44. Saying goodbye to Virginia, more sensitively.


Marshmallow invasion: The first wave.

You might find this hard to believe, but it’s quite a while since I’ve been punched in the nose. Especially considering the number of times I have ‘misjudged the rapport’ with our service users. However, I just discovered a product called ‘First Defence’, which creates a very similar sensation, but without the violence. First Defence sounds like the name of an outsourcing company for mercenaries, or possibly the military wing of the bus company, but rather, is a product made by Procter and Gamble, to prevent the early symptoms of a cold turning into a screaming, streaming viral attack. It’s a kind of Early Intervention Service, in a little spray.
Many of the Early Intervention services for mental health problems have been scaled down or discontinued. However, there has been a refocussing of efforts to stop our patients going on to develop lifestyle-related problems such as obesity, diabetes and vascular disease. NICE intend to step up the anti-smoking component of our role.
For every new consultation, our first questions will be about smoking, exercise, diet and alcohol use. For our inpatients, nurses will not be allowed to facilitate or supervise them going for a smoke. Furthermore our nurses will not be allowed themselves to smoke, wearing any kind of uniform or NHS regalia, not even a Charter Mark badge from 1994, nor one of those badge / lanyard accoutrements that staff-not-at-risk-of-being-strangled wear round the neck.
Please note the new CCTV cameras behind the bike sheds.
You can see now why I started with the punch in the nose issue. Before the patient has a chance to tell us anything, we will have:
Recorded the names and ages of their children and where they go to school.
Made them sign a confidentiality agreement stating that we will shop them to the police or social services if they come out with anything too alarming.
Calculated their Body Mass Index, including commenting whether they are shaped like an apple or a pear. I could perhaps disguise that bit as a personality test – if you were a kind of fruit, what fruit would you be?
Guaranteed to break the ice, I think you’ll agree. We’ll hear about your problems shortly, as soon as we’ve got through my agenda.
Whether we can make a difference to patients’ lifestyle is rather dubious. A sceptic might point out that it is really difficult to treat obesity or cigarette smoking in people who are feeling fine, let alone those who are going through difficult times. Even well directed smoking cessation programs struggle to achieve a lasting effect beyond the first 6 months. By 12 months most people with major mental health problems are back on the weed. Yet, in anticipation of the NICE guidelines, the effectiveness of such programs is being ludicrously oversold, often by the same people who dispute the efficacy of medication for mental health problems.
Psychiatrists will not be allowed to stay out of the lifestyle war. Unfortunately, we have unwittingly caused part of the problem by promoting tablets that cause weight gain, and letting people smoke in our hospitals, to help them calm down. Most people with psychotic conditions like to smoke – upwards of 70%. In surveys they say they enjoy the experience.
The orthodox view is that cigarettes do not help people concentrate or relax. They merely reduce the effects of nicotine withdrawal the smoker is already suffering. We have tended to view smoking as a relatively minor problem relative to mental illness. Now we are being asked to make it more of a concern. This is all OK, except for the damage it might do to people’s relationships with their doctors and nurses.
Coming across as positive is one thing, adopting the tone of a sports coach is another.
Very few psychiatrists wanted to be PE teachers when they were little. It’s just a hunch. Many of my colleagues – let’s put it nicely – wouldn’t make it as underwear models. Are we in a good position to set the lifestyle agenda? ‘Mindful walking’, to us, is being careful not to trip over those yellow signs that cleaners leave on stairways. Some of us even remember what the inside of a golden virginia packet looks like.
We know from long experience that telling people what to do is a bad idea. We know from many surveys that people like us to listen to them. We know that genuineness and empathy are key therapeutic ingredients. Yet only this week a social worker, who had just detained one of our patients under the mental health act, told me she thought what would really help the gentleman concerned was a back-packing trip across Scotland, rather than tablets.
Luckily, there is no section of the act that mandates back-packing or cross-country running. Yet.


37. Rejecting the Domino’s Theory.


This creature’s camouflage is poorly suited to the urban jungle that is Hull.

My iron is warmed up and the fire extinguisher is ready, but my Ironing Coach is late today. Let’s hope we can stick with simple shapes again and not attempt anything complicated like pleated trousers. I was never that good at thinking in three dimensions, which is probably why I am not a surgeon.

One of my theories is that Specialisation has been very bad for us. I can understand how such a thing came about, following the industrial revolution, the invention of production lines, and the division of labour.

But every time a specialism is created, such as Pastry Chef, Tyre Fitter, or Middle-Third-of-the-Duodenum-Surgeon, a potentially useful activity has been taken away from the rest of us.

Not only are we all deskilled, but also we now have three very bored people, doing the same thing all day. Nowadays it is possible and probably lucrative to have one very finely honed skill, particularly if it is one that has been professionally colonized and denied to amateurs.

Professionals, and by this I mean the old professions like Law, Medicine and Accountancy – I nearly said Prostitution – were the first to stitch up areas of activity which would become highly rewarded and restricted to club members.

More recently we have seen Plumbers and Electricians get in on the act. Fair enough. These are occupations that need special skills and equipment and could represent a danger to people if done carelessly. But have we overdone it? Couldn’t the plumber do the electrics and vice versa?

Couldn’t someone more like a blacksmith – a person with a large shed and no backache – do tyre fitting, along with general welding and repairing? Why for instance is the person who mends shoes uniquely the person allowed to cut keys and change watch batteries?

Dominos seem to have developed an extremely narrow niche product. It’s for people with a motivational level just above the point for making phone calls but just below the point where they can put a frozen pizza in the oven for 13 minutes. A surprisingly large section of the population inhabit precisely this energy zone.

Ivan Illich was an influential writer in the seventies. I went to see him speak once in Leicester. I mainly remember that he refused to use a microphone, because he believed this invention had stolen the power of public speaking from the non-miked. However Ivan had an extremely loud speaking voice, so hardly needed any further amplification. He was easily able to drown out his opponents, which is the essential skill for a one-liner polemicist.  His message was to criticise doctors and teachers for stealing areas of expertise away from ordinary people.

As regards Medicine, there are pros and cons in his argument. It’s true that many areas of normal life have been falsely medicalised, such as insomnia, addictions and obesity. But it’s also true that high tech procedures such as coronary artery grafts have become massively more successful, providing the person carrying them out has done a large number of them, uses the right equipment and follows a strict protocol.

This week on the front pages of our newpapers we find a report about Depression supposedly commissioned by Nuffield Health. Whatever the report actually says, what has come through the press releases are some of our favourite chestnuts:

Depression affects one in four people.(Why not one in four hundred or everybody – it depends merely on where you draw the cut off point?)

GPs dish out antidepressants by the bucketful. (Who is this Willy Nilly and why can’t we stop him?)

Exercise would be just as useful as antidepressants.(As though obese people didn’t have to carry round an extremely heavy weight all day round their tummies.)

Not surprisingly, we find that Nuffield Health has taken over a lot of gyms recently. The more thoughtful papers go on to say that a Cochrane Review has shown that the value of exercise in Depression is doubtful to modest.

No-one much has a bad word to say about exercise, but lets inject a note of caution. Exercise might be an excellent pursuit, but very few people persevere with it. Much as they don’t persevere with Cognitive Therapy. Because they are hard work.

As opposed to swallowing a small tablet once a day, which is easy work. Our problem I think is in expecting either exercise or tablets to do miracles.

At the present time we have a situation where a professional person presides over getting hold of antidepressants, whereas we are still theoretically free to run upstairs or lift bags of potatoes.

However, the fitness lobby has made significant progress in colonising exercise-taking. Are we seeing the development of what could be called Big Exercise, where gym companies, sports gear and food manufacturers team up with coaches and personal trainers to create a new orthodoxy of fitness?

I predict that we will soon be able to buy antidepressants in Tesco, but if we want to take any exercise we will need expert supervision. Much like Ironing. It’s going Corgi-registered soon.