Depending on where you stand on this argument, either it is being enormously under-utilised or you can’t believe it’s still going on at all.

Because the NHS mainly seeks to discourage people turning up to use its services, nothing much has been done to promote electrical treatments. The premises used are a bit drab and though they are strictly regulated, the ambience is a bit like the blood – doning centre, being a strange mixture of homeliness and apprehension.

After ‘One Flew over the Cuckoo’s Nest’ was made and shown to generations of students, the Royal College decided that ECT could never be made to look cool ever again.

Regulators like NICE narrowed down the number of indications and the treatment itself changed a lot subsequent to most of the controlled trials that were conducted. A different anesthetic is used, the energy level has been reduced, the ECT box is not made of mahogany any more and some units don’t even provide free toast after treatment. Arguably, the toast issue has been the most damaging.Whereas 6 to 8 treatments used to be standard in the toast era, now it’s often 12.

I doubt if ECT will be hived off to the private sector, but it wouldn’t totally surprise me to see new departments of electro-therapy in different settings, like sports medicine clinics or the corner of Debenhams.

Unlike ECT, tDCS has acquired a better vibe, being used by the Air Force to keep people concentrating and allegedly by students to improve their performance in games and exams. Perhaps more psychiatrists should be looking at it, but they won’t hurry because they are still struggling with their electrical baggage.

Steampunks would be delighted with a treatment like tDCS that was invented in 1798, but psychiatrists haven’t yet learned to love and embrace the anachronisms of modern life.

86. Setting food on fire: not really politics and not really science.

Warning: hair fires are getting more common.

Behavioural activation is one thing, but most therapists wouldn’t recommend attacking a breakfast cereal cafe in Shoreditch with fire torches, even if such action seemed to strike at the heart of the neoliberal orthodoxy. As a child, I remember putting various kinds of food on to an open fire to see how well they burned. Result: cereals burn extremely well. Discussion: a packet of Ricicles with the top torn off is virtually a Molotov Cocktail. Have people learned nothing from the great fire of London?

There must be better ways of challenging gentrification. Karl Marx spent years in the great reading room at the British museum, working out how to win the class struggle. Possibly he over-thought the whole thing, but direct action against muesli wasn’t on his agenda.

As the person next to you in the waiting room might say, let me tell you about my latest hallucination. I was half asleep at the time, so the experience would be of no interest whatsoever to a psychiatrist. ‘Hypnagogic’ or ‘hypnopompic’, both suitable names for an electropop band or a small disco in Albufeira, are words to denote an experience that occurs when you are just dropping off or waking again. Such things are firmly in the ‘that’s- yawn-normal’ category and would only rate a single line on page 119 of a psychopathology textbook, even if anyone was still writing those.

Anyway, here’s what it was like. It was a circular image, on the lower half of my left visual field. It was brightly coloured but hard to make out. There seemed to be a mountain and on top of the mountain something like a person. There was no sound, but somehow the words ‘good works’ became associated with it, though the words were not spoken.

That’s it. But what to make of it? A trip to the slightly-over-intimate optician at Specsavers, or start a new religion? One explanation of why we dream is to allow the rehearsal of potential responses to feared scenarios. Primitive peoples would have dreamt of being attacked by wild animals but now we dream about how we would turn the water off if the pipes burst – you may have different nightmares, but you should still install service valves for each appliance.

In the dream scenario, we appear to be paralysed and unable to take necessary action. This is supposed to be because these dreams occur in REM sleep, when the body’s motor system has been taken off-line for maintenance. But this is not helping me interpret my vision. It’s unlikely that a man on a technicolor mountain will give me instructions, if only because there are no mountains where I live, unless you count the coal tips at the power station.

Good works could mean a number of things, but I’m sensing the gist of it as behaving more constructively or generously or just more usefully. At the very least ‘good works’ means I’m not going to pursue my latest business idea, which is a range of homeopathic soups, provisionally titled ‘Memories of Heinz’. And it probably means stopping putting opportunistically low best offer bids on ebay items, just in case the seller is desperate to raise money.

Decades ago, I remember Father Higgins causing a stir when he seemed to go against the idea of Prayer. I think what he said was that you are judged on what you do, not what you think or say. Looking at that now, it doesn’t seem too controversial, following all the scandals that hit the churches. People were clearly behaving badly yet talking sweetly to the boss.

At a meeting this week I found myself in the coffee queue, behind an eminent colleague. I noticed him place his cup just slightly off beam below the dispensing nozzle, so that he got the full quota of frothy milk, but none of the squirt of coffee, which comes out about an inch to the left of centre. I watched the coffee spurt to the side of the cup and I watched him not notice. I watched him take a slurp of his coffee and complain it didn’t taste of anything. Why didn’t I say something? Answer: too much thinking and not enough behaviour, just like Karl Marx.

Getting the balance right between thinking, emotions and behaviour is what therapists do – on diagrams. The point of my dream, I think, is that behaviour comes first and we should help colleagues operate coffee machines even if they work for NICE.

Lots of strands of information feed into our dreams. If ‘good works’ means something to do with behaving better, then it does chime with some of the stuff I wrote about last year. I suggested that behaviourism had been abandoned prematurely in favour of cognitive approaches. I suggested that Art and Music and other skills therapies had been neglected in favour of talking. And I praised hunter / gatherer activities, or pottering, which is the natural human condition. I attempted to steal Nike’s slogan ‘just do it’ to symbolise putting the B back into CBT.

People are abandoning old assumptions about how to protect against sadness and anxiety. They are resorting to eclecticism and mixtures of lifestyle improvements and increasingly, to apps connected with social contact and fitness. Not to mention the people who are connecting batteries to special hats to improve their exam performance, or using Nitrous Oxide to make TV more enjoyable.

This is heretical, but merely running for miles is not a good work. That is why athletic activities have to be artificially and laboriously associated with charitable causes before they acquire a moral value. This is even more heretical but I venture to suggest that neither knitting nor chatting nor a combination of the two are intrinsically valuable activities. It’s easy to say what isn’t a good work; much harder to say what is. Here are my first thoughts on the matter, in the form of a multiple choice question.

Which of the following is a Good Work?

Donating one of your spare copies of Songs about Jane by Maroon 5 (statistics show there are on average 2.6 copies per household) to Cancer Relief.

A mindfulness based breathing exercise, such as blowing up a balloon, pausing to enjoy the pleasing tension in the larynx and the slight dizzy sensation caused by lowered pH.

One short burst of primal screaming followed by a cigarette

Writing down a negative thought using lemon juice as invisible ink, revealing it with a hair dryer and then burning it

Playing the Killers’ song ‘Everything will be alright’.

A friend tells me the man on the mountain sounds like Moses, the person who probably invented bullet points and coined the word ‘covet’. Moses set fire to lamb at times but not I think as part of an informal science experiment.

85. Facing the inevitable barrage of organic fruit.

Body language gets you 90% of the marks.

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

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

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

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

We are accused as follows:

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

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

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

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

84. Learning lessons from cleverer sorts of creature.

Dolphins. They don’t do SATS.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

83. Bandwagon for sale, very low mileage.

A concrete windswept piazza, early in the morning, before the philosophers arrive.

I tried to warn the Liberal Democrats about the negative halo effect that occurs when anyone talks about mental illness in the media. As soon as the talk gets round to mental health, people become upset and change channel, without even knowing why. Not only that but they get grumpy and choke on their pop tarts. The reaction is deeply intuitive, like a brain stem reflex.

The Libs banged on about mental illness affecting one in four of us and needing to be put on the same footing as physical illness services, eliminating suicide etc, just as though they hadn’t read this blog. They didn’t listen and now they are a burned out ruin on the hard shoulder of politics.

Though the halo effect has been known for more than 50 years, this has not stopped a succession of doomed public awareness campaigns such as ‘defeat depression’.

We know that mental health information is perceived as toxic, but no-one has adequately explained why.

Since Shirley Star’s studies of public opinion in fifties USA, the consistent findings have been that people with mental illnesses are regarded as dangerous and unpredictable. Presumably, so too are violent criminals, but they get massive media coverage and scrutiny. Most likely, the ingredient that puts people off dealing with mental health is having to try and understand it. Once you start to think about it, even if you’re in the business, there’s a large parcel of mental work to be done before you can process the information.

For instance, drawing the line between unhappiness and depression, separating personality disorders from illnesses from disabilities, let alone facing the mind brain problem. We’re pretty quickly into Melvyn Bragg territory, but without his panel of expert communicators.

It’s exactly the same for other specialists. A motor mechanic recently tried to explain to me – in some detail – about what had gone wrong with the car’s air conditioning. I remember the phrase ‘wobble plate’, but to be honest that’s the only thing I can tell you about it now. I’ve had to abandon any smug pretensions to knowing my way round a Compressor. Though I will, soon, find an opportunity to say the words ‘wobble plate’, somehow or another.

I’d compare the negative halo to the effect of encountering a protest demonstration in a shopping centre. First instincts are to avoid it, not particularly in case of violence, but more in case you are called upon to examine a complex issue, like whether a remote area of a foreign country has been shabbily treated. Thinking is the last thing you want to do in the Arndale Centre. But it’s the kind of thing you might do by listening to Radio 4 at about 8pm, alone in your car on a smooth stretch of highway. But then that’s your choice, if you’re in the mood for mental activity.

Outside the police station, a large sign reads PRIDE. I’m going slowly enough to recognise that PRIDE is an acronym – after each capital letter is a smaller word. Subliminally, I perceive the words to be: Pride, Respect, Integrity, Dedication and Empathy. Are these virtues (or sin, in the case of pride) really top of our list of desirable qualities in a police service? Surely, these are not the words you want to hear when the machetes are waving and the AKs start popping.

Having said that, I’ve had no success in weaving an acronym from the words, Taser, Cuffs, Tear-Gas, Smith, Wesson, Court and Prison.

Doubtless the police have their reasons for presenting themselves as social workers, such as the diminished number of real social workers. And obviously they have to try and maintain the moral high ground. Nevertheless, my brain stem reaction to the PRIDE sign was: misguided PR campaign. People are proud of the police because they stand up to horrible people, not because they are empathic. Bad Boys 3 will not be subtitled Good Boys.

The negative halo effect cannot be countered by dressing things up. On the contrary, we are set on guard most acutely by any hint of deception. Very large and fast neural systems are devoted to spotting trickery. It takes a lot of considered reflection to counteract such defences, which means weighing things up carefully. The very thing that stresses out the wobble plate.

82. Euripides Trousers …

Bees. They just get on with it.

Up until recently being a teenager was not regarded as a mental disorder. After David Cameron urged us to hug a hoodie, teenage angst was virtually eradicated from the diagnostic landscape. But now, some people seem to want to regard teenagers not just as sad victims of poor trouser design, but as Patients.

Someone’s looked at the lyrics of The Kids are Alright by The Who and recognised that they really meant the opposite. The Times is running a campaign about children’s mental health. A lot of assertions are being made that children are unhappy, that they are living through unusually stressful times, that they are victims of the modern world.

Horrible articles are being written about teenagers, suggesting they are unfathomable monsters and the National Theatre is running Medea again. I’m sorry, but this children’s mental health campaign feels like a moral panic. Who is stoking it up, and why?

Somehow or another, ‘subjective well being’ has become confused with becoming mentally ill. I’m a hypochondriac, but does that really affect my chances of getting ill?

Here’s a test of your subjective well being, the one used by the Children’s Society, the people who gave us the christingle:

Here are five sentences about how you feel about your life as a whole. Please tick a box to say how much you agree with each of the sentences: My life is going well; My life is just right; I have a good life; I have what I want in life; The things in my life are excellent.

Subjective well-being is arguably a test of how smug and complacent people are. How would John Lennon have scored? How would we have wanted him to score?

Before we go any further, how desirable is it for everyone to think the things in their lives are excellent?

Children are apparently scoring worse in such studies since 2008. And UK children are being dragged down the international league table by girls’ concerns about their appearance. British girls are second last, only South Koreans scoring lower, despite their excellent android phones.

It’s election time, so Nick Clegg is using the present tense when he should be using the future subjunctive, which apparently exists in Spanish. He’s claiming that stuff is happening, like expanding children’s services, that just might happen one day but probably won’t. He is comparing children’s mental health services to cancer services. If doctors did that they’d be accused of an absurd fixation with the medical model.

Libby Purves, still top of my list for head of state once we become a republic, compared children’s mental un-health to cholera, though admits that there is ‘no single pump handle’ to sort out.

To Libby’s credit, she soon recognises the problem is not like cholera at all. She blames children’s unhappiness on: divorce, drug use, exam anxiety, peer pressure, early sexualisation, information overload, loss of contact with nature, ubiquitous screens, TV, games consoles…

Just like our generation suffered so much from CDs and colour TV. Just like our parents generation was thrown into abject misery by antibiotics and Walt Disney.

And she goes on to suggest a list of practical solutions: a smartphone ban in schools, art classes, choirs, safe outdoor spaces, park keepers, bus conductors, beat coppers and finally, ‘volunteering and youth groups to be made fashionable and fun’.

No doubt Libby is on the right track in terms of placing the issue firmly in the Sociology Department. There’s a squeeze on social capital and no sign of quantitative easing. That’s not to say that useful modern inventions like apps and text messaging are deleterious to social capital – quite the reverse is true judging from the queues in Costa and Macdonalds.

Very soon, the children’s mental health campaign will have to contact Blur to see if they can borrow the slogan Modern Life is Rubbish. But remember, that album was released in 1993, which to the under 18’s is somewhere between Roman times and Wolf Hall. Modern life really was rubbish then, before graphical user interfaces and flat screens. And it was probably rubbish in 1893, the year when the US Supreme Court declared the tomato officially to be a vegetable.

And isn’t the rest of The Times newspaper filled with all the stuff that Libby regards as a cholera fountain? The cholera in question being market-driven, intra-sexual competition. There’s a lot of stuff about girls who hate themselves and almost nothing about bus conductors or park keepers. In the fashion section all the items are unfeasibly expensive apart from one token item from Primark. Any article about anything whatsoever, such as which is the best digital tyre pressure device, will be accompanied by a picture of a thin female person, probably one of the tiny girls employed to make the DFS sofas look massive. If Libby finds that pump handle she ought sort out some of her co-workers with it.

People have been casting aspersions on younger generations throughout history. This is perhaps the first time that teenagers are being castigated by being labelled mentally unhealthy. It’s a change from being considered morally deficient or stupid, but just as fatuous.

Mostly, there is no sense in medicalising the problems children face. There are no specific treatments or therapies that will help them and no army of skilled professionals waiting for Clegg to deploy them.

Luckily, there is little evidence that youngsters are any more mentally unhealthy than any other age group. Mental illness, like most other illnesses, gets more likely when people get older, like rust on cars. Children don’t get mentally ill in the same way as adults, not very often anyway. Although it is unbelievably awful when a suicide occurs in a young person, teenage girls’ rates of suicide are three time lower than middle aged women and twenty times lower than middle aged men.

People are not growing huge thumbs as a result of texting or walking into traffic because of ear phones. A teacher asked me recently whether schools should have mindfulness programs. But surely, a school is a mindfulness program?

Attempts are being made to impose guilt on schools and companies for being competitive, with the aim of selling them mental health services to patch up any bruised egos. The Times is doing something similar within its internally contradicted hand-wringing departments of greed and anti-greed. Thankfully our children our savvy enough not to join the stampede down to CAMHS.

Anyway, they can’t run in those trousers.

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