84. Learning lessons from cleverer sorts of creature.

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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.

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

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Finally, a new logo for the National Health Service.

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

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

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

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

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

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

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

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

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

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

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

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

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

63. Being a do be, not a don’t be.

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Voyeurism can be a problem for creatures that mate outdoors.

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

*An investigation into the therapeutic benefits of

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

28. Removing labels, without toxic chemical solutions.

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Cows are basically hippies.

Who are those people hiding behind the boiler house, just outside the strict boundary of the Foundation Trust premises? Are they common or garden smokers? Are they A and E attenders, who have finished all the books they brought to read while they wait? Or are they escaped but tagged dementia patients?

If you go near them they shy away, like geese, toward a small clutch of untidily parked Fiats and Volvos. Finally, I realise who they are – they are my colleagues who work in community psychiatry.

They are hiding for a good reason though. People are pursuing them, ‘wanting a diagnosis’. And those people are angry.

The history of mental health tends to characterise psychiatrists as predatory. The accepted wisdom is that psychiatrists are part of the forces of social control. Their traditional prey, according to folklore, is a harmless eccentric or political dissident. Their modus operandi is to label these folk with an invented illness concept in order to render them powerless in the eyes of society and the law, so as to drug them or lock them up or both. Such is the myth of ‘anti-psychiatry’.

People used to fear the psychiatrist like a 70s DJ fears the child protection team. But now the tables are turned. Some people are desperate to get labelled as mentally ill. None of my colleagues know why, but they mutter about the internet, celebrities and the drug companies, not to mention the benefits system.

The world seems to have turned upside down, like Twelfth Night. Not as regards boys playing women on stage whose characters are pretending to be men. Rather, more in terms of poacher turning game-keeper.

The story usually starts this way. A short GP letter ending with the words ‘this man thinks he has bipolar disorder, please do the needful’. A patient with a large bundle of papers downloaded from the net. Stating that the description of bipolar disorder fits him perfectly right down to the last semi colon.

The psychiatrist tries to explain that diagnoses are merely conventions about what to call things, that in the UK at least people are rather conservative about the use of diagnostic labels, that labels in their own right can become dangerous and lead to people thinking of themselves in an unhelpful way, even getting stuck in a sick role and benefits trap.

That he doesn’t really seem to have bipolar disorder, at least according to the absurdly narrow conventional diagnostic system that bow tie wearing people in Geneva have written on our behalf in quill pen on parchment.

Finally the meeting ends under a cloud, unless the psychiatrist gives in and recommends a tablet with Q or Z in its name.

It’s tempting to blame our cousins in the US and /or big pharma. There is money to be made from atypical antipsychotics, but only if a group of people can be convinced they need to take them. I have not tried this (Your Honour), but I’m pretty sure atypical antipsychotics and mood stabilisers have practically no street value.

Last time I went to the US I saw some hilarious direct to public advertising for these substances, where the baritone disclaimer tag – ‘may cause impotence, heart failure, convulsions coma and sudden death, take with caution’ – was longer than the advert itself.

I’m not sure why labels are fashionable now. Labelling theory was all the rage in the 1970s and we were all taught not to label people and put them in pigeon holes. Perhaps it started with designer clothes, where the Nike swoosh added $20 to the value of a $2 tee shirt. People who took labelling theory too literally even got tattoos. When we make a diagnosis, we always play it down – we say it’s just a name people give to this type of problem area.

My proposal is that we use a barcode instead. This is a cheap shot, but I think  one or two of my colleagues would be happy to advise people where to stick it.

4. Getting over the mind brain problem

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What it looks like inside your mind.

One of the biggest barriers to tackling Depression is getting hung up on the Mind / Body, or more specifically the Mind / Brain problem. Its the mind part that’s the issue. As soon as the word ‘mental’ comes into play, people get all upset.

Its hard to adjust to the fact that we may be nothing more, or nothing less, than very clever machines. Its also hard to believe that consciousness can emerge gradually from a wiring network, providing that network is large enough.

Surely, if all you needed for consciousness was a massive wiring system, then British Telecom would be a god like super-creature bent on world domination. Hmm…

So can consciousness, or the mind, be considered a separate entity from the body? This argument still hangs heavily for many when they think about mental health problems.

The mind / brain issue did preoccupy philosophers for many centuries and still occupies a large section of Wikipedia. Some philosophers thought that mind and body were entirely separate devices. This idea is called ‘dualism’ and tends to persist in the way people think about the human control system.

If mind and body were different ‘dual’ entities altogether, like sound and light, then how could they interact? Some kind of transducer device, as proposed in the pineal gland by Descartes? Or simply, (cheating really) bringing God into it to solve the problem, God acting as a cosmic DJ, operating the twin turntables of mind and brain, making sure they were synchronised properly at all times?

(This school of thought was termed ‘occasionalism’ and probably did not influence the Faithless song ‘God is a DJ’ nor even Pink’s cover version. Pink was yet unknown in ninth century Iraq).

Glossing over Philosophy and Religion for a short moment, there is a lot to support the argument that the brain is a very sophisticated computer system.

For instance, nerve cells which make up the brain are long and thin and transmit electrical charge, just like wiring. The nerve pathways in the brain look a lot like the wiring loom in your Honda Civic. Damage to part of the wiring system, such as after a stroke, can clearly bring about symptoms, like loss of movement to a limb.

Higher up the brain, the nerve networks get more complicated and seem to provide for various different types of mental activity. There is the completely automatic type that controls basic physical functions like the operations of the lungs, heart and gut. Then there’s the largely automatic thinking system that does things like drive you to work and make toast. And then there is the reflective part of the mind that chooses what to think and do, or thinks it does, or you think it does.

Computer speak has given us a new ‘dualist’ model to consider, the division between hardware and software. Sometimes it can be helpful to think of the brain as the computer and the mind as the operating system. As an analogy it is both helpful and unhelpful.

The plus points are that factors such as social learning and experiences and memory can be seen as software, running within the brains basic wiring network, which starts off as a largely empty system and gradually fills up. The mind’s ability to process information and store it, or create actions, are similar to an operating system.

There is also a nice computer analogy to be made between the mind’s two main memory systems, long term and short term. Stored memory can be seen as similar to a computer’s hard drive, whereas short term or ‘working memory’ has features similar to RAM. Working memory is far more limited than long term and easily exceeded by multiple or complex tasks, such as chewing gum and walking at the same time.

Many memory problems, such as those found in Depression, occur within the process of moving memory between the two systems. Depression very often reduces the power of concentration, which is needed to retrieve information from the storage system, and also to file memories away.

Against the software / hardware model however is the following problem; the brain is not a fixed system like your PC or Mac. It can create, remove or change its physical structure as it goes along. The changes are not just electrical, as in hardware, or even just chemical – the brain is continually creating new connections. This is why the brain is called ‘Plastic’ – the term is used to mean flexible and open to structural change.

In babies and children there is a huge and continuous rebuilding program of nerve cells. In adults there is a much more limited program of nerve cell slum clearance but sadly not much in the way of inner city regeneration. Depressed people may lose their ability to generate new nerve connections in certain parts of the brain. In fact an attractive theory of antidepressant therapy (both drugs and psychological therapy) is that these may work by stimulating nerve cell growth in certain key areas.

And this brings us, a little early, to the punch line. Which is that structure and function are inseparable features of our control system. They are so interactive that it make no sense to identify two entities called Mind and Brain.

In practical thinking this dilemma presents itself frequently in thinking about mental disorders. For instance in thinking of some illnesses as either mind based or brain based. In particular illnesses that were once considered to be ‘psychosomatic’ such as bowel or fatigue syndromes. Within Fatigue Syndrome there have been heated arguments by some sufferers that they should not be regarded as mental health patients, even though CBT may well be very helpful, as it can be in ‘physical’ illnesses like chronic pain.

The law has frequently got itself into a pickle by trying to separate what is due to the mind and what is due to the brain. We have seen concepts such as ‘non insane automatism’ invented to illustrate this area. The newish Mental Capacity Act speaks of a disorder of ‘mind or brain’, to get over the possible argument about which one was disordered. Could one ever be disordered without affecting the other?

Within Education, we have seen concepts such as ‘Brain Based Learning’, or ‘Mind Brain Constructivism’ as it is more properly known. Here again the proponents are careful to use the term mind/brain as a portmanteau concept. Strangely, educators have been rather uncritical about the supposed ‘Brain’ aspects, such as improving food and water consumption for students. The ‘healthy mind in a healthy body’ notion has been about for a long time in schools. Before Michael Gove, and in fact before even Socrates, neither of whom would have seen the mind as a wiring loom.

One of the more interesting findings from Brain Imaging has been the recognition that psychotherapy may bring about structural brain changes. For instance, changes have been found to the mid-brain serotonin transporter system, after psycho-dynamic psychotherapy. A much larger number of studies have shown changes to nerve cell functioning during and after therapy.

It could be argued that these sorts of changes are not actually ‘causal’ but rather just a secondary indicator of mood change. Nevertheless, there is clearly a mood control system in the brain that is represented in physical structures.

So we have the Fatigue Syndrome lobby who resent being considered as having a mental health problem, and we have the ‘anti-psychiatry’ lobby who hate the so called ‘biological’ model of Depression.

The fatigue lobby would be delighted if one day a clear biological cause is shown for the illness – presumably then it becomes like MS or any other ‘proper’ illness?

And the anti- psychiatrists would be delighted if absolutely no biological change could be found in the brains of depressed people. They have been similarly delighted by the findings that antidepressants are not as effective as people used to think. Their response is not at all to suggest finding a more effective antidepressant, but rather to debunk the whole concept of Depression.

If you need to ask how can simple chemicals substances change the way people think and behave, then you have (wisely) not visited Nottingham city centre at 11pm. If you doubt that faults can occur in complicated electronic control systems, and that such faults are impossible to diagnose and treat, try using a 10 year old Beko washing machine. It has a mind of its own.

It seems the learning point is never to try and assign a problem to mind / or body, and always to recognise that the two are one. If that makes us just a brilliant machine or merely thirty nine dollars worth of chemicals dressed in a suit of similar value, so what?

Well, for one thing, less stigma, and less guilt. If we have defective mood control systems, whatever the basis, then this is a health problem and not shameful.

I was taught by Irish Nuns that ‘man thou art dust and to dust you will return’. (Its the kind of thing Rugby Forwards say to each other before a game). The dust cost less than thirty nine dollars in those days.

And if God is really acting as DJ, is he playing enough soul?