Tag Archives: appraisal

105. The Firehose Paradox.

The first rule of psychotherapy?  Never quote song lyrics, even if they seem devastatingly apt. Even if someone says ‘it’s like a jungle out there’, do not be tempted to reply ‘you sometimes wonder how you keep from going under’.

Even if someone says, ‘some people call me Maurice’, as actually happened to me once, don’t be tempted to get out the air guitar and play the riff from The Joker. (No, I didn’t do it.)

Quite likely your client will recognise the words, in which case your authenticity is blown. 

Nevertheless, songwriters are great at encapsulating a feeling. If you must quote, include the attribution. Like, ‘as Leonard Cohen would say, Everybody Knows’. 

I’m a late convert to Leonard Cohen’s music and poetry. Clearly, he should have won the Nobel prize instead of Dylan, just for this song. Everybody Knows. In 5 minutes and 37 seconds the song lists all kinds of skulduggery that passes for normality. The dice was loaded. The good guys lost. And in particular, a concern about Fidelity: ‘You’ve been faithful, give or take a time or two’.

There are lots of lines in the song that sound like paranoia but fall just on the right side of understandability. Everybody Knows gets close to conjuring a ‘delusional mood’, an altered state of experience where nothing seems normal. Everybody Knows creates a resonant view of the world’s main problem, which is Falsehood.

But does ‘everybody’ mean ‘everybody’ or just ‘everybody but me’? 

There are hundreds of words for Falsehood and the list is growing. I like ‘knowing’, but you may prefer terms that allow a little more nuance, like ‘greenwashed’, ‘gaslit’, or ‘spun’. Not to mention, for Bill and Ted fans, the evergreen word ‘bogus’.

I am using ‘knowing’ to describe a situation where deceit is implicit but unspoken. Knowingness describes a situation where people quietly share an awareness of falsehood. Like when the checkout assistant asks whether you found ‘everything you were looking for’ today and you say Yes, but you mean No.  The assistant has been told to say that to every customer, perhaps in case Bono ever visits Eurospar. And is still looking for whatever it was he was looking for in 1987. 

What the checkout operator is really saying is ‘I’m being held hostage in this shop, call the cops’.

In Casablanca, (spoiler alert)  everyone knows that Rick shot Major Strasser, including Captain Renault who was there at the time. Instead of arresting Rick, the Captain orders his men to ‘arrest the usual suspects’. Note, Renault does not actually tell a lie.

How often does arresting the usual suspects resonate with our experiences today?

Take this Guardian article by Rafael Behr*

This followed a Sunak speech pretending that he had cancelled a tax on meat, mandatory car sharing, needing 7 recycling bins and other fictitious green policies.

Behr observes that the speech was ‘delivered without the trademark Boris glint that showed at least some awareness that he knew that you knew that he was bullshitting’. Worryingly that means that Sunak is either a better liar than Boris or the opposite, that he has no insight into his own scam and thinks he is telling the truth. 

The glint, the knowing look, is the sure sign of a ‘knowingism’. But if the glint is not discernible there’s a problem. Knowing who knows and who doesn’t has become a major challenge. At one end of the scale, which we can call Glint Positive, is the account of two Russian tourists who visited Salisbury in 2018 and who were suspected of poisoning people. They claimed when interviewed that Salisbury Cathedral was ‘famous, not just in Europe but in the whole world for its 123 metre spire, for its clock, the first one of its kind ever created in the world, which is still working’. 

This is a clear ‘Everyone Knows’ situation. Salisbury cathedral isn’t even famous in Wiltshire.

At the other end of the scale perhaps, I once had a colleague who left stacks of casenotes on every horizontal surface, so that you could hardly see him across his desk. He complained every time you met him that he was grossly overworked. I never knew if he really was stretched to the limit or merely conducting a strategy, possibly one he had learned on a management course, to stop people asking him to do anything. I don’t think he had a glint in his eye though. He probably just had a terrible job.

What happens when a person has learned to disguise that tell tale glint? Or more likely, when a person has talked himself so well into a role that he has forgotten he’s acting?

Misrepresentation, distortion or outright lying is rife in politics, advertising, in corporations and in the public sector. 

Top of the list for doctors in the UK is the monstrous carbuncle called Revalidation. Keen to be seen to respond to the Harold Shipman scandal and strangely determined to force as many retirements as possible, the General Medical Council imposed a time consuming and user unfriendly annual charade on its captive audience of practitioners. As an appraiser and as an appraisee, there are glints in both eyes throughout the process. There is even a glint each time you type the nonsense into adobe acrobat, send it a few times between you and your appraiser and eventually ‘lock it down’.

The GMC removed thousands of licences from doctors for ‘failing to engage in the requirements for their revalidation’. It’s not quite a Post Office Scandal level event. But Revalidation has probably accounted for 10% of medical time and 90% of medical exasperation since it was introduced. And everybody knows that Harold Shipman, if he hadn’t been caught, would have sailed through the Revalidation process and probably led appraisal workshops during which people unaccountably died. (Trevor doesn’t seem to have come back from the coffee break…’)

Doctors would probably settle for a much lower pay rise, or even a pay cut, if they were never again forced to fill in a ‘reflective portfolio’. The GMC say they exist to ‘protect, promote and maintain the health and safety of the public’ much as LAPD  supposedly exists to Protect and Serve. 

The psychology of knowingness was famously invoked by Donald Rumsfeld in 2002:

 ‘as we know, there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns—the ones we don’t know we don’t know’

Rumsfeld was ripping off a piece of psychology called the Johari Window, which has been a stalwart of management workshops since its invention in 1955. 

The four parts of the window are Known / Known; Known / Unknown; Unknown / Known and Unknown / Unknown. Leonard Cohen helpfully simplified the four window system into one – just Known / Known. 

You can probably recall those kinds of workshops and remember the levels of knowingness you felt in the room; the facilitator earnestly drawing the four windows on his flip chart, asking people to think of things that he can write in each window. Meetings where people whispered ‘beam me up Scotty’ from time to time.

Even though the song Everybody Knows, from the album I’m Your Man, came out in 1988, slightly preceding the breakdown of the USSR, the Russians got more and more fascinated with disinformation strategies.

For some reason, the capacity to generate and disseminate false information has become regarded as a work of genius. Russia’s ‘Firehose of Falsehood’ strategy has been hailed as massively effective by some psychologists.

Sometimes attributed to Putin or his advisor Surkov, who presumably read ‘1984’ in the Lower Fourth like we all did, the Firehose involves multiple competing and often conflicting streams of information.

It has been observed that Surkov’s strategy was only really effective because he revealed what he was doing. So that everyone really did know that nothing was what it seemed.

After several decades, the question remains, what has it achieved? 72nd place in the GDP per capita league? And Surkov under house arrest? Yes, but is he?  

Like pirates, a few individuals have made fortunes out of chaotic conditions. Some have been lucky, most have not. The armaments industry has done well, even if there never was a real SDI ‘Star Wars’ program, even if Ronald Reagan pretended there was. As though nobody knew he was an actor.

On the contrary, creating and broadcasting falsehoods is neither difficult nor clever and most often results in a negative outcome for the agent. Take Macbeth for instance. His strategy: kill the king, kill both his bodyguards, blame the bodyguards for the murder, make yourself king, then remember your colleague knows you did it, but have your colleague murdered too. What could possibly go wrong? Only getting PTSD, wife going mad and killing herself offstage and finally getting killed after not noticing a forest creeping up on him.

Macbeth’s plan, like the Rwanda scheme, fell apart under the weight of its own complexity.

The basic problem for propagandists is that disinformation is self-defeating. Especially in the case of propaganda whose objective is to stop people believing anything. Although repetitive and plausible disinformation can seem to be effective in the short term, does it really have a lasting effect? Did it really advance Putin’s agenda if, as a result of the Firehose of anti-vax falsehoods, there is a slightly higher rate of measles in Skegness? Or do beliefs just settle back to where they were before? Every action has an equal and opposite reaction. It’s not rocket science – oh wait, it is!

There’s a contrary view. And an alternative definition of Knowingness. Jonathan Lear, in the book Open Minded,  describes it as a posture of ‘already knowing’ – of purporting to know the answer even before the question arises. Knowingness is a false claim to knowledge that makes it impossible to be surprised by anything new.

According to Malesic,** knowingness can also take the form of ironic or cynical distance, of seeming to have ‘seen it all and gotten over it’. Which is pretty much the world view taken in Everybody Knows and perhaps the true meaning of the song, a jaded acceptance of failing humanity, always attempting to punch above its weight.

It’s become trendy to label such human failings as cognitive distortions, which is a nice way of regarding different ways of lying to oneself. 

As a result perhaps of decades of propaganda, most people’s beliefs nowadays are super shallow – often what the last person they heard told them. Popular beliefs are like topsoil or shifting sand.  

In time perhaps the sands do move and another house in Scarborough falls into the sea. 

In general though, the number of people with views that can be described as ‘fanatical’ stays below 15%, 3% or 1%, depending on where you draw the cut off line and start using terms like ‘far left’ or ‘far right’. For instance, in the UK only about 1.5% of people belong to a political party. This has been falling gradually over the last 70 years.

So, not Everybody Knows. Just 98.5% of people.

Confucious said that real knowledge is to know the extent of ones ignorance.

Socrates said that the only true wisdom is in knowing you know nothing.

Abba, more realistically, just said: knowing me knowing you – its the best I can do.

*https://www.theguardian.com/commentisfree/2023/sep/28/rishi-sunak-success-failure-general-election

**https://psyche.co/ideas/our-big-problem-is-not-misinformation-its-knowingness

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101. Manchego Nights

I’ve had a lot of dreams recently. Most of them I can’t remember. Analysts used to like interpreting dreams, but now I think dreams are viewed as a kind of mental Pilates, rehearsing possibilities and dangers ahead.

I knew a patient once who thought that we were recording all his dreams and sending them to Disney to be made into cartoons. DIsney never replied to his letters. With medication and therapy he stopped believing his dreams were stolen, but sadly when this happened he also stopped dreaming altogether. I’m sending some of my new dreams to Disney right now before I forget them or get my medication increased.

Driving the bus

This one comes up quite frequently. I’m driving a double decker but from the upper deck, looking down the little periscope window at the right front corner. Sometimes it changes into a Volkswagen Variant station wagon which I drive from the back seat. The bus very nearly topples over round corners. Probably one for the Freudians.

Quantum of Amnesia.

In this one, no-one can remember anything about the Bond movie Quantum of Solace, even though everyone has seen it at least once. Even straight after watching it on TV I cannot remember any of the plot or characters. I find that others have noticed the same thing. Some anaesthetists in China are showing the movie in operating theatres instead of using gas. A news article finds that Quantum of Solace is the favourite movie choice for date rapists. The Alzheimer’s Society calls for the film to be banned.

Wisconsin Shuffle.

I am a professional gambler, working the Mississippi river boats, dealing the Wisconsin Card Sort Test. The other big players are all psychologists, some of whom I recognise, though now they all have moustaches and one of them wears the uniform of a Norwegian navy captain. 

The dream suddenly moves to an appraisal meeting where I am facing the Trust Board. They demand a share of my winnings and suddenly the medical director produces a Derringer from up his sleeve and the chairwoman comes at me with a tiny dagger. I protest that my gambling takes place in my own time and not one of the Trust’s programmed activity sessions. ‘We’ve changed the paradigm,’ laughs the chairwoman. As she lunges forward I see the little NHS Trust logo on her stiletto and then I wake up.

Prince Andrew

Prince Andrew arrives for his CBT session. He’s upset because he’s going down in the line of succession. He was eighth in line to the throne, now he’s ninth, overtaken by baby Lilibet Diana. How badly upset should he feel? Ninth out of sixty million, surely not too bad? 

‘In line to the throne’ is Andrew’s best top trumps suit, even though he’s now overtaken by a tiny girl.

As consolation I remind him he’s still Earl Of Inverness. ‘They can’t take that away from me’ he nods, though in his homework assignment he has found that some residents of that city are trying to sack him. It’s a title that’s been created several times, in 1718, 1801, 1892, 1920 and 1986. I make a note of the sequence to put in a pub quiz one day.

Ward twenty something

In this one I’m admitted to a hospital in Scunthorpe, left in A and E for 12 hours without any water or food, wrongly diagnosed and sent to an inappropriate ward. The other 3 patients in the 4 bedded bay appear to be zombies. Mrs EP visits me and asks if there is any food available. The nurse shakes her head sadly. ‘A long time ago we had vending machines but they have all been taken away’. On her way out, just outside the ward, my visitor sees an enormous bank of vending machines full of chocolate and pepsi. She has enough change for a Twix bar and Ribena, which she brings back for me. I try one finger of Twix, but the effect is like the wafer thin mint in Meaning of Life and I vomit till I explode.

Tower of Babel

This one is like a biblical epic movie, in letterbox format and starring Kirk Douglas. It’s meant to be a comment on the modern world, where there are too many words being uttered or written. But Kirk keeps saying things like  ‘I know there is huge merit in talking about your issues and the only thing about keeping it quiet is that it’s only ever going to make it worse’ and the director just keeps saying ‘cut’.

Be mindful

Its mental health awareness week yet again. I learn that stress affects exactly 74% of people. I take the Perceived Stress test and am surprised to find I score 16, which is described as moderately stressed. Apparently I could reduce it to 10 by taking a Be Mindful course.

After a cup of tea, I take the test again and score 8. Apparently I could reduce it to 5 by taking a Be Mindful course. I open up the Be Mindful course on a web page and a giant shark comes out of the screen and I wake up.

Spacey is exonerated

In this one the actor is totally cleared of any wrongdoing. As a recompense, the movie All the Money in the World, for which he was replaced by Christopher Plummer, has to be re-shot frame by frame with Spacey CGI’ed back in place. I wake up when Spacey seizes the Oscar from Plummer’s cold dead hands.

Learning points

Are any of these dreams food-related? Scrooge, in Christmas Carol, attributed his ghostly night fantasies to tyramine-rich products:

‘You may be an undigested bit of beef, a blot of mustard, a crumb of cheese, a fragment of underdone potato. There’s more of gravy than of grave about you, whatever you are!’, he yells at the ghost of Jacob Marley. 

Dickens was quite advanced in suggesting a molecular basis for psychopathology, even though later Scrooge found plenty of meaning in his dream.

Scrooge changed his whole life around but I came up with two small changes from my dream work. 1. Avoid the combination of Manchego, Chianti and Amitriptyline before bed time. 2. Don’t go to ward twenty something ever again.

    17. Giving feedback without using the hairdryer.

    Image

    The characters seemed a little two dimensional and transparent in places.

    For a long while, every time I filled the kettle with cold water first thing in the morning I thought I heard someone upstairs scream. I wondered at the time whether this might be an interesting kind of hallucination.

    A ‘functional hallucination’ is a false perception that occurs at exactly the same time as a real perception, such as the sound of running water. I had assumed till then it only occurred in old German text books and multiple choice exam questions.

    It turned out there was a more mundane explanation. The reduction in water pressure caused by turning on the kitchen tap caused the person having a shower elsewhere in the house to experience a sudden water temperature change, first quickly upwards followed by quickly down. The culprit was and still is a poorly operating thermostatic mechanism in the shower unit.

    Although the shower over-reacted in terms of temperature control, I am careful to state that the showering person reacted completely appropriately.

    The thermostat is our basic model of a feedback system. It senses the temperature of the water. If the temperature goes too hot or too cold, it responds by cutting or increasing the power to the heating element.

    The same sort of negative feedback system occurs in most devices, throughout our bodies, and more generally through social systems.

    It requires two prongs – a sensing device, and a device that effects a change.

    When we come to try and understand the word ‘dysfunctional,’ that seems to describe certain behaviours or relationships – sometimes even applied to an individual – most often we are looking at a faulty feedback mechanism.

    In British culture we have a great deal of trouble knowing how to react to things. For instance, it seems the height of bad manners to criticise someone directly. That would be like sounding a car horn. Instead, we tend to use a low key grumbling approach via third parties – like trip advisor, or writing a rude letter and not sending it.

    There are a few exceptions, such as talent shows, and the army. If you want a more challenging annual appraisal, perhaps Alex Ferguson would oblige, using his famous ‘hairdryer method’.

    But in general it is very difficult to get honest feedback.

    If you write a reference for someone who is absolutely terrible at their job, the custom is to write a glowing reference with the tiniest hint of faint praise, e.g. ‘may lack ultimate commitment’.

    One guide to how to behave in a crisis is watching drama. Millions watch soaps like Eastenders on a regular basis. How far do people model their social behaviour on such programs?

    Whereas stage actors tend to exaggerate voice and gesture, movie actors have to play it deadpan. TV is somewhere in between, perhaps to do with the size of the actors face relative to real life. If shows get made specially to be viewed on a smartphone, they will probably star Brian Blessed.

    Like actors in Greek tragedy, people with Depression tend to ‘catastrophise’ in reaction to events. Odysseus’s mother apparently committed suicide after hearing flimsy evidence that he had died.

    In drama, Greek or Soap, no-one ever responds to a crisis by calling a helpline.

    British people are more likely to under-react to a crisis. David Beckham found out one of his tattoos had misspelt the word Victoria, written in Sandskrit, as Vichtoria. History records that he was not unduly concerned, merely resolving to stick to Latin for further etchings.

    A gentleman with OCD I used to know told me this story. One day he had taken his long suffering ‘good lady’ to the seaside, leaving early to avoid the traffic. Having driven 120 miles to the coast, he was confronted by a completely empty car park with hundreds of spaces. He drove around several times, unable to choose a space and eventually had a panic attack. After recovering, and still not in a parking space, he drove home again.

    ‘I’ve been a bit silly again’, he finally told me.

    I should perhaps have anticipated this kind of eventuality and suggested a simple algorithm for parking. Recently I discovered that elevator systems in large buildings have just such a system for deciding which lifts should go to each floor.

    Apparently, according to Mitsubishi Electric, a person becomes irritated immediately he presses the lift button and nothing happens. However, the level of irritation is proportional to the square of the waiting time. From this we can begin to understand how people can develop rage attacks surprisingly quickly.

    Remember Christian Bale’s outburst on the set of Terminator? Apparently a technician walked across his sightline during a scene.

    I know the feeling, from trying to talk to acutely psychotic patients in the same hospital room where builders are operating pneumatic drills and ripping up the lino with Stanley knives.

    There are a number of ways to explain why certain people seem to ‘lose it’, experiencing an acute change in mood and behaviour.

    Steve Peters would call it ‘letting the chimp out’, meaning a switch in mind-set, allowing a different set of brain pathways to take over control. Thankfully, Mitsubishi have not included a Chimp Mode in their elevator systems. Though Beko appear to have included a ‘Surrealist Mode’ in their washing machines.

    A more neuroscience-based model still, is the possibility of positive feedback, or kindling, where the response actually goes the opposite way from restoring the norm. This is often called a vicious circle.

    One theory of panic attacks uses a vicious circle model, where mild signals of distress from around the body are over-read, cause anxiety and thus further physical distress signalling, such as breathlessness, palpitations or chest pain. Finishing with a slightly embarrassing visit to the coronary care unit.

    A behaviourist could explain ‘losing it’ in terms of social learning. Previous tantrums or losses of control have been rewarded by parents or others, either in terms of letting the upset person have his way, or by way of reducing ‘messing’ with that person. Having a ‘short fuse’ can be quite useful in certain situations. I once worked for a consultant who was completely benign 99% of the time, but the word about him was, ‘watch out, he goes berserk every now and again’.

    One of the triggers seemed to be handing him a post it note with a poorly worded or scribbled message and a phone number. It was not that he had been hypnotised previously and made to react this way, although this is possible, knowing the hospital involved.

    It was just that being handed a post it note is a metaphor for being handed a problem, but without the information needed to act on it properly.

    I’d like to think that his reputation would have worked to reduce the number of post it notes he got handed, but I never saw any sign of this. Post it notes continued to flow like confetti. Perhaps he should have set fire to them immediately or eaten them.

    In the NHS, feedback loops operate comparatively slowly, so it would have taken about 20 years to see the post it notes’ eventual downturn.

    Remember the film, ‘Falling Down’? Here, the character, D Fens, is played by Michael Douglas, who is a screen actor and therefore tends to play deadpan. D Fens progressively loses it after a ‘rare morning’, ending up in a spree of violence across LA. The trigger event appears to be a shopkeeper refusing to give change.

    An older theory of ‘losing it’ relied on the notion of a repressed or over-controlled person, which I think is what the director had in mind. D Fens had seemingly suppressed his anger by being extremely tidy and organised, never allowing himself to become emotional, and therefore never setting appropriate limits on people.

    Here I suppose the systems analogy is the pressure cooker. This has a very primitive feedback loop, so that a massive degree of change from steady state is needed before the feedback occurs, in the form of opening a safety valve.

    Here the feedback loop is too coarse to make rapid enough corrections, necessitating an external over-correction, such as being gunned down, albeit reluctantly, by Robert Duvall.

    CBT is designed to improve a person’s feedback system: on the cognitive side to make sure the right information is collected; and on the behavioural side to make the appropriate responses.

    Luckily the government has given us a new way to make sure we react appropriately.

    We’ve been used to making a 999 call, for moments where we identified a very serious crisis. However, the 999 system is abused on a daily basis. One of the problems is that TV never shows anyone calling a helpline appropriately, so we don’t know what constitutes a 999 level emergency.

    People have rung 999, for instance, to ask ‘how to dial 111’; because they were not being served in Macdonald’s; to try and obtain a laptop password, and to report the theft of parts of a snowman.

    Now, to create a kind of crisis scale, at the milder end, we also have the 111 call.

    That gives us the potential, provided British Telecom goes along with this, to fill up the numbers in between, 222, 333, etc, with a sliding scale of catastrophisation.

    Let’s put in some examples to test the system.

    You are Henry VIII, the most powerful king England ever had.

    You have some marital issues, and in particular no male heir to the throne.

    I’m thinking 333 would be about right.

    Instead of which Henry over-reacts massively, dissolving the monasteries and the catholic church, divorcing his wife and executing some of his best pals.

    There is no indication that the younger Henry was overly ‘buttoned up’, casting some doubt on the over-control theory. Although if he really had cerebral syphilis, that might have damaged some of his feedback loops.

    Or try this one: Confronted with a pompous email from NHS management you write a reply you misguidedly think is witty, accidentally pressing the Reply to All button, so that every person in the whole NHS gets a copy.

    555, agreed?

    You eat a yogurt from your fridge mistaking the sell by date 2003 for 2013?

    Not even 111, I don’t think. Yogurt never kills.

    We are going to need an advisory panel of some kind as arbiters of how to interpret and assign a crisis to a number scale. This would be an efficient resource, especially if we can charge a premium rate for the crisis line. I hope the NHS is working on this.

    Failing that I think Mitsubishi could run something up. For indecisive parking, press 111. For misspelt tattoos, press 222. For incorrect change, press 333…

    What if the elevator seems awfully slow today? Press 444. Pressing using the fingers is sufficient. It is not necessary to use the axe.