91. Monster Munch – it’s silly not to.

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‘The crabs stayed with me until the day I simply decided that they bored me and that I just wouldn’t pay attention to them’ – Jean Paul Sartre.

 

I don’t like crisps that much, but at the market you can buy 10 bags of Monster Munch, marginally outdated, ‘flamin’ hot’ flavour, twenty per cent extra in each bag, for £1. Or for £2 you can buy a whole box (of 20). Or, for £2 you can get 48 bags of Marmite flavour. That’s unreal isn’t it?

Psychiatrists have dabbled with unreal experiences and created a few technical terms to describe them.

Depersonalization means a sense of unreality within the self. Derealization is a similar experience but refers to a sense of unreality outside of oneself, in the environment. Such experiences have been largely neglected, perhaps because no specific drug therapy is indicated, though an unusual coloured pill – ochre? – is surely needed.

Neither word really does justice to a situation where unlikely events seem to happen,so I propose we co-opt* a new word, Surrealization.

I propose we use this term to describe experiencing events so unlikely you tell yourself, ‘no surely, this can’t be happening’. Situations where you might have tried pinching yourself to check you weren’t dreaming, if you hadn’t seen Inception.

Surrealization is not an anxiety disorder.  Unlike ‘Deja Vu’ (due a remake?) it is not a sign of complex partial epilepsy. Nor have I been sprinkling ‘Special K’ on my Special K. I think it’s just the world getting more peculiar. I can’t prove this yet, but I’m starting to keep tabs on the modern world, using a Surrealization Diary, in the best traditions of cognitive therapy. Here are some recent entries:

I don’t like opera that much, but I find myself at a performance of Carmen in Sheffield. The cast includes a donkey and a white stallion and there has to be an awful possibility of the animals misbehaving on stage. Backstage they probably have a ton of sugar lumps for reinforcement purposes.

I begin to hear short bursts of high-pitched noise and at first I assume the radio-microphones on stage are picking up feedback from local cab operators. Then I realise there is an older gentleman sitting right next to me, starting to fiddle with his two hearing aids, which is where the noise is coming from.

The whistling noises get more frequent and louder. But after a while my neighbour takes out both hearing aids and puts them in his pocket, looks relieved and closes his eyes. But the noise continues and gets louder and more screechy. People start to look round and shuffle in their seats, but I realise he is now completely unaware of the aids ‘going turbo’ in his pockets. I try and catch his eye and signal, I point towards the hearing aids and put my finger over my lips, but he takes no notice.

Clearly we are on the edge of an awful scene, until suddenly, the man’s equally elderly female partner shakes him and shouts in his ear: ‘Take the fucking batteries out Ian, take the fucking batteries out’, which, after quite a lot of scrabbling, he manages to do. I write the acronym TTFBO in my diary.

I don’t like literary occasions that much, but this is a good one. I’m standing in a field in Lincolnshire, next to a very busy main road, at a tree planting party, listening to a small female person reading out a chapter of Winnie the Pooh. She speaks movingly but very quietly and her words are lost between the northerly gale and the massive lorries on the road behind her.

I don’t like Health Secretaries that much, but I am reading about Jeremy Hunt’s plans for dementia. Mr Hunt said seven-day services will improve for dementia patients in hospitals, with patients in high dependency care seen and reviewed by a consultant twice a day, every day of the week, by 2020. What the consultant will do when he meets each patient is not explained. We all hope and pray there will be effective treatments for dementia one day, but until then the consultant will be stuck with discussing the cricket score twice daily.

As Bernie Taupin might put it, if he ever met Jeremy: ‘but, then again, no’.

Now I’m at a blood-doning session, standing waiting in the foyer of a community centre with the other donors, waiting for the staff to finish their break. No doubt it makes sense for the staff to have a break between sessions, but it’s a bit weird to keep everyone in the hallway while the staff have their tea and biscuits. They are chatting loudly and I hear one of them explain to another how to pull a sickie by pretending to have diarrhoea. Mrs EP is with me and it is her 50th doning session and she is pumped up expecting the gold badge. But she has filled her forms in with a gel pen and she is told off. Gel pens have joined the long list of things blood donors should be careful about.

I don’t like health screening that much, but at Specsavers there is often a voucher you can get for a free eye test. Sometimes the voucher is on the back of the pay and display car park ticket. If not, under a bit of pressure, the assistant will produce an eye test voucher from under the counter, in a free spectacle case. Today there is a free voucher online, so it’s silly not to have your eyes tested, isn’t it? This is probably the best value in all of health care. It includes a careful examination of the retina by a properly trained person who can see right into your soul with a special lamp. When I ask for my prescription the assistant says I can’t have it because the copier is not working. I offer to write down a copy for myself or just take a photo with my phone. No, she says, data protection. Stupidly, I begin a short discussion about some of the urban myths surrounding information governance. Luckily they don’t have bouncers at opticians, so I leave without my prescription, but uninjured at least.

Now in my diary I am recording an attempt to get to Springfield Hospital from Tooting Bec tube,using Google Maps, missing the entrance and walking all the way round the block. My phone, though I haven’t asked it, tells me I have walked 3 miles and it congratulates me.

Back to the government then, who have been rolling out a short series of surreal announcements under the loose working title in my diary: ‘It’s not going to happen’. On 10 January the prime minister announced he’d be transforming housing estates. On 7th Feb he announced the transformation of prisons. And in March he announced that the NHS will be helping to plan a number of Healthy New Towns.

Quite likely, Surrealization is a reaction to this kind of Orwellian propaganda and luckily there is a specific therapy in the form of observational comedy and political satire.

A word of warning: if you suffer with Surrealization, it’s not safe to say so out loud. You will be stigmatized as awkward, cynical, negative, old or grumpy. And you will quickly be told to TTFBO.

*Co-opt because the term has a limited meaning in the arts, such as creating drama out of dream material. That’s not a problem as a lot of technical words in psychology have a day job, such as Obsession, and many of them moonlight as fragrances too.

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90. Spoiling the ship for a ha’p’orth of warhead.

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Keeping the doctor away: one apple and three bottles of Cipramil.

 

2016 is turning out to be the year of the internal saboteur, but the abbreviation I.S. is already taken. Examples are all around us of people deliberately choosing to inhibit their functioning.

In this town, people are dying their own hair green and getting misspelled tattoos like ‘No Regerts’. New buildings are getting fewer parking spaces than needed, not enough to discourage people from using cars, but just enough to inconvenience everyone. The Royal Bank of Scotland has told us to sell everything and put the cash in the freezer disguised as a chicken korma.

On a national level our politicians are fighting amongst themselves in each party. Jeremy Corbyn is suggesting running the Trident subs without the nukes on board. There’s a doctors’ strike that no-one can fully understand. And, in an unbelievable U turn, the chief medical officer says alcohol is really bad for you after all.

And if this wasn’t bad enough, David Bowie has died.

Psychoanalysts were good at explaining this kind of thing, examining the metaphorical bullets that people fired into their metaphorical feet, but they are gone, replaced by computerised CBT and web-based expressive writing.

There’s a theme to this: Medical Nemesis, which was the name of a book by Ivan Illich. Ivan’s idea was that doctors had medicalised significant areas of normal life and were set to colonise all human experience, by deeming everything to be Medical. Illich felt there was an inevitability to this process, much as he felt Communism would conquer the world, domino by domino. He also pointed out that a large amount of medical activity was counter-productive, so that the net effect of modern health care was marginal and in due course would become detrimental on balance.

Medical Nemesis was published in 1975, which was the year I went to medical school and David Bowie released Young Americans. Eerily and probably coincidentally, the rise and fall of Psychiatry as a successful enterprise has run in parallel with Bowie’s career. Studying the two timelines, the Bowie discography versus the history of psychiatry, there is a broadly positive correlation, with a slow decline after 1983. I expected to see something significant in 1990, to coincide with the launch of Clozapine, but there is only Tin Machine. No model is perfect.

The theme to our current medical nemesis is this: the counterproductive effects of medicine have been escalated so that they now outweigh the positive effects. After a brief period of medical effectiveness – basically the  few weeks that followed shutting down the cholera pump on Broad Street – we are back to doing harm to people.

It’s a bit complicated to say why, but we’re talking about the net effect. There is no doubt that some medical activities are helpful, such as removing marzipan and toy animals that children have accidentally stuck in their ears. But a lot of the old certainties, like spraying the countryside with antibiotics, are over.

Even in 1975, we were taught that the increasing life expectancy that occurred in the twentieth century was mainly due to improvements in hygiene and public health, rather than laser surgery and machines that went beep. Now it is possible that life expectancy is set to reduce. It is already reducing for those who are now in later life, particularly women.

Some of the factors that have inhibited the usefulness of medicine came from outside the profession, such as the food and alcohol industries. Some have come from health industry predators, such as management consultants. Mostly however, the bullets fired into the soft underbelly of medicine have been fired by doctors themselves. For those who like acronyms, the health industry has fallen victim to the 3 P’s, namely: Pomposity, Pretension and Ponderousness. These are the outward signs that medicine has gone where it doesn’t belong, ‘medicine gorn mad’ as Dr Allenby would have said.

Focussing on Mental Health for a moment, we are living through a very unhappy period. Round about the time that Illich wrote Medical Nemesis and Bowie became the thin white Duke, the treatment of mental illness was hitting a purple patch. Psychiatrists still worked out of large mental hospitals with hundreds of beds. About a third of the beds were occupied by patients with poor-outcome psychosis, the ones we pretend now don’t exist. Another third were allocated to elderly patients with dementia. Hospitals had wards that could deal with acutely disturbed psychotic patients, without bundling them into a van and sending them to a private hospital two hundred miles away.  But most of the patients were already in the community and there were satellite clinics and community nurses in most towns. Drug therapy, with the exception of Clozapine, had already peaked, using typical antipsychotics and tricyclic antidepressants. Medical training still revolved around the ‘firm’ model, each firm belonging to a Consultant. Trainees learned all the German words for mental phenomena and sat a proper exam with essays and a long case. There was no purchaser provider split. Hospitals were administered, not managed, by a triumvirate of administrator, nurse and doctor.

Can it be possible, 40 years later, with all the endeavour that has gone into research, reorganisation and regulation, all the millions of hours people have spent in committee meetings and working parties, all the billions of pounds spent on management consultants, that our services have actually deteriorated?

Making such an assertion, one is quickly accused of being a grumpy old man or woman. Suffice it to say that not everything a senior or experienced person says should be discounted automatically (just most of it).

There are many examples however of monumental enterprises that fail. The best known are IT projects like ‘Connecting for Health’ which was wound up in 2013, having spent more than £14 billion. The audit office concluded that ‘it was not demonstrated that the financial value of the benefits exceeds the cost of the Programme’. A scenario right out of Illich’s book.

Not only does medicine go where it doesn’t belong. Often it abandons areas where it does belong. For example, ECT. Without wishing to denigrate ECT, the evidence base for its usefulness is quite limited. Suffice it to say it probably works for certain types of acute psychotic condition, mainly the ones that it’s not used for. A lack of evidence that ECT was effective at all did not stop the Royal College setting up a complex system of training and accreditation, called ECTAS. It’s guidelines, along with those written by NICE, were stringent enough to put most ECT units out of business, much to the delight of those opposed to ECT, which is practically everyone.

Now, newer types of electrical and magnetic stimulation are coming out of the closet which are not evidence based or regulated or subject to the protective effects of the mental health act. For better or worse, ECT was regulated to death, but my tip is to hang on to those electrodes for now, pending the development of ‘swimming with electric eels’ holidays.

If Illich’s theory was correct, we would arrive at a point where medicine – in terms of its beneficial effect on society –  is taking exactly 100 steps backwards for every 100 it takes forwards. What is unclear is whether we have entered the recession yet. How will we know when the oil tanker of medicine has reached a standstill relative to the sea bed?

A possible indication of such a low point would be, say, identifying a medical condition that has recently been invented, by annexing an aspect of normal life. A condition that has escalated dramatically, filling thousands of outpatient clinics. A condition that can’t be treated effectively by health services. A condition where treatments are poorly evidenced and have clear harmful effects, like stunting growth. You know where I’m heading: by 2003, nearly 8% of American children were diagnosed ADHD. By 2011 this figure is said to have reached 11%, with a large increase in girls diagnosed with the disorder. As with life expectancy, and as Bowie would have noted, girls are the new boys.

In the metaphorical history of psychiatry then, ADHD falls into the long dark period, somewhere between Reality and The Next Day.

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

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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.

79. Cashing the reality check.

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An anthropologist, studying a hipster, spotted in Dalston.

This week I had a root canal filled. Guess what, it went well, because I was literally wearing rose-tinted glasses. Radio 2 was playing, everyone was jaunty, the banter flowed as freely as the lidocaine. The craic was mighty, as they (don’t really) say in Ireland.

Fans of CBT know that to stay healthy we need constantly to examine the way we look at the world and the future. I used to be afraid of dentistry but now I easily prefer it to hair care, where the craic is poor and there is no anaesthetic. Although dentistry is invasive and scary, the dental experience can still be positive if the atmosphere is right. Similarly, it’s possible to frame our view of the world as a positive one, though it may be necessary to stop watching BBC News Channel, with all due respect to Clive and Martine.

While we are on the subject of Reality, and how not to face it, let’s ask the question: where have all the scientists gone, the ones who didn’t become dentists?

If you’re reading a scientific paper you expect every single assertion to be carefully argued and referenced. Statisticians will have hosed down the results, using streams of numbers to wash away the confusion. Conclusions will be couched in cautious tones. Where a crisp punch-line is needed, instead there’ll be mumbled suggestions for further research. Anything that a scientist says is subjected to peer review by other scientists before it gets published.

There may be no such thing as absolute truth, but scientists probably come the closest to finding it, or at least wanting to find it.

I often wonder what it would be like if we asked scientists to form a government. This is virtually the opposite of the current situation, where, in the UK at least, scientists are barred from politics. Ok, Mrs Thatcher had a chemistry degree, but that’s about it.   Otherwise all our leaders studied PPE or law or history. Apparently there is only one scientist in the house of commons, out of 650 MPs.

Perhaps, more than any other fact, this one epitomises the British Disease. Which is talking a good game instead of playing one. We don’t know how to use a torque wrench – we use a talk wrench instead.

Most of modern history pays homage to Freud somehow or another. His nephew, Edward Bernays, pioneered the field of propaganda. Bernays had grave doubts about the democratic process, preferring a system where the masses are guided by an Enlightened Elite. Propaganda specialists gradually took over politics in the West, culminating in the election of PR man David Cameron as Top Banana. Bernays was influenced by his uncle, to the extent of recognising there was no such thing as objectivity. We all have different ‘takes’ on reality and we fit any new information into our existing preconceptions.

Clashes between worldviews can’t be resolved by a simple look at the facts. What facts? It all depends on how the evidence is collected and sifted. My view is that we need more of a scientific approach to making sense of information, but others may feel differently. How often do you hear people say that they don’t trust scientists?

Remember, for example, esteemed psychiatrist David Nutt being sacked from the Advisory Council on the Misuse of Drugs? For saying that some drugs are more harmful than others. And for saying that politicians distort and devalue research findings. The Home Secretary who sacked him was ex-postman Alan Johnson, now a national treasure. Here’s the narrative then: scientists are too narrow or cranky to see things clearly, that’s why we need politicians to decide how to classify drugs.

Quite who belongs to the Enlightened Elite nowadays is open to question. Maybe it is the shadowy ‘new world order’ and their lackeys in the media. Or maybe it is the ‘liberal consensus’ epitomised by the BBC. Or maybe it’s the Hipsters in Stoke Newington. Writer and film-maker Adam Curtis suggested that the Enlightened Elite are manipulating the news to keep us confused and afraid, a process he recently described as ‘oh dearism’ or non-linear war.

The connection between ‘oh dearism’ and Depression in individuals is not clear, but that hasn’t stopped writers like Joanna Moncrieff from asserting that Depression is just one of the missing arrows from the big Venn diagram of discontent, fear, capitalism and drugs.

I’m not sure why the Enlightened Elite would seek to make us all miserable and afraid when – if they had that kind of influence – they could just as easily make us jolly and bright. They are accused of such intent when they stage feelgood events like the Olympics and Children in Need.

In China, being governed by an enlightened elite is not just admitted, it is celebrated. And most of China’s top government officials are scientists. The president, Xi Jinping, studied chemical engineering at university. The last president, Hu Jintao, was an hydraulic engineer. How about the one before that, Jiang Zemin? Yes, he was an engineer too. Cue ‘machinery of government’ metaphor.

Could it be true that people in China have a better grasp on reality than people in the West, because they know the difference between a torque wrench and a thingybob? Do people in China take a more positive view of the world and the future?

Interestingly, it has been reported that there has been a massive drop in the suicide rate in China between 1999 and 2011, some say by as much as 58%.

China is a country run by scientists, which is not to say that UK would become like China if we rounded up our few remaining scientists and sent them to Westminster to rule over us.

Our scientists are just not used to being respected, listened to, or paid very much. Very few of them are party members, attend socialist summer camps or got seconded to tractor factories during their formative years. Our scientists are just not ready to form a party of government.

There is a solution and it will happen anyway, sooner or later. Why not invite some Chinese scientists to join our government, just like the ‘immortal seven’ (the enlightened elite of the day) invited William of Orange to become special guest king? It’s a controversial strategy, but so was the Battle of the Boyne. (Too soon?)

In December, Prince Charles gave a speech about our attitude to engineering. ‘The skills crisis has reached critical levels’, he stated, ‘particularly in the fields of mechanical engineers, machine setters and engineering professionals, which are among the most difficult posts to recruit’.

Like the house of commons, the royal family has only one scientist, Peter Phillips, who did sports science at Exeter. Shouldn’t he be promoted? And is it too early to get George his first electron microscope?

72. Falling back on homes under the hammer.

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Hull Trains are quite influenced by the Terminator series.

 

On the breakfast news there is almost always a mental health item. There are two types of mental health news reports: the short one and the long one. On the short one, the presenter merely reads out two statements, one from a survey and one from the health service.

First statement: a survey conducted by a charity reveals that there are no services for the mentally ill north of Milton Keynes and that depressed people in the north are simply rounded up and dropped down coal mines.

Second statement: more people are being treated than ever before due to increased investment in acronyms like IPT and IAPT.

You wait for a moment of analysis or commentary, a denial from someone in the coal industry perhaps, or an acronym buff, but in a blink, its over to the Midi dress. Should it really end at the thickest part of the lower leg?

The longer version of the mental health report is just the short one followed by an interview with a ‘service user’. Typically, the service user seems suspiciously mentally well, despite their long period of suffering and eventual escape from the coal mine. It took years of waiting, but eventually they reached the top of the Mindfulness Therapy waiting list, after which they were cured in a jiffy and made ready for TV.

This week, we just had the short version: One in six people attempted suicide while on the waiting list for psychotherapy, which is more than a year on average. NHS England says that there are more mental health services than ever before and even now new acronyms for services are being coined at their new DOA. (gettit?)

It is such a relief when the news stops and Fred Dibnah’s World of Steam, Steel and Stone finally begins, even though every episode is the same. Then there is a program where people buy a small house at an auction, paint it magnolia and rent it out. After that two people try and decide whether to emigrate to Australia, nearly go and then don’t quite go. Following on, a lovable cockney sorts out some dodgy builders in the style of Jack Regan from The Sweeney. Daytime television can seem massively interesting, but only under certain circumstances.

Normally these programs leave the viewer underwhelmed, but that all changes if you get ill. Once you are debilitated and a little delirious, daytime television takes on a whole different dimension. The level of stimulation the human system requires, or can even tolerate, is greatly reduced in cases of biological malfunction.

The key to successful television seems to be following a formula. Even though we’ve seen it a thousand times, we still love a plot that ticks along like a Swiss clock. To a very alert person, formula means repetition and repetition means boredom. To a stressed or unwell person, formula means familiarity and familiarity means comfort. Entertainment has a long history of formulaic productions, from Punch and Judy through James Bond to Strictly Taxidermy. Every time we are presented with a repeatable pattern, the part of the mind that ticks boxes is comforted.

I once asked an older colleague how people used to treat serious mental illnesses before the invention of antipsychotics. His reply was ‘Institutionalisation’. At the time I took this to be an attempt at irony, especially as institutionalisation had come to be regarded as oppression. Now, I realise he was giving a serious answer. Reducing stimulation and imposing regularity were ways of calming people. Perhaps it is just a coincidence that large asylums closed just as daytime TV began. Or perhaps, television just happened to hit the right level of stimulation to suit chronically ill people. One person’s stultification is another persons action thriller. On the acute ward, I noticed that really ill people hardly watched TV, not even football, but could just about manage old Top Gear repeats on Dave.

Disruption of biological rhythms is almost the hallmark of Depression and the first thing that psychiatrists ask you about. Sleep pattern, diurnal mood variation, bowel habit etc. Disruption of biological rhythms is also the hallmark of twenty-first century society, now that shops and the internet are open all hours, pubs never close and you can watch Dr Who whenever you want. I’m not saying the two are causally related, any more than fridge ownership is causally related to crime statistics (other than ice pick murders).

But possibly Stress is being met with De-Stress, in the form of Repeatable Pattern Seeking Behaviour or RPSB, as it will never be called again (too similar to the RSPB, who are a very powerful lobby). Accordingly I may have to forgive people who own pets or buy lottery tickets as simply stressed people in search of fixed schedules. Perhaps they just have nothing to do – besides panic – between Street Patrol UK and Cash in the Attic.

If you just don’t ‘get’ the Fast and Furious series, now you can understand why the same bits are in every film. Humans like patterns. Much of our brain is a scanning device and every cell has a system of time clocks.

Which is why, even before they had CAT scans, Interferon or Clozapine, Regional Health Authorities had their own carpet designers. One design was blamed for people hallucinating. Another type caused terrible friction wounds to frail people. Our own hospital replaced carpets with ‘abattoir-chic’ red lino. Cue carpet jokes: Where to sweep things now?

Like TV programs, carpet that can look fine – just a bit hectic – when you are fully conscious and alert, may look like a pit of vipers to a delirious person. Wetherspoon’s know this only too well.

Last time I was really sick, I remember thinking The Weakest Link was a brilliant program. But after taking a Zantac it suddenly lost all its appeal. It goes to show, if you are sick, you need to titrate your choice of programming carefully against your drug therapy.

Like hospital carpet design, there probably needs to be special programming for sick people. Or just accept that most television is aimed at people with impairment and should be run by Occupational Therapists. It already has?  DIY SOS, Blue Peter, Celebrity Master Chef, Come dine with me, Extreme Fishing…

TV is the new OT and we even have one on the ward.

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

61. Punching above your weight, with Britney.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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