92. Doing without experts, or even people who wear spectacles.

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The CEO presents his new organisational structure, shown here as a Venn diagram.

 

A cat is out of its bag. Not Kevin, the actual cat – he can’t get through Kevlar sacking – but metaphorically speaking.

There’s a book out called ‘Where there is no psychiatrist’. Though the phrase ‘developing world’ occurs somewhere in the description, and the front cover depicts a place where people carry water in stone jars on their heads, so probably not Mexborough, in actual fact this manual is meant for Britain itself. There is no psychiatrist in your town or mine. That fellow with the beard is just a hipster. That guy with the carefully-crafted-designer-vagrancy look you admired so much is just a vagrant. Though some people are pretending otherwise, for better or for worse, mental health is going DIY.

There are exactly ten reasons for this:

  • Very few new doctors are choosing psychiatry as a speciality
  • A lot of psychiatrists are retiring to open artisan cheese shops
  • Psychiatrists who don’t use a medical model are more expensive than social workers
  • Psychiatrists who use a medical model aren’t cool enough at parties
  • Psychiatrists have to wear a T shirt that says ‘in case of disaster I am to blame’
  • People have noticed that the NICE guidelines for mental illnesses are the same ones for every single disorder
  • Illegal drug dealers have got more and better new drugs than we have in the NHS
  • Maplin have got more and better electrical treatments than we have in the NHS
  • The GMC now require you to cut down the mightiest tree in the forest, with a herring, in order to get revalidated
  • Conspiracy theorists have stolen all our best delusions

Now that we have youtube to show us how to do every task, the main constraints on DIY are statutory regulations rather than not knowing how to do things. But where there are severe penalties for unauthorised gas fitting, there is no penalty at all for pretending to be a mindfulness therapist, or for lighting candles in people’s ears.

Surely, before we start selling prozac and zyprexa in Poundland, before we legalise ketamine, before we hang special magnets from our earlobes, there should be youtube videos on how to interpret evidence and follow logic? No mate – this is England. No-one likes an expert round here.  

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3. It looks a bit DIY

Experts - do we need them?

Experts – do we need them?

There are surprisingly restrictive laws to prevent you doing bits of wiring and plumbing around your own home. Anything gas related is particularly strict, needing someone who is CORGI registered.

If you replace your gas hob, despite the fact that you can turn the gas off with a big tap, that the hob uses a simple bayonet joint, that gas is very smelly in case of leaks, that you have watched the CORGI man do it several times, that you don’t intend to do it with a lighted cigarette behind your ear – despite all that, if you disconnect it yourself you will be placed in the Tower of London for 100 years and tortured every Tuesday. Your crime is that you thought you knew better.

Surprisingly, when it comes to helping people with health problems, things are much looser.  There are professional bodies regulating the top end of the market – doctors, nurses, psychologists, but even here there is very little regulation of what types of therapy they actually do.

Lower down, blurring into the alternative therapy market, pretty much anything goes. This market is full of therapists who think they know better. Better, that is, than any evidence they can produce to support their work.

Its often fascinating, as a psychiatrist, to see how people have attempted to deal with mental health problems prior to ‘calling in’ the NHS.

We know people delay seeking medical advice for health problems. People tend to adjust to symptoms for a long while, often attributing them to random and coincidental events such as biological washing powder or a mystery virus.

Such accommodation to symptoms only breaks down if something happens – you notice specks of  blood over your white piano keys, like Chopin; your mum makes you an appointment for the GP. Or you are arrested in a public place under section 136 of the mental health act and taken to a place of safety.

Before we get to the point of needing professional advice, how long have things been deteriorating? In the case of psychotic and depressed patients, we know they have been unwell on average for many months before seeing anyone for help.

Some events are so traumatic that the person goes straight to hospital without passing GO or collecting £200. But the majority of medical events develop slowly, more like accepting a £10 fine, or, like Mr Huhne, taking a chance card instead. The first part of any illness is usually in our own hands to manage.

That means we have to consider health issues within the reflective mind, however much that part of the mind wants to sweep them under the conscious carpet.

When it comes to mental health problems there are times when we need an objective person to give advice. Another person can be a vital source of insight. Often just talking to another person helps us reflect better. Before we tell another person we are on our own and at the mercy of the limited perspective of the single view.

Even after we have convinced ourselves, and maybe our mums, that we have a problem, we encounter barriers around the health care system. These have been built good and high to filter out the excess demand placed upon a free health system.

The ‘culture of fear’ that NHS-managementism has created extends downwards towards service providers and users.

Firstly there is a healthy scepticism about what motivates the NHS  behind the scenes: 1. the nanny state; 2. targets that determine payments; 3. drug companies.

Then there are simple filters such as a permanently engaged phone line, KGB receptionists and a lack of appointments.

Perhaps more of a barrier for most people is just not knowing how to engage. What should you take to the doctor, how do you describe it, how do you present it? Should you take someone with you, should you write things down on a bit of paper, should you google it first?

Once into the mental health system we are very unlikely to find an ideal therapist we can relate to. One reason is that the demography of the NHS workforce nowhere near reflects the demography of the population it serves.

Another reason is the very small number of trained professionals relative to the number of people who suffer from mental illnesses.

For example, our GP has 2000 patients on average. Lets assume 3% of them (more later about the 3% issue) have severe depression – that’s already 60 people. Our local psychiatrist serves – again on average – 40,000 people. He or she will have a caseload of several hundred.

How many hours are there in a week? In the NHS, about 12, by the time we have allowed for bureaucratic intrusions, mandatory training, focus groups, and having our hair done.

Without wishing to denigrate anyone involved, or indeed undermine the foot-ware industry, the NHS mental health services are run on a shoestring. The negative halo effect that surrounds mental health issues also effects prioritisation and funding, relative to hotter specialities like Fever.

Having thought about all these barriers – starting with our own reluctance to think about our health, stigma, bureaucracy, shortages, shouldering our way into a system that feels like rush hour in Naples – its amazing that anyone gets treated at all.

Luckily, unlike with the CORGI fitter, a lot of it can be done by yourself. Often using equipment you can find in your own kitchen, such as another person.

But the first rule has to be: don’t think you know better (until you can prove it).

The second rule is: no cigarettes.