Tag Archives: behavioural activation

62. Displaying the pottery fish, with pride.

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My alarm clock rings to tell me it’s behavioural activation time, also known as Nike Therapy, which means just do something and think about it later, if ever.

My eventual aim is to re-write the classic publication ‘365 things to make and do’ in an updated style to suit these post-ironic times. Also, I’d like to add a 366th project before 2016, which is the next leap year.

Today’s project is to shred a few copies of the NICE guidelines for Depression, mix them with PVA and turn them into hats.

As I shred, I realise that these guidelines do mention the term ‘behavioural activation’ but don’t explain how to do it. They say nothing about arts, crafts, music or hats. Which is surprising, given that there is a long tradition of arts and music therapy in mental health.

My hypothesis is that people need to do something with their hands to feel properly human. Manual work, crafts and organised sport have declined, leaving the hands as mere vestiges of devices that once could dig or sew or fire an arrow. Most people still prefer a mouse to a touch screen, when there is a choice. Many people still prefer a manual gearbox, even though automatics are now superior in all respects.

I have another project coming along which is more complicated. This involves taking photos of bits of stained glass windows, printing them in different sizes, using all the different, clichéd image filters in Pixelmator (such as the ‘ennui’ tool), tearing them up and sticking them onto a collage, which in itself looks like a stained glass window.

For some reason I’m having trouble (as though it was the printer’s fault rather than incompetence on my part) getting them printed at the right size, so they are coming out like postage stamps instead of A4.

If I had to give this activity an hourly rating for mood improvement, I’d have to rank it slightly below checking the lawn for cat faeces, collecting it on a special trowel and flinging it over the garden fence onto the railway line. But it might improve.

Either the picture is going to be postcard size, saving a lot of PVA, or I’m going to have to ask a teenager how to resize the images. Or perhaps find an art therapist, just to check whether this whole activity is artistic or not.

There are no art or music therapists in my local area and come to think of it, none in the hospital where I work. This demise of arts and crafts based therapies has been insidious and largely unreported. This seems like a pity, and I wonder who’s to blame.

Somewhere or other, the mental health establishment has got the idea that ‘therapy’ has to involve a bus journey across town to speak to a person in an office for about an hour once a week for about 20 weeks. True, these activities are evidence-based to an extent. It’s just that the evidence has been collected along narrow strands of enquiry, being derived mainly from a ‘clinic’ context.

No-one has bothered to see whether listening to good music or watching football or making rhubarb crumble can treat Depression effectively. And imagine the practical difficulties in conducting such studies.

Therapies where numerical ratings are intrinsic, such as computerised CBT, have the advantage in terms of generating evidence of improvement. They have largely taken over from other modalities, leaving a long queue of psychoanalysts at Jobcentre Plus.

There’s perhaps a lesson to be learned from Interpersonal Psychotherapy, (IPT). This therapy was invented by Klerman, Weissman and colleagues in the eighties. It’s a standardised approach with a proper instruction manual, which makes it amenable to testing. In particular, it was tested against drug therapy – in those days mainly tricyclic antidepressants.

Its designers were highly scientific individuals with an excellent grasp of the various different ‘models’ of Depression: biological, family, cognitive, psychoanalytic, feminist etc. They knew how to fund and conduct controlled trials and publish the evidence properly. And thus IPT is one of the two types of therapy that NICE bother to endorse.

Compare that approach with a study by Mike Crawford in 2012, purporting to show that weekly attendance at a group arts project had no benefit for patients. I quote:

‘Members of activities groups were offered activities that did not involve the use of art or craft materials’.

My italics, meaning ‘why on earth not?’ It’s not the full Blue Peter, not without the sticky-back plastic.

This is what the new version of ‘365 Things’ should try and achieve – a standardised arts and crafts therapy manual. So we can finally show that meaningful activity is good for people. Each task should be spelled out clearly, like in Marguerite Patten’s 1000 favourite recipes.

And include proper materials like policy documents, shredders, glue and paint. For a long time the surest way to upset an occupational therapist was to mention basket weaving. Now, I say it’s about time for a raffia revival. And it’s time to display the pottery fish, if you’re lucky enough to have one.

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 Detail from Queen of Heaven, by M Healey, 1933, St Brendan’s Cathedral, Loughrea

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50. Taking Canadian Living more seriously.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

29. Growing cress heads for no particular reason.

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This morning, the council came to collect the 3 bins I leave outside on Tuesday mornings, and I think they have brought another new bin – to dump your Guilt into. So much better to have it safely disposed of rather than giving it to another person. Guilt just doesn’t compost down.

I’m hoping for more metaphorical bins in the future, now that local government has taken over public health. In hospitals we have sharps containers coloured yellow, which is a safe place to put barbed comments.

Today, just as The Times reported that health checks for the over 40s were a complete waste of money, I received a letter from my local surgery asking me to come in for a health check with the practice nurse.

Though I am a supporter of evidence-based medicine, it took me less than a minute to make myself an appointment. I am also a hypochondriac.

To be honest, evidence-based decision making can conflict with common sense. Everyone knows that a stitch in time saves nine. As far as I know, there is no equal and opposite proverb to cancel this one out. My strict adherence to the evidence based approach probably doesn’t go much deeper than the occasional casting of nasturtiums on the alternative sector.

So many decisions we have to make are based on intuition rather than double blind randomised control trials. For instance, choosing what we eat. I start with the null hypothesis as follows: nothing that you eat – within reason – makes any difference to you. There are occasional bits of conflicting evidence, but in general nothing to disprove the hypothesis, which is based on the sound principle that the human body is a chemical factory.

I have yet to see any convincing evidence for the five fruits a day policy, nor the arbitrary alcohol consumption limit of 21 or 28 units per week. Which leaves me with a bit of a dilemma over what to tell the practice nurse about my lifestyle. I don’t want to come across as a fanatic of any kind. Like an NHS Trust, or Everton FC, its safest to be half way up the league table rather than at the top or bottom. But there is no real ‘gold standard test’ for lifestyle to pass or fail, apart from a few aspects of what we consume.

Like everyone, I find it very difficult to explain the increasing numbers of people who suffer with obesity. I watched a recent documentary attributing this to the corn syrup industry, but was not entirely convinced. Maybe it is a virus or other infection we have yet to identify. The concept of ‘food addiction’ has gained some adherents, certain products turning out to be incredibly ‘more-ish’, such as chocolate, pizza and ice cream.

Since obesity has increased rapidly over the last 30 years, we could attribute it to any or all of the social trends of the last few decades, from computer ownership to the decline of progressive rock. Psychiatrists have made their own contribution, in the form of atypical antipsychotics, which have doubtless added to the lard mountain.

My own hypothesis – no, really my own intuition, is that obesity is inversely related to pottering.

Pottering has been defined as: ‘to busy oneself in a desultory though agreeable manner’. Pottering behaviour should be largely unplanned, enjoyable, unhurried and diverse. Crucially, pottering does not derive from a work ethic, but from a natural tendency to interact with one’s environment. It’s roots are probably in thousands of years of hunting and gathering.

The habit of pottering has been hard hit by lifestyle changes toward electronic media and industrialisation, and away from localism, arts, crafts, hobbies, games and sport. Home made food is fast going the way of home made clothes.

What is surprising is the lack of a response, either from mental health services or the pharmaceutical industry, to the obesity epidemic. Surprisingly, there is a lack of evidence about what treatment to offer.

As anyone knows who has been on one of those treadmills with a calorie counter, you have to run about a thousand miles to counteract the effects of one Mars Bar. So its hard to see how increased activity alone could be the answer.

CBT does embrace ‘behavioural activation’ and ‘activity scheduling’ and mental health services do employ a small number of occupational therapists. We could begin to rehabilitate a pottering based lifestyle, but we need badly to find a new word for ‘potter’. It’s just too old-bloke-in-a-shed-based. And we need new pottering clothes, instead of tracky-bottoms and cardigans.

So here’s my five point plan:

Pottering should be re-named Freestyle Active Behaviour – fabbing, for short.

Village Shows to be re-named ‘Fabathons’

Stella McCartney / Adidas to bring out a new fabbing range, using a tweed / kevlar fabric mix.

A new talent show, called Britain’s got Knitting.

A new ‘more modern’ penthalon event, consisting of: repairing a stuck window, making a cake, learning the saxophone, growing cress in old eggshells with a face drawn on them and visiting granny.

(Yours may be different).

So far, none of this is evidence based, but neither, it seems, is going to the health centre for a check-up.