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

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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.  

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88. Making sense of everything that’s ever happened.

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A service user, just hoping the CQC will make an unannounced visit.

There’s a backlash against drug therapy and a lot of people hate the fact that life expectancy has increased and there are effective treatments for cancer and diabetes. It’s just not natural is it? It’s no work at all just to take a tablet once a day with a glass of chilean merlot. It’s just inherently non-puritanical, especially as medicines don’t taste horrible any more.

Sadly pharmacists and drug companies won’t pretend their products are made out of tree bark or geranium leaves, they won’t put them in medicine bottles, they won’t colour them green – apart from Methadone, which still comes in a retro package – they won’t use the word Potion and they won’t make it taste like socks. Instead they almost celebrate the industrial origins of medicines, so that they are packaged and named like computer parts. Try a course of Celeron, and move up to Radeon if there’s no improvement after 6 weeks.

The market is wide open for a no pain no gain therapy, like the training montages from the Rocky movies, but instead of physical punishment, experts have come up with a therapy that’s more like school detention: History Therapy.

‘Historian and broadcaster Dan Snow and psychologist Richard Bentall get to the root of 21st century melancholy, and propose a cure’, we are promised

They will ask: Does meditating on the lives of our ancestors help us get a better sense of perspective toward our own problems? Can history nourish and console? Is the study of history, in short, a form of therapy?

They are putting History, in a bottle, on your tablet shelf, between Vitamin G and Vitamin I. It’s only £30 to attend the history session, which is less than the price of 100 Prozac tablets. Just remember that history is far more difficult to flush away.

I didn’t say this about Dan Snow and I’m quite scared about repeating it online, but some historians don’t think he’s a proper historian:

‘he routinely refers to himself as a historian when he doesn’t have a PhD or equivalent and therefore has not done the years of original archival research that professional historians have undertaken and then he takes our research and re-hashes it without any credit. And gets his facts wrong but still continues promoting himself as an expert. I think he is a dick and every time I hear the BBC refer to him as a historian I shout “No he fucking isn’t!

(http://gasheadau.blogspot.co.uk/2015/05/a-delightful-discussion-of-self-made.html)

Please, proper historians, try being a psychiatrist, a field where absolutely everyone you meet is an expert.

Anyway, where you stand on Dan is likely going to indicate where you stand on the treatment of Depression.

Is Depression:

  1. A major common medical condition with a high level of morbidity and mortality, that should be treated by experts in the NHS with proven treatments? Or:
  2. A medical metaphor for the stresses of modern living, that should be treated by creative people broadening one’s outlook?

Those of us sensible enough to realise that our bodies are made of molecules still enjoy putting things into them to help them work better and we would use computer parts if we had ports on our bodies, like Jude Law in eXistenz.

For us, if you’re walking away from the GPs without a prescription in your hand, at some deep level you feel that your mission has failed. Now there’s a win / win solution. Regardless of your condition, however big a hypochondriac you might be, you still collect a script. But instead of taking it to Boots and running the gauntlet of their ‘counter intuitive’ queueing system, now you can take it to the library instead and exchange it for some Bibliotherapy, aka books.

The downside of this is that you are at the mercy of your GP in terms of reading material. The other downside for the library is that it becomes a germ exchange and none of the staff use alcohol gel, not externally anyway.

Quite likely your GP, in the last of your eight minutes of consultation time, will rush the all important choice of book and palm you off with The Hunt for Red October. I can just see a bit of confusion ahead, down to the fact that doctors call collecting information from patients ‘taking a history’. e.g:

Patient: I want to take some History

Doctor: That’s my job.

Patient: Can you prescribe me a bit of Dan Snow?

Doctor: No, but we do have some Dan Brown left over.

70. Reporting soap shortages, before they get serious.

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A poster reminding people, in several ways, that they are too old.

 

The techno-thriller genre gave readers a thirst for irrelevant information. It wasn’t enough to say someone travelled on a Boeing 707. You had to hear about who made the engines, how the landing gear was inspected by a man with a set of tuning forks and how the pilot’s socks were monogrammed in alpaca by a silent order of nuns in Seattle.

The behind-the-scenes stuff became obligatory for thriller writers – quite a feat before the days of google. Presumably, Forsyth and Clancy spent huge amounts of time visiting airports, submarines and arms factories, asking people, ‘what does that yellow handle do?’

The most obvious spin-off has been the increased number of adjectives we find in grocery products. It’s not enough to say Oven Chips. You need to give them a bit of character development:  Maris Piper, thrice-fried, goose-fat oven chips, at the very least. And even then, you’ve said very little about the goose. People want detail nowadays.

Another consequence of the increased audience for background information is the ‘Troublehooter’ style of TV series, started by John Harvey Jones and continued by the likes of Gerry Robinson and Digby Jones.

A man in a striped shirt and hard hat wanders round a huge factory, shaking his head slightly, asking every now and then: what’s that thing for? As a TV show, it’s a tired formula. But, as a metaphor for personal growth, it’s got potential. The striped shirt man is a therapist of sorts. He’s an independent expert, but he’s neutral and polite. He’s robust and challenging, but he’s kind and might even hug you, though you’re still getting fired. Like a certain type of clinical psychologist, he’ll make you a flow chart, showing you which arrow is missing, such as the one between Theakston’s Old Peculiar and poverty.

It could be helpful to get someone to troubleshoot your life. But what about businesses – can an outsider really understand them? Does expertise in the field really matter?

Troubleshooter appeals to people who like to look behind the scenes and are disappointed that Arthur Hailey died before he could write ‘NCP Car Park’. Ironically, the Troubleshooter himself is not the slightest bit concerned about forged composites or digital motors. He’s looking at the system as a whole. He’s drawing Venn diagrams and talking about Synchronicity, just as though it wasn’t the worst Police album.

Gerry Robinson wants the NHS to have more centralised reporting systems, like the food industry:

‘Imagine a McDonald’s in Leicester, say, where things are going wrong. Perhaps the wrong number of chicken nuggets are being handed out, or the washrooms aren’t supplied with soap. These problems would show up immediately via a weekly reporting system which compared its performance against every other McDonald’s in the country, and you’d have a senior manager down in days to sort out the problems’.

Gerry’s background is in catering, so he’s comfortable with that model.

But, senior managers never visit NHS units, partly for fear of infectious disease, but largely because it would never occur to them to do so. Boards and Hospitals are different planets, with different atmospheres and gravitational fields.

Whereas the coffee available to senior managers comes out of a capsule machine, the coffee provided to wards comes out of industrial size tins labelled Maxwell House. It’s Maxwell House, Jim, but not as we know it.

Whereas NHS management premises are carefully protected behind air-locked entry systems and fierce receptionists, anyone can walk, unchallenged, into most hospital departments, including intensive care units and even operating theatres. This fact is portrayed in countless thrillers, where assassins get a second chance to finish someone off by stealing a white coat and strolling in.

As further evidence that NHS Boards and Hospitals are separate worlds, consider the fact that boards comprise upwards of 12 members, only one of whom is a practicing clinician. Does Gerry not think this is a bit odd? Does he not realise that Boards and Clinicians, like matter and antimatter, must never come into contact with each other and if they do, the universe will be annihilated?

I am not a management guru. But even I can spot the key differences between Macdonald’s and the NHS, such as Product Range. Which leads me to ask: who troubleshoots the troubleshooters?  It suits managers to propagate the notion that it doesn’t matter much what the company does or makes, that you can move between Catering, Television, NHS and it’s all the same. But often, the detail is what matters most. John Harvey Jones forecast the demise of Morgan for instance – he just couldn’t understand how cars could be made of wood. It’s not a mistake Tom Clancy would have made. He’d have known all about the aerospace properties of ash.

Whereas thriller writers regard craftsmanship in awe, managers regard it in contempt. In a techno-thriller, the emperor’s new clothes would be made of kevlar. And the boss would know what the yellow handle did.

To be fair to John Harvey Jones he did tell the Chief Constable of South Yorkshire that his strategic plan was ‘a load of bloody cobblers’. This comment pretty much ended their foray into footwear repairs.

 

67. Choosing exactly the right cakes, by law.

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

 

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

Am I a character from a John Le Carré novel?

Am I a teacher at an Islamic school?

Or have I just missed my Risperdal tablet today?

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

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

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

It applies to nearly everybody then.

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

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

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

Social Worker: At least 25 hours.

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

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

Manager:  Then you better get started right away.

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

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

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

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

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

 

61. Punching above your weight, with Britney.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

47. Predicting the New Year, without proper guidelines.

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Psychiatrists are able to read the future. That’s why there are very few about – most have made a killing on the stock market or at the bookies and have retired to Tahiti. Or so our managers think.

Just to prove the point, here are some predictions for the New Year:

1. Badgers will launch a surprise counter attack on David Cameron. They are already digging a tunnel towards Downing Street. Badgers are classic terrorists, with long memories and sharp teeth. In panic retribution measures, Brian May will be blamed and sent to the Tower of London.

2. People will begin to notice that google searches are getting more polluted by advertising. Google will offer a premium service where you pay a subscription for an ad free version.

3. Universities will begin a series of mergers and takeovers, so that eventually there are only four big players, as with supermarkets, petrol, energy etc. University Challenge will start at the semi finals.

4. There will be an upsurge in Placebo based treatments of all kinds, and NICE will issue lengthy guidelines on how to choose and use them, with a forward by Prince Charles.

5. Private GP practices will develop in the larger cities. They will give you the sleeping tablets, painkillers and Betnovate cream that you have longed to obtain, without any tut-tutting.

6. Building regulations will be tightened up, so that new buildings will have wider letterboxes, to accommodate take-away pizza.

7. Swiss cheese makers will be stopped from injecting carbon dioxide into the holes to make it weigh heavier on the scales. Conversely, Ryanair will check for Helium in your hand luggage.

8. The forces of social control – police, probation, mental health and social work – will increasingly blur together. The new force will be re-branded as Lifestyle Services. The uniform will look suspiciously like G4S.

9. Further updates in nomenclature. G4S to G5S, E45 cream to E46. Boots 7 goes to 7.1. Players No. 6 are re-launched as Players Number Free. They pre-empt the packaging ban by going for a plain white carton. It worked for the Beatles after all.

WD40 surprises everyone by going straight to WD million.

10. Liverpool FC will embrace Mindfulness. Their new kit will be orange robes.

If you want a more accurate prediction, and you don’t know any psychiatrists, you can do equally well or better yourself, using a set of dice or random number tables. Please note, NICE do not recommend the use of tea leaves, bones, fund managers or even physicists. Prediction is very difficult, said Niels Bohr, especially about the future.

From Tahiti, I wish you a Happy New Year.

43. Deciding whether to decide, or not.

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Some KFCs are quite opulent on the inside.

I’m hoping to acquire one of those official looking G4S-style jackets that parking inspectors wear, along with a peaked cap and mirror shades. The reason is, I live next to a school, and every morning the parking situation gets worse. The invention of the SUV has blurred the harsh boundaries of road, pavements and yellow lines and turned them into a mere probability distribution. There’s an Audi Q7 that behaves like a two tonne hippo, just setting itself down wherever it pleases. If I just stood outside, in my Parking jacket, maybe the madness would stop. Until I got arrested, anyway.

Parking properly is one of those skills, like cooking Yorkshire Pudding or wiring a plug, that 57% of people can’t do. Recently two surveys showed that modern school-leavers are no more literate than their grandparents were at the same age, and that they would lose a 100 metres race to their grandad. And that’s as he is now, aged 95, with advanced emphysema.

Surprisingly then, Britain, the country at the bottom of the skills league table, where only recent immigrants actually know how to do anything, introduced the Mental Capacity Act.

Luckily, like the parking outside the school, it is not enforced.

So called ‘mental capacity’ means that a person is able to make a decision. It depends to a large extent on how complicated the decision is as to whether the capacity is present or not. For instance a person could have mental capacity to choose breakfast, but not have capacity to make a will. In between these, somewhere, is capacity to have sex or get married, or both. If a person does not have capacity, they should first of all be suffering from a deficit of ‘mind or brain’. Then they must fail one or more of the following steps of decision making: Understanding the information, Retaining the information, Weighing the information up, and Communicating the decision.

Immediately obvious is the amount of greyness in the ‘weighing up’ part.

While the Mental Capacity Act makes it clear that making an unwise decision need not mean that the weighing up process is defective, it certainly leaves scope for an argument over the point where an unwise decision becomes irrational, and the point where irrational means lacking capacity.

Perhaps the intention of the mental capacity act was to give the illusion of clarity, while still leaving a huge judgement call to doctors or other professionals. The irony is that no professional person really understands the mental capacity act and certainly doesn’t retain it in his mind or communicate it well. The mental capacity act code of practice was written on the planet Zarg, in Zarg language, which is similar to Welsh.

So, only case law will reveal the dividing lines between unwise and irrational.  A series of judgements will set the goalposts for issues like leaving all your money to the scientologists, marrying your attractive but 70 years younger carer, buying a Porsche 911 to celebrate your 100th birthday etc.

For instance, last year, a judge ruled that an autistic woman with an IQ of 64 did not have mental capacity to have sex,

‘on the grounds she does not fully understand she could say no to such actions’.

Mr Justice Hedley said the 29-year-old lacked the mental capacity to consent to having sex, and made the order to protect her best interests.

He said she had to be protected from ‘potentially exploitative and damaging’ relations in the future, as she had already been involved in risky behaviour with people.

http://www.dailymail.co.uk/news/article-2096472/Judge-bans-vulnerable-woman-having-sex-lacks-mental-capacity-consent.html#ixzz28nA227ia

Would scientists or doctors have come to the same decision as the judge? I suspect that scientists would tolerate fuzziness better than lawyers, simply accepting that the person had some mental capacity but not as much as most other people. But the legal system is black and white, not grey.

Whether a person can choose to have sex or not soon becomes a question about how the mind and body work together. And this in turn leads to an examination of how the Automatic part of the Mind interacts with the Reflective Part. It would be nice to think that sexual behaviour falls to the Reflective Mind, but its association with the older parts of the brain and the older types of intoxicant means that it probably doesn’t. Whatever the IQ.

So rather than being a Parking Officer, perhaps I could be a Mental Capacity Inspector. Outside the school, armed with my new jacket, the Mental Capacity Act Code and the Oxford Dictionary of Zarg, it’s time to Stand up for Sensible.

Firstly, do these errantly parking motorists suffer from a disorder of mind or brain? Most of them look absent minded and some are clearly in a trance like state. Some seem distressed, shouting at their children. At least two are using nicotine. One appears to be wearing a dressing gown and slippers. In fact, none of them seems entirely well.

Then, have they really decided where they want to park? Do they know what yellow lines mean? Can they weigh up the ethical trade off between blocking the traffic and parking on the pavement? Would they know that squashing cyclists can hurt them?

Enforcing Parking Capacity is just the start. Irrational behaviour is going on all over town, much of it in the context of mind / brain dysfunction, such as Special Brew Disorder.

Firstly, the National Lottery till at the newsagent. Anyone who doesn’t understand Probability – a GCSE in Pure Maths with Statistics will suffice – should be politely turned away in their own best interests.

Then Ladbrokes. Look at these other customers – do they look like rich people?

The tattoo shop – this sounds silly, but do you know that won’t wash off? And KFC. It’s chicken Jim, but not as we know it.

The mental capacity act can only do so much, since it respects unwise decisions, or any decision made by someone of sound mind. That’s why we still need the Style Police and the Fashion Police. It’s vital these functions don’t go to G4S, even if they have the jackets already.