98. Monstrous carbuncles revisited.

This image has an empty alt attribute; its file name is img_20190620_133529.jpg

People had been working on measures of social deprivation for decades before Donald Trump invented the shithole scale.

Sadly, the Donald didn’t colour in the broad canvas between Haiti on one end and Norway on the other. Africa and El Salvador were reported somewhere in between, but where for instance would he place Mexborough?

In the UK people love to write satirical articles slagging off their towns, including architecture, town planning, the appearance of the inhabitants and their behaviour. There are a few reasons for this, beyond what Jeremy Corbyn might call ‘english irony’.

The project ‘Crap Towns’ was an attempt to say something about urban deprivation in the UK. Crap towns featured in a series of publications associated with The Idler.

Most of the crap towns identified would also rate as deprived on scales of social deprivation such as Townsend or Jarman, but Crap Towns is more subjective and much more fun.

People nominate their towns and surveys are carried out. The process has not been tightened up or ‘operationalised’ as much as social scientists might like. As a result the essential notion of the crap town has been far-fetched to include entities like London, York and Chipping Norton. These places are not face-valid as crap, even though some of their inhabitants know better. There are plenty of aspects to criticise, even in affluent towns. Try walking past the Grafton Centre, Cambridge late on a Friday evening, where the cast of Mad Max has reassembled.

In another survey conducted by iLivehere.com, Peterborough came out as the worst town. Runners up to Peterborough include traditional favourites like Halifax, Doncaster, Rochdale and Rotherham. ILiveHere self-identifies as satirical but its findings seem broadly valid. In most of those towns over a quarter of general practice patients are depressed and taking cheap generic fluoxetine.

Most of the Crap towns voted Leave in the referendum, and in general the Leave vote was closely correlated with the CQ (crap quotient). Crap towns are all about self-flagellation.

I lived in crap towns, including Peterborough, most of my life and I enjoyed them greatly. I have to say Peterborough is not a proper crap town. It has a John Lewis store which may reopen one day and a fine cathedral, not to mention an excellent road system. It does not have a branch of Boyes (the nearest one is in March) though it does have three B & M stores. There is a large suburb called Eastern Industry, telling it like it is.

For me, in a proper crap town the shops will include Boyes, B and M, Superdrug (not a proper Superdrug, but its poor relation, Savers) and at least 5 charity shops. The charity shops will have hundreds of DVDs and Jack Reacher books. There will always be a CD copy of Misplaced Childhood, by Marillion. There may be a branch of Heron Foods, which is a portal to a Waitrose in a parallel universe.

Greenwood menswear, Weigh and Save and Bargain Booze are now boarded up, having teetered off the top end of the CQ scale.

There are often shops that specialise in outdated food items. You don’t have to be a food scientist to know that cream sherry will never deteriorate during your lifetime.

The post office has usually been transplanted to the corner of a Spar Shop. People tend to travel by electric scooter. These move silently along the pavements catching unwary people lumbering out of Martin McColl’s scratching lottery cards.

If it’s a particularly cold and windswept day, four TalkTalk reps will be in the market square, trying to make you feel sorry enough for them to engage in light banter. One of them is usually nice looking enough to have attracted the attention of two big girls with prams. There’s a hairdressers that charges £4.99 for a cut and the barber looks like Liberace.

Crap towns should have poor Air Quality. Crap towns to the West have less pollution, with the exception of Port Talbot, which has the worst air in the UK. Crap towns to the east have less rain, but what rain there is gets more acidic. Scunthorpe is an Industrial Garden Town, or so it says on the signpost, telling it like it isn’t. Scunthorpe has the worst air quality in England. It might be worth spraypainting over the word Garden if you’re passing the town sign.

I don’t go there now, although I can thoroughly recommend the colonoscopy department. I don’t imagine there’s a better colon imaging experience anywhere in the world – I still treasure those intimate photos – which goes to show, there is much more to a town’s amenity than its deteriorated retail area. Many facilities that we used to think we needed are now obsolete, following the harsh judgement of the Covid crisis:

Pubs – like your living room, but with more infectious particles, and drinks three times the price you pay in Lidl.

Cinemas – like your living room, only someone is sitting behind you crunching popcorn and someone in front of you is staring at a very bright phone screen, scrolling down ebay items. You can’t skip the trailers by pressing a button.

Shops – like your living room (using Amazon) but you have to drive, park, pay and display and not find the thing you want.

Cafes – like your living room but tea is 200 times as expensive and you need a code for the toilets.

Libraries – like Amazon but without the book you wanted

Schools – like your living room but without proper IT or chocolate biscuits.

This change toward online living is another reason for shrugging off some of the aesthetic limitations of one’s town centre. Since most retail and many services went online, does it matter any more where you live, providing you have robust lungs, a smartphone and noise cancelling headphones?

For instance, when you’re asleep – does it matter then where you live ? Or when you’re watching TV, does it matter then? Or staring at a computer screen?

What about the neighbourhood, what about crime, what about those yobbos on mopeds? What about those hot hatchbacks parked window to window, exchanging little packets of not very legal substances in the leisure centre car park?

Granted, some areas are a bit too clockwork orange to feel comfortable, but in general, the real risk of violence is far lower than the subjective risk. Even in a crap town, you are far more likely to fall down stairs texting or get hit by a scooter than get knifed in the subway.

There are many more subjective accounts of terrible environments, such as featured in Failed Architecture and the long running Private Eye column Nooks and Corners. Everyone has their own ideas about which towns truly suck. After a while it becomes obvious that none of the towns are as bad as people make out. Writing about crap towns has become a genre. The writers more often love their towns than hate them. Rather than paint the towns ‘warts and all’ this genre just paints the warts. Finally The Telegraph runs an article called ‘Crap towns and why we love them’. Most people get the joke. We learned to live with concrete and steel. Prince Charles never did. That thing he called a monstrous carbuncle was an art gallery extension, something we’d have celebrated if they’d built it in Stirchley.

Which is surprising. Charles came from one of the most privileged families in the world and yet was sent to a prison-like boarding school where the dormitory windows were always kept open and he was systematically bullied. He should have written the definitive textbook on family sabotage, a book called ‘how and why we make rods for our own backs’. Instead he went on to attack modern buildings, usually ones that were made of concrete, forgetting that they were often very useful, warm and nice inside, like the crap towns they formed.

94. The road to Hull is paved with good intentions.

mona lisa lego

It’s surprising how people you’d think would know better let their electronic stuff get covered in grime.

Although no-one got a Nobel Prize for inventing the microfibre cleaning cloth, one of these, plus a bit of solvent, is the answer.

Luckily Isopropyl alcohol can still be obtained legally in the UK. It’s an excellent way of cleaning computers, smartphones, spectacles etc

Or so I thought, until today, when I handed a pair of broken spectacles to the assistant manager of Specsavers. I mentioned they just fell apart while I was cleaning them. He asked me what I was cleaning them with and I replied, a little proudly, ‘isopropyl alchohol’.
‘That’s what killed them’, he fired back. ‘I’m afraid it’s smack on wrist time’. Specsavers haven’t been to the breaking bad news gently workshop.

Isopropyl alcohol should not be used on certain types of plastic, it turns out. When doctors make mistakes they are called ‘blunders’ in the press. But I’d prefer to call this one just an ‘adverse effect’. No-one is saying those spectacles weren’t clean.

There are probably other friends and relatives remembering that I cleaned their macbooks, wristwatches, phones etc and, come to think of it, they were never quite right ever again.

Isopropyl alcohol might just turn out to be everyone’s perfect scapegoat. ‘The first side of Scary Monsters never sounded quite right after you cleaned it’, people will shout at me. In the years to come the Brexit vote will probably be blamed on accidental exposure to cleaning fluid, rather than the usual ‘death wish’ theory.

To be honest, I cannot really explain my choice of solvent, except that it used to come in a tiny phial, with a cotton bud, for cleaning the heads on cassette tape machines. It seemed somehow so precious. But it was probably why cassettes never sounded very good, not even the ones called ‘metal’.

Like many interventions, from insulin coma therapy to prostate surgery, alcohol cleansing might do more harm than good. I thought that cleaning was improving the world just a little, sublimated baptism perhaps. Instead it was simply vandalism.

Such contributions are part of what I like to call the ‘behaving admirably agenda’, which I see as The Way Forward.

To be honest, I got the idea of behaving admirably from my cousin who lives in Australia. He is fantastically handy at fixing things, so that when he stays with someone, he likes to fix something as a kind of thank you note. For us, he sorted out the little wheels that guide the glass door on the shower. My cousin had taken the best aspects of the Random Acts of Kindness movement, and refined it into ‘specific and targeted acts of kindness’.

Combined with a few other thoughts I was having at the time I came to the conclusion that actions speak louder than words. Partly because Word Inflation has reached record levels. More words are being created and written down than ever before. So that the value of each written word is virtually zero. Take this blog for instance…

There are so many words about that people have taken to rendering them into cloud diagrams, so that words most frequently used get written larger and more often. Our leader, for instance, would just have the words Strong and Stable written over and over again in a very strong and stable font like Roboto Mono.

Our leader can’t even talk a good game. Which brings me to my point, which is that behaving admirably is far more difficult than initially meets the eye.

My idea of behaving admirably, while probably the same as yours, may not be the same as the lady up the road who keeps 14 cats in her bedroom, or the guy in the deerstalker hat who drives his disability scooter at 10mph round Tesco.

That is perhaps why we have little aphorisms like, ‘the road to hell is paved with good intentions’. And phrases like ‘unintended consequences’. (A lot of aphorisms about this year – maybe the warm winter?)

While it is undoubtedly virtuous to pick up empty beer cans from the street corner and put them in the recycling, and indisputably evil to hang little bags of dog poo from tree branches, in between there are huge grey areas of ethical ambiguity. Many behaviours that are taken to be virtuous at face value, such as mindfulness exercises or prayer, could be seen as horribly self indulgent or even narcissistic, compared say with crown-green bowling or topiary.

One good intention that comes to mind is the current campaign to champion the cause of ‘mental health’. Lots of people have been piling onto the mental health bus recently, from the Royals and Prime Minister downwards, toward the self-congratulatory metropolitans who lead our Royal College.

If we constructed a ‘word cloud’ from the mental health media coverage this year, what would it look like? The phrases ‘examination stress’ and ‘school mindfulness first aid’ would be in 96 font, whereas the words ‘schizophrenia’ and ‘psychosis’ would be written in size 8 Ubuntu Condensed. And you would need an electron microscope to reveal words like ‘Section’ or ‘ECT’.

Whilst accepting that the mental health discourse is a lot broader than that perceived through the half-moon spectacles of traditional psychiatry (smashed, as they are, by alcohol misuse) it looks as though the notion of severe illness has been drowned out of the conversation. Who would think that mental illness tends to affect older people, that it doesn’t always respond to talking a lot and sometimes disables people for years or decades?

You could get the impression the government was piling money into mental health services, instead of shutting down all the day facilities, closing wards and sacking community support workers.

The mental health movement is well intentioned but it is all based on words. In particular the notion that the more a person speaks, the more his problems will be solved. Instead of talking, people should try behaving differently, or even admirably. Instead of shouting at your IAPT low intensity worker, why not clean the rubber bits around the washing machine door and the top of the fridge? I have just the solution for you.

Words are just clouding the picture, like the view you get through contact lenses cleaned with alcohol and cotton buds.

Sorry about that.

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

cipramil

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.

84. Learning lessons from cleverer sorts of creature.

Dolphins. They don’t do SATS.

Matisse and Chase are action dogs who won Britain’s got Talent. The fact that dogs can be taught to walk across a tightrope should make the education establishment pause briefly over its tall latte. As legions of children are subjected to ever-changing methods of learning and testing, has it never occurred to teachers that all they need is a packet of food pellets and a buzzer? If not, they should try writing the learning objectives and lesson plans for a dolphin show.

The problem seems to be in the notion that learners need to ‘understand’ things.

Once you start down the road of Understanding, sooner or later, you will lose your way. As Spinal Tap observed, it’s a very thin line between clever and stupid.

The road to understanding ends with a Philosophy experiment, like how Schrodinger’s Cat can be alive and dead at the same time. The pursuit of Understanding has killed off skills learning and almost no-one can walk across a tightrope nowadays, not even Matisse if safety rules are respected. Apparently Matisse hasn’t got a great head for heights.

As I understand it – which I don’t need to – operant conditioning happens as follows: People (or dogs) blunder around randomly, certain behaviours get associated with nice or nasty experiences. This, in turn, makes it more or less likely the behaviour will be repeated. Rewarding behaviours with biscuits or fish allows trainers to create showbiz animals. It’s embarrassing to accept that operant conditioning remains the strongest determinant of our behaviour. But there are examples all around us if we look.

In front of me for instance is a jar of eucalyptus honey, which I am putting on my elbows. Although I have sat through countless hours of training in evidence – based medicine and statistics, my experiences with honey are completely homespun, not to say stupid. Like most experiments, it started randomly at a hotel somewhere. A particular constellation of circumstances occurred: sore elbows / time to waste / poor impulse control / spare sachet of honey / no-one looking / short sleeves / suspension of disbelief / random fluctuation of self limiting condition / not liking honey as a food.

Add to that perhaps the knowledge that many great discoveries really did happen by chance.

I am not saying – GMC fitness to practice committee, please note – that you should put honey on your sore places. I don’t think I should be doing it myself to be honest, since it is wrecking my reputation and my wool jumpers. And honey just does not fit into a touch-screen world.

I’m aware I am falling victim to Attribution Error. Being aware of it doesn’t stop it happening though. Placebo can still work, even if the subject is told it is a placebo. Even if there are neon lights flashing the word ‘Placebo’ in front of you and a fifty-strong male voice choir singing the word ‘Placebo’ right behind you. That’s why Understanding just isn’t necessary and might even be dangerous.

Which is also why it may not be quite as necessary to try and explain things as the current versions of User Involvement dictate. Some psychiatrists have got into trouble saying stupid things to patients in an attempts to explain how drugs work. The worst thing you can say, apparently, is ‘chemical imbalance’. It’s OK to say ‘chemical’ I think – though some people struggle with the notion that the brain is made of atoms – it’s the ‘imbalance’ part that does the damage.

Once you start using words like ‘imbalance’ you can be sure you’re on slippery foundations. Next thing you’ll find you’ve said ‘Time’ or ‘Nature’ or ‘Rest’. Then its only a short step to mumbling something like ‘striving officiously against the inevitable darkness’ and ‘tickets to Switzerland’. If you say the words ‘balance’ or ‘imbalance’ you will hear the examiners screaming with laughter behind their one way mirror.

Psychiatrists might use the word ‘deficiency’ in the context of brain chemistry, but not ‘imbalance’. Not that deficiency (e.g. of serotonin) is a proven cause of depression. But the monoamine theory of depression did guide people’s understanding of the illness for many years. ‘Increasing’ serotonin was the simplistic explanation for how antidepressants might work, particularly those named serotonin re-uptake inhibitors.

There are reams of internet pages given over to an argument between anti-psychiatrists and the psychiatric establishment about whether any psychiatrist has actually used the phrase ‘chemical imbalance’. And indeed as to whether the monoamine theory included notions of balance.

Further reams explore whether it was a term that used to be used but has now been abandoned and the usage covered up, like documents in 1984.

Anti-psychiatrists argue that psychiatrists concocted the notion of Imbalance with big pharma, in return for free logo pens. One of them scoured the literature to find use of the ‘I-word’ and came up with this example from a 2003 textbook:

‘Sometimes the explanation is as simplistic as ‘a chemical imbalance,’ while other patients and families may request brain imaging so that they can see the possible psychopathology or genetic analyses to calculate genetic risk’

As far as this paragraph goes, the stupidity of the chemical imbalance part is overshadowed by the rest of it, such as the idea of seeing psychopathology on an image of the brain. Even so, the usage seems to be an example of low-end explanatory waffle, rather than as a deliberate falsehood the board of Eli Lilley dreamed up as they circled their cauldron.

When talking about drugs, or honey, smart people know how to say ‘I don’t know’ But it’s not OK, as Ed Milliband found out at the election, to say ‘who cares?’

Just to reassure you, I am not keeping the medicinal honey anywhere near the food honey, and I have labelled it ‘Medicinal Use Only’ and ‘Not for Internal Use’, just like the Boots chemist would have done in 1965. It works by Osmosis I think, which is quite different from correcting an imbalance.

79. Cashing the reality check.

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?

76. Keeping in with the in-crowd, going where the in-crowd go and knowing what the in-crowd know.

An item from the new ‘dysmorphophobia’ range at John Lewis.

It’s November 25th, a slow news day, so an announcement is made that young people with Depression will be treated with apps. That’s no more true today than last month or last year, but apps are now the way forward, rather than electrofolk workshops.

Every time these announcements are made, which is monthly, for some reason Nick Clegg, deputy prime minister, mentions three things; that mental health remains ‘in the shadows’ – again failing to add the obvious quip ‘like Hank Marvin’, that antidepressant tablets laid end to end would now reach as far as Neptune and that ‘1 in 4 of us’ will suffer mental health problems. The question is, why 1 in 4, rather than all of us?

After all, mental health problems are not sharply defined entities at all. Most of them shade into normality along a spectrum, so that we can draw the line between cases and non-cases anywhere we want, from 0% to 100% of the population. Would anyone – even a politician – ever say that 1 in 4 of us suffer from physical illness, now or during our whole lifetime?

Statisticians like to set the cut-off points for illnesses a certain number of standard deviations away from the mean, giving rates like 32%, 5% or 0.3%, depending on how far north of London you want to start calling it The North. This is why most artificially constructed illnesses have those rates. There’s no need to go from door to door sampling people, if you set an arbitrary cut-off point in the first place. Someone described epidemiology as ‘counting swans on the lawn’, but in reality it is much less complicated than that.

The answer seems to lie in a complex calculation about ‘otherness’.

If we make something look too alien, then it will be categorised with all the other rare diseases with pseudo-Greek or exotic names. That gives it kudos, but it’ll have to compete for interest against names like Von Recklinghausen’s disease and Blackberry Thumb.

If we make it look too common, then people will say it’s just part of life and why don’t they deal with it like anybody else. But – as presumably dreamed up in PR, since there is no evidence to support a 1 in 4 lifetime incidence figure – if we make it 1 in 4 then we probably don’t have it ourselves, but the bloke two doors down almost certainly has it. Presumably the intention is to create a ‘there, but for the grace of God’, feeling, that would send me two doors down the street with a basket of fruit and a compilation CD of eighties power ballads.

I have serious doubts whether the 1 in 4 strategy will work, either in terms of reducing the stigma attached to the fourth person, detecting cases, or promoting treatment. The precedents for 1 in 4 type disorders are not good, if we think about Obesity, Smoking, Diabetes, Backache, or Alcohol misuse. All of these are both common and stigmatised. In fact I would argue that 1 in 4 disorders are the ones that are the most stigmatised of all, the sufferers inevitably regarded as the authors of their own misfortune.

Like the extras included in a Star Trek landing party, someone with a 1 in 4 disorder knows they are going to die soon, but only because they will make stupid space mistakes, the kind that Scotty or Bones would never make, like handling dilithium crystals without oven gloves or forgetting to charge the cloaking device.

This phenomenon gave rise to the term ‘red shirt’, meaning a fictional character who dies soon after being introduced. 73% of the crew killed in the original star trek series wore red shirts, something lost on the UK audience who mainly watched in monochrome.

Rather than assuming a ‘grace of God’ scenario, we conclude that this would never happen to us. We are main characters in our own minds, not extras.

There is nothing about 1 in 4 that protects against ‘otherness’. Its roughly the proportion of people who vote for one of the main two political parties. It’s roughly the proportion who watched the return of Dirty Den to Eastenders. It’s a number that can get killed in the worst civil conflicts. I in 4 can be a highly divisive ratio.

And it’s just a ratio that no-one wants to be part of, as opposed to say, the three in a thousand who might get Blackberry Thumb.

If mental health problems really affected (as few as) one in four of us, and we were all detected and referred for treatment, even if we only were ill for a short time, that would still overwhelm the mental health system, but it would not overwhelm the massed ranks of smartphones and tablets. Some accounts suggest that as few as 1 in 4 people don’t have devices that could run apps. What a coincidence!

As Bryan Ferry put it, you want to be in with the in crowd and go where the in crowd go. As far as the song went, this meant knowing how to have fun. Fun, like therapy, is very hard to find. But it could mean playing a party app on your Nokia, so you don’t have to actually go to it, which is what social media have done for us. Inevitably, social media will become the new group psychotherapy.

Imagine an in crowd that included 25% of the population. Statisticians wouldn’t trust it and Bryan Ferry wouldn’t join it. On the other hand, it’s a number Nick Clegg’s party, the Liberal Democrats, can only dream about now.

75. Feeding jokes and riddles into Multivac.

Because I’m worth it.

Obviously I can’t say anything about it, but I’ve been on Jury Service. I’d love to tell you all about the case but I can’t. Suffice it to say, as a spectator experience, this beats soaps and reality shows and probably boxing too.

There are some things I just have to write down. There’s a lot of time hanging round in the jury waiting room, which is about as comfortable as a Ryanair departure gate. Though they do have daytime TV, it keeps being interrupted by the How to Be in a Jury DVD. Luckily one of the ushers is a stand up comedian and keeps popping in to try out material on the captive audience.

For some reason, jokes, like dreams, don’t seem to bed themselves into the memory banks very well. When it’s time to remember a joke to tell, the memory just vanishes. Isaac Asimov based a whole short story, ‘Jokester’, on this premise, concluding that jokes were part of a psychology experiment carried out by aliens.

This time I resolve to write them down straight away.

A man comes into the doctor’s surgery.

‘Doctor, I think I’m a moth’.

‘You really need a psychiatrist rather than a GP’

‘Yes, I know, but your light was on’.

No-one laughed apart from me. That’s a bit worrying, since the jury is one of the very few occasions where a random sample of the population has been assembled. Is my sense of humour, statistically, a bit odd? Everyone seems very normal, at least compared with the people I normally meet. Perhaps they have heard it before, or perhaps its because I like psychiatrist jokes more than the average person. Perhaps I am tuned in to contrasts: here’s an ultra sober setting, a Crown Court where people are being tried for sex crimes and murder. And here’s one of the court officers, dressed in a gown, telling gags. Humour often arises out of adverse situations, but why exactly? Why do people make sick jokes about Princess Diana or Fred West?

The usher announces further delays. We see one of the judges arrive in his Impreza and a flunkey goes out to open his door and hold an umbrella over him as he walks five yards to the court entrance. That would never happen in the NHS, not even for Lord Winston.

A man comes into a doctor’s surgery.

You should know I’ve got a rather unusual congenital problem

Tell me more about it

I was born with five penises

Hmm. That must make it difficult to get your trousers on

Actually, they fit… like a glove.

I laughed more than the others again, but I like stand up and even pay to see comedians live, which probably places me in a small minority of the population.

The usher pauses ever so slightly between the words ‘fit’ and ‘like’ in the punchline. For some reason that bit of timing is critical in adding humour, the split second somehow priming the laughter pump, like turbo lag. As he finishes the last line he turns and swoops out of the room in a grand exit.

Jokes and dreams. Why can’t we remember them? Is it a lack of concentration, which stops us filing them away properly, or do they just belong to a different part of the brain from the usual memory, like singing uses a different system from talking? Is there an equivalent of a Save command in the memory system, that somehow doesn’t always get pressed?

There are many psychological theories about joke memory, including a rule that the very best jokes are the most difficult ones to remember. Maybe it’s because jokes are inherently discordant and can’t be processed into patterns. And perhaps humour offers a defence mechanism against discordant experiences, like horrific crimes.

I have a friend who races snails. He takes it very seriously. In fact he has one extremely fast snail that he enters for national competitions. For the snail Olympics, to make it even faster, he decided to improve the snails power to weight ratio by removing its shell. After this, it won its next race easily.

I asked my friend how he felt about it.

He said, great performance, although somehow… just a bit sluggish.

I’d like to think that a sense of humour is an asset in working with people with mental health problems. I used to think it was a moral imperative to state a witty remark if it happened to come into your mind. Nowadays though, especially with regard to some people’s interpretations of political correctness, the smart move is to keep it to yourself. No-one would be allowed regular comedy slots in an NHS department, not even dermatology. Even though you can buy a book called ‘The best ever book of dermatology jokes’ on Amazon.

Here’s a joke I found sent into a forum. You are meant to answer the question: Why does no-one trust a dermatologist? The answer is supposed to be ‘he keeps making rash decisions’. Instead someone has responded, in capitals:

BECAUSE THEY SAY YOU NEED A MOLE REMOVED WHICH CAUSES NO PROBLEMS AND INSTEAD LEAVE AN UGLY AND EVEN BIGGER SCAR

I don’t know why that’s funny, but it is. Discordant notes again I suppose. It doesn’t pay to overanalyse it.

At the end of ‘Jokester’, once it was revealed that jokes were nothing more than part of an experiment, humour was simply ‘turned off”. Was Asimov anticipating the PC movement, or was Jokester just a true story?

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

Finally, a new logo for the National Health Service.

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

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

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

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

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

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

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

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

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

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

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

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

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

71. Not going looking for trouble, rather, knowing where to find it.

I’d like to say he won’t hurt you. But statistics show it’s possible.

Remember the beginning of Three Days of the Condor, when Robert Redford goes out for a sandwich, and returns to find that an assassin has moved systematically from room to room with a machine gun and murdered all his colleagues? That was pretty much the scene I found when I visited my old workplace yesterday.

I’d like to think there was more to morale than petty behaviour behind the scenes. And that whatever the atmosphere, patient care wasn’t affected. But that is plainly ridiculous. Now that I am a patient more than I am a doctor, I’d rather my doctor wasn’t grumpy even before I tell him about my knees.

The NHS is an intensely tribal organisation, where the various power groups live within a precarious ceasefire. Only a thin membrane of etiquette stands between normal working and bouts of senseless slaughter. Sometimes it only takes one small incident – like shooting an Arch Duke – to set things off.

Etiquette is an intensely important aspect of medical culture. It’s history goes back to the middle ages, where practitioners were divided into three ‘medical estates’ – barber surgeons, apothecaries or physicians. Barbers had the sharp instruments and physicians had the sharp suits. Apothecaries, as now, had the shops on the high street. The professional codes of practice we have inherited are derived from power sharing agreements worked out centuries ago.

The thrust of recent changes has been the ascendency of Management, at the expense of the older professions like medicine and nursing. Like a new religion, or political party, managers have yet to establish a proper code of etiquette. Like the dog in the park, they jump up at people and leave muddy prints. Their owner tells them, fifty times a day, not to jump up at people, they’re not supposed to. But it takes a long time before a dog gets a firmware upgrade.

It’s unbearably rude to write about the position of the medical profession in terms of power relationships. As I write, I almost have to change fonts to something spidery, to reflect the delicacy of the discussion. Should we say, at least, that managers and doctors have an ambivalent relationship? Not love / hate exactly. More fear /loathing to be honest. This probably just reflects a wider unease about elitism in British society. The NHS is locked in a post-war time warp where snobby types need to be cut down to size. The NHS tends to regard eminent persons as ‘toffs’. If you’re a decent sort of toff, you can be a ‘boffin’. But just because you can recite the periodic table, including the rare earth metals, don’t think you can start telling anyone what to do, let alone bring your bike in your office.

I suspect other skilled technicians like engineers and pilots are still treated this way in their industries, apart from finance and banking, where elitism is positively glorified. I’d love to say something like, ‘it doesn’t take much to keep people happy, it’s the little things that matter: just bring back the lady with the tea trolley; let’s renew the subscription to The Guardian’. But I fear its gone too far. Max von Sydow is still lurking in the building. In fact he’s just reloading. But whose side is he on now?

70. Reporting soap shortages, before they get serious.

A poster reminding people, in several ways, that they are too old.

The techno-thriller genre gave readers a thirst for irrelevant information. It wasn’t enough to say someone travelled on a Boeing 707. You had to hear about who made the engines, how the landing gear was inspected by a man with a set of tuning forks and how the pilot’s socks were monogrammed in alpaca by a silent order of nuns in Seattle.

The behind-the-scenes stuff became obligatory for thriller writers – quite a feat before the days of google. Presumably, Forsyth and Clancy spent huge amounts of time visiting airports, submarines and arms factories, asking people, ‘what does that yellow handle do?’

The most obvious spin-off has been the increased number of adjectives we find in grocery products. It’s not enough to say Oven Chips. You need to give them a bit of character development: Maris Piper, thrice-fried, goose-fat oven chips, at the very least. And even then, you’ve said very little about the goose. People want detail nowadays.

Another consequence of the increased audience for background information is the ‘Troublehooter’ style of TV series, started by John Harvey Jones and continued by the likes of Gerry Robinson and Digby Jones.

A man in a striped shirt and hard hat wanders round a huge factory, shaking his head slightly, asking every now and then: what’s that thing for? As a TV show, it’s a tired formula. But, as a metaphor for personal growth, it’s got potential. The striped shirt man is a therapist of sorts. He’s an independent expert, but he’s neutral and polite. He’s robust and challenging, but he’s kind and might even hug you, though you’re still getting fired. Like a certain type of clinical psychologist, he’ll make you a flow chart, showing you which arrow is missing, such as the one between Theakston’s Old Peculiar and poverty.

It could be helpful to get someone to troubleshoot your life. But what about businesses – can an outsider really understand them? Does expertise in the field really matter?

Troubleshooter appeals to people who like to look behind the scenes and are disappointed that Arthur Hailey died before he could write ‘NCP Car Park’. Ironically, the Troubleshooter himself is not the slightest bit concerned about forged composites or digital motors. He’s looking at the system as a whole. He’s drawing Venn diagrams and talking about Synchronicity, just as though it wasn’t the worst Police album.

Gerry Robinson wants the NHS to have more centralised reporting systems, like the food industry:

‘Imagine a McDonald’s in Leicester, say, where things are going wrong. Perhaps the wrong number of chicken nuggets are being handed out, or the washrooms aren’t supplied with soap. These problems would show up immediately via a weekly reporting system which compared its performance against every other McDonald’s in the country, and you’d have a senior manager down in days to sort out the problems’.

Gerry’s background is in catering, so he’s comfortable with that model.

But, senior managers never visit NHS units, partly for fear of infectious disease, but largely because it would never occur to them to do so. Boards and Hospitals are different planets, with different atmospheres and gravitational fields.

Whereas the coffee available to senior managers comes out of a capsule machine, the coffee provided to wards comes out of industrial size tins labelled Maxwell House. It’s Maxwell House, Jim, but not as we know it.

Whereas NHS management premises are carefully protected behind air-locked entry systems and fierce receptionists, anyone can walk, unchallenged, into most hospital departments, including intensive care units and even operating theatres. This fact is portrayed in countless thrillers, where assassins get a second chance to finish someone off by stealing a white coat and strolling in.

As further evidence that NHS Boards and Hospitals are separate worlds, consider the fact that boards comprise upwards of 12 members, only one of whom is a practicing clinician. Does Gerry not think this is a bit odd? Does he not realise that Boards and Clinicians, like matter and antimatter, must never come into contact with each other and if they do, the universe will be annihilated?

I am not a management guru. But even I can spot the key differences between Macdonald’s and the NHS, such as Product Range. Which leads me to ask: who troubleshoots the troubleshooters? It suits managers to propagate the notion that it doesn’t matter much what the company does or makes, that you can move between Catering, Television, NHS and it’s all the same. But often, the detail is what matters most. John Harvey Jones forecast the demise of Morgan for instance – he just couldn’t understand how cars could be made of wood. It’s not a mistake Tom Clancy would have made. He’d have known all about the aerospace properties of ash.

Whereas thriller writers regard craftsmanship in awe, managers regard it in contempt. In a techno-thriller, the emperor’s new clothes would be made of kevlar. And the boss would know what the yellow handle did.

To be fair to John Harvey Jones he did tell the Chief Constable of South Yorkshire that his strategic plan was ‘a load of bloody cobblers’. This comment pretty much ended their foray into footwear repairs.

escapedpsychiatrist

A topnotch WordPress.com site

Tag Archives: depression