Tag Archives: behavioural therapy

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

New Image

Warning: hair fires are getting more common.

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

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

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

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

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

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

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

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

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

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

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

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

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

Which of the following is a Good Work?

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

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

One short burst of primal screaming followed by a cigarette

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

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

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

Advertisement

49. Saying no to Mister Kipling.

Image

My new laboratory

Outside Ladbrokes, it occurs to me that behavioural psychology, one of the greatest discoveries of the twentieth century, has fallen, like that other great Russian invention, the Kalashnikov, into entirely the wrong hands.

Clinicians have neglected behaviourist explanations and treatments for mental health problems, leaving these dark arts to commerce.

Though still called cognitive behaviour therapy, CBT has edged out the behavioural aspects, such as facing feared situations in real life, or reducing unwanted repetitive actions like texting during mealtimes.

The move towards Mindfulness has taken things even further in this direction. Whereas behavioural techniques can be applied successfully to animals, mindfulness cannot. Herein lies the problem. Therapists are most reluctant to regard the human being as an animal, whereas it suits some commercial interests for people to act like plankton.

In fields such as gambling, shopping, advertising and food, simple behavioural strategies have proven to be devastatingly effective. By placing rows of sweeties either side of the checkout in supermarkets, or sending a tinkling food cart slowly but surely up and down planes and trains, we are made to drool. Our sense of scale is disrupted, by selling massive chocolate bars for £1, next to tiny versions for 65p and three-for-two offers. Greater consumption seems to make sense.

Behavioural interventions like graded exposure and exposure response prevention are too dangerously similar to common sense to warrant an exorbitant fee in clinical practice. Whereas a gambling machine or a chocolate bar has no problem reducing you conceptually to the role of laboratory animal.

I’m just dreaming up another screenplay, which is for a re-make of Traffic, but with people addicted to sugar instead of heroin, with fat actors instead of thin.

I’m hoping it’ll get funded before the current moral panic about sugar dies down. The idea is to examine ‘the sugar problem’ from different perspectives, from politicians and big business on the one hand, to the crowds of diabetics camped outside Clinic 16 on the other, via the sticky pavements outside KFC.

Here’s the background theory as I understand it, simplified for the movie:

1. For some reason, the USA has a big corn syrup industry and puts corn in all kinds of food products.

2. Fructose, made from corn, is sweeter than glucose and has less feedback effect on the brain, leading to over-consumption and frequent trips to the Spar shop.

3. People get more tolerant to sugar, increasing their consumption progressively.

4. They may experience craving and withdrawal effects similar to chemically addictive drugs, leading to sugar addiction

5. Sugar tweaks the dopamine and endorphin pathways in the brain. These are shown diagrammatically as massive cables connected to the addiction box, which is sited just behind the nose.

6. Recognising they have an addictive product on their hands, the food industry takes advantage, increasing the sugar concentrations, fructose content and portion size. 500ml becomes the new 330ml. We are asked at food shops if we want to ‘go large’ and we say yes. Shouldn’t there be a consent form for such a far reaching decision?

7. Big Sugar runs a clever diversionary tactic, blaming Big Fat for everything.

8. The insulin manufacturers get richer.

9. Politicians propose a Sugar Tax, forgetting it was an OMD album and they probably still have copyright.

10. Grand Designs features an edible house made of Glacier Mints.

Did the mental health industry play its part in the great sugar rush? At first sight, it looks as though our hands are also sticky. Mainstream psychiatry demonised the use of amphetamines, barbiturates, benzodiazepines and antipsychotics as tranquillisers, while promoting ‘atypical antipsychotics’ that were strongly associated with weight gain. Psychiatrists promoted the concept of addiction and started applying it to things increasingly difficult to compare to heroin, such as chocolate, sex, darts and embroidery. As a result, the concept of addiction has become a metaphor for any repetitive pleasurable behaviour that has a downside.

The mental health industry is buying into the idea that drugs and even foods have power over us and may enslave us if we weaken. In terms of reducing the crowds at clinic 16, will it help to regard sugar as an addiction? More likely it will prove counterproductive to empower sugar by deeming it a chemical of substance. There’s no denying that sugar is a powerful ingredient – the taste for sugar is hard-wired. After all, it’s only competing with three other tastes, two of which are bitter and sour. It’s a taste that children seem to love, but that many grow out of. But in the end it’s just a molecule, not a mystical power. Food and drugs are tools for us to use, not the other way round.

I’m pretty sure, in a double blind trial, I could not tell Coke from Diet Coke. Yet everyone I ask assures me there is a massive difference. There’s an urban myth that sugar intake creates a ‘rush’ or increases energy, even risking overexcitement. Who planted that idea in popular consciousness? Mars, perhaps.

As a debunking exercise, I did a small field trial on the so-called Death By Chocolate. Suffice it to say I survived. Should I have asked for my money back?

Image

The Death By Chocolate, before the experiment

Maybe the marketing men did not envisage how strongly sugar would catch on, given a combination of chemical and social reinforcement and low pricing. Companies say they have increased portion size and fructose content because people are demanding larger and sweeter products. A kind of forward feedback has occurred, and the moral is, conditioning is a powerful motivator.

How to end this movie then? One idea is to have all the dark psychologists who manipulate our food preferences arrested in a raid on Tate and Lyle? Or an upbeat ending with scientists discovering Baking Canderel? Or a line of addicts at the sugar clinic, receiving treacle in little pots, instead of methadone?

Incidentally, please do not attempt the Death By Chocolate challenge without medical advice. Sometimes these urban myths have a grain of truth in them.

45. Hosing out the caves of plenty.

Image

Celebrating the end of the cull.

Consider this: Celine Dion has sold over 200 million albums worldwide. Kodak sold over 70 million Instamatic cameras.  And more than 5 million ZX Sinclair computers were produced. Where have they all gone? The answer is: the house on Gladstone Street, the one with the twenty-foot-high overgrown garden and council notices pinned to the door.

There’s a new diagnosis in town and its name is Hoarding Disorder. Everyone’s talking about it, but no-one is doing much about it yet. That may be because there is no recommended drug therapy, and it’s even a bit dubious whether behaviour therapy will help, unless the sufferer wants to change.

I know, the word sufferer is politically incorrect, I’ve been on the disability and diversity courses. And in this case it is literally incorrect, as the people who suffer are neighbours, relatives and carers, rather than the hoarders themselves.

In DSM5, Hoarding Disorder escaped from the OCD section and was given its own little category. It’s significantly different from OCD, so, like South Sudan, though considerably more cluttered than that country, it has gone its own way.

There are a few other categories associated with squalor, including the so-called Diogenes Syndrome. And there are some similar scenarios which are not considered mental health problems, such as Collecting and Teenage Room Disorder.

Most psychiatrists will have visited homes like the one on Gladstone Street, and sat in sticky chairs, next to overflowing ash trays the size of buckets. We get pressurised by housing departments and public health officers to assess the people who live in these conditions.

In Diogenes Syndrome, which apparently is unfairly named, as Diogenes was a minimalist and lived in a barrel, the affected person simply gives up on the fight to organise, recycle and dispose of stuff, so that a rising tide of garbage fills their house, and finally flows out of the doors and windows, past the complicated row of empty recycling bins.

We could regard these problems as brain based, as in frontal lobe dementia, or part of some other problem, such as Depression, disorganised-type schizophrenia, or Compulsive. We could take a view that such habits are eccentric, or even just lazy. I prefer to look at environmental causes. Hoarders are basically overwhelmed by modern life. It’s not so much the quality of the environment as the quantity. They are victims of what should be called ‘Stuff Inflation’.

Whereas economic inflation leads to money losing its value, stuff inflation leads to manufactured items getting cheaper per cubic inch. Combining this effect with reduced living space – British homes are small on average – gives an ever increasing stuff to bloke ratio. There’s even a magazine called Stuff. And there’s a shop called Poundland, from which Stuff flows, like water from a fountain.

If the alcohol industry creates more product than people can consume, some of it will accumulate excessively in certain individuals. If the availability of alcohol is adjusted up or down, a lesser or greater number of people will consume it to excess.

Similarly, if the world’s factories create more stuff than can be recycled or land-filled, a pooling effect will occur.

Quite how these ‘trickle down’ effects affect particular individuals is the big question for clinicians. Like Magpies, humans have an innate urge to acquire items, and there is a whole industry directed toward persuasion. Why Magpies like shiny metal trinkets is a bit of a mystery. I have never seen a Magpie wearing jewellery, or queuing up in Cash Converters, or playing a slot machine.

I suspect that, like many mental health problems, Hoarding Disorder will turn out to lie on one end of a spectrum rather than behave as a discrete disease entity. I’d be surprised to find anyone who didn’t show some signs of hoarding, if we looked in their loft, car boot or Celine Dion collection.

People hate to lose things they already have, and retain an evolutionarily useful tendency to stock up in case of a bad winter or poor harvest. People need some token or another to explain why they have been at work all day.

Faced with a tsunami of disposabilia, some people just give up trying to cope with it. Hoarding may be just one of many ways people give up on dealing with modern life.. There are so many waiting for DIY SOS, or International Rescue, or the A Team to come, but sadly, there is no De-cluttering service in Yellow Pages. The time cost of sorting through piles of possessions far outweighs the value of any items unearthed, so it even costs money to have everything taken away.

The solution probably lies at political level, with more powerful Stuff Police and a new Ministry of Trinkets. A landfill windfall tax for Poundland would be a good start. NICE could come out officially in support of Minimalism. More of the plinths in Trafalgar Square could be kept empty. I think the NHS has already adopted the slogan Less is More. David Cameron could issue an official apology to Diogenes.

On a personal level I think we should recognise that we can all go down this road if we are not careful, so some attention to Stuff Hygiene is needed.

In previous EPs we destroyed any vinyl records or cassette tapes we had left. We invited the British Heart Foundation into our homes, as bailiffs of charity.

Beyond this, the solution may lie in The Cloud. Somewhere in the world there are some very untidy banks of computers, but, importantly, they are not in Gladstone Street.