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.


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


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.  

83. Bandwagon for sale, very low mileage.

A concrete windswept piazza, early in the morning, before the philosophers arrive.

I tried to warn the Liberal Democrats about the negative halo effect that occurs when anyone talks about mental illness in the media. As soon as the talk gets round to mental health, people become upset and change channel, without even knowing why. Not only that but they get grumpy and choke on their pop tarts. The reaction is deeply intuitive, like a brain stem reflex.

The Libs banged on about mental illness affecting one in four of us and needing to be put on the same footing as physical illness services, eliminating suicide etc, just as though they hadn’t read this blog. They didn’t listen and now they are a burned out ruin on the hard shoulder of politics.

Though the halo effect has been known for more than 50 years, this has not stopped a succession of doomed public awareness campaigns such as ‘defeat depression’.

We know that mental health information is perceived as toxic, but no-one has adequately explained why.

Since Shirley Star’s studies of public opinion in fifties USA, the consistent findings have been that people with mental illnesses are regarded as dangerous and unpredictable. Presumably, so too are violent criminals, but they get massive media coverage and scrutiny. Most likely, the ingredient that puts people off dealing with mental health is having to try and understand it. Once you start to think about it, even if you’re in the business, there’s a large parcel of mental work to be done before you can process the information.

For instance, drawing the line between unhappiness and depression, separating personality disorders from illnesses from disabilities, let alone facing the mind brain problem. We’re pretty quickly into Melvyn Bragg territory, but without his panel of expert communicators.

It’s exactly the same for other specialists. A motor mechanic recently tried to explain to me – in some detail – about what had gone wrong with the car’s air conditioning. I remember the phrase ‘wobble plate’, but to be honest that’s the only thing I can tell you about it now. I’ve had to abandon any smug pretensions to knowing my way round a Compressor. Though I will, soon, find an opportunity to say the words ‘wobble plate’, somehow or another.

I’d compare the negative halo to the effect of encountering a protest demonstration in a shopping centre.  First instincts are to avoid it, not particularly in case of violence, but more in case you are called upon to examine a complex issue, like whether a remote area of a foreign country has been shabbily treated. Thinking is the last thing you want to do in the Arndale Centre. But it’s the kind of thing you might do by listening to Radio 4 at about 8pm, alone in your car on a smooth stretch of highway. But then that’s your choice, if you’re in the mood for mental activity.

Outside the police station, a large sign reads PRIDE. I’m going slowly enough to recognise that PRIDE is an acronym – after each capital letter is a smaller word. Subliminally, I perceive the words to be: Pride, Respect, Integrity, Dedication and Empathy. Are these virtues (or sin, in the case of pride) really top of our list of desirable qualities in a police service? Surely, these are not the words you want to hear when the machetes are waving and the AKs start popping.

Having said that, I’ve had no success in weaving an acronym from the words, Taser, Cuffs, Tear-Gas, Smith, Wesson, Court and Prison.

Doubtless the police have their reasons for presenting themselves as social workers, such as the diminished number of real social workers. And obviously they have to try and maintain the moral high ground. Nevertheless, my brain stem reaction to the PRIDE sign was: misguided PR campaign. People are proud of the police because they stand up to horrible people, not because they are empathic. Bad Boys 3 will not be subtitled Good Boys.

The negative halo effect cannot be countered by dressing things up. On the contrary, we are set on guard most acutely by any hint of deception. Very large and fast neural systems are devoted to spotting trickery. It takes a lot of considered reflection to counteract such defences, which means weighing things up carefully. The very thing that stresses out the wobble plate.

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.

59. Cutting costs to the bone and a few corners.


Behind the scenes at Boots.

While we’re on the subject of newspapers (see 58) I’m wondering if the Sunday Times shouldn’t go on the top shelf at the newsagents, along with Total Carp and Darts Illustrated (Swimwear Edition). I’m seriously wondering if its worth queuing up behind the lottery victims, paying £2.50, just to have your world view tarnished and warped.
What is happening at the Sunday Times? Has the influence of Jeremy Clarkson begun to infect the other journalists, who have failed to realise that Clarkson’s work is ironic?
World war three will probably be a fight between thin people and the obese. I wouldn’t put money on the thin people – yes they can run faster, but they can be squashed more easily and might not survive a nuclear winter. In a bid to kickstart the war, Rod Liddle wrote a vicious attack on obese people, entitled: ‘Chew on this insult, lardbucket. It’s for your own good’.
Elsewhere in the paper we learn from Prince Andrew that failure is good for you. I wonder if he’s fully understood what his therapist told him.
And, if that’s not gratuitous enough for you, Camilla Cavendish writes an article this week entitled: ‘Dr Useless says he’s busy. Fine, I’ll be off to the pharmacist then’.That’s a bit more serious, in that Camilla Cavendish is on the board of the Care Quality Commission, and usually wears a serious writing hat to comment on health services, such as contributing an influential report advocating standard training for health care assistants.
The gist of the article is that doctors are very hard to get to see, ‘just to get antibiotics’. It takes weeks to get an appointment. Whereas you can just walk into the pharmacy shop and see a very nice man in a labcoat who will give you whatever you want straight away.
Does this article suggest there is a significant lobby in favour of reducing the role of GPs in favour of pharmacy shops? Private companies have been rather slow to muscle in on the general practice market. Tesco and Morrisons often have pharmacies, but never seem to offer medical specialists, not even dermatologists.
But more recently, Tesco and Morrisons have been struggling even to run the grocery section properly. Instead of supermarkets taking over health care, it’s more likely that the GP will start selling fruit and vegetables.
If one takes the view that a slimmed down health service will confine itself to drug therapies and leave the chat to the private sector, supermarket pharmacies might become the first port of call for the health shopper.
Like Trad Jazz and CBT, pharmacists have no natural predator – no-one has a bad word to say for them. That view could change, if they take on a more central role in primary care. Pharmacy shops are businesses that make their money from selling tablets and potions. Are they likely to offer a free consultation with a professional person and advise you just to wait and see? Or will they sell you some tablets? Will they give you Paracetamol for 16p or Panadol for 89p? I think you know the answer.
While some commentators are predicting that pharmacy shops will take over from GPs, I say: why not cut out the middleman altogether? And that is where Poundland comes in.
Luckily, mental health is a field where the very cheapest tablets are as good as the luxury products. The NHS doesn’t want to spend money on mental health, and isn’t going to. Luckily, it needn’t cost you a fortune either.
Don’t tell the Royal College I said this, but a reasonably sensible person with access to google and the Poundland Pharmacy, should it ever exist, could get a months supply of an effective antidepressant or antipsychotic for 99p. You could get some free counselling from a local religious organisation or the Samaritans and have enough left over for your bus fare and a flat white. I also wonder why Poundland can’t start a Sunday newspaper that’s a bit nicer to fat people and doctors.

10. Insuring the uninsurable.

ImagePendleton’s headquarters.

Might you get depressed one day?

If you answer yes to any of the following questions, this is quite likely:

Do you tend to play a Party App on your computer rather than attending a real party? Do you support a perennially unsuccessful football team? Has everyone in your extended family been treated for depression? Do you regard your pet snake as the best friend you have ever had?  Have you been depressed every single day of your life so far?

Depression is likely to affect a sizable minority of us at some point. I’m skeptical of surveys that tend to show practically everyone in some areas (Slough?) is suffering from depression, but suffice it to say it is a major common condition on a par with blood pressure or diabetes. So, is it worth insuring yourself against getting depressed? There are several reasons why not, at least in terms of popping into Swinton or calling Direct Line.

When we consider insurance we are embarking on what is now grandly termed Risk Management. By this is meant that we need to look into the possible future and explore some hypothetical events, such as burglary or fire. Whether we might get ill or not is rather hard to predict. And also it is something we are most reluctant to think about. Some people do take out health insurance, but most of us do not.  Perhaps the main barrier is thinking that it will never happen to us.

And people are right to be skeptical about the insurance industry. Everyday someone texts me to urge me to claim back mis-sold PPI. Please can we go back to Nigerian banking scams? I have never seen a specific Mental Health Insurance Policy, though some aspects of mental health may be included within a wider health policy. Why?

First – insurers tend to specialize in more concrete types of illness like cancer or heart disease. They like to know you have not had previous episodes of the same illness. They like to be able to say categorically whether the illness has happened or not, whereas a diagnosis of depression often falls within a grey area.

Second – depression is so common that the premiums would likely be very high and riddled with snags and get out clauses.

And third – it’s not as though you can really buy a guaranteed effective treatment with your payout. The treatment of depression is as much a lottery as selecting an appropriate insurance policy.

A policy might pay out to protect your income if you cannot work due to depression. But this can lead to a horrible situation where a person is locked in an insurance- perpetuated sick role, much like the benefits trap, where it makes sense financially to continue to act like a depressed person.

But there are other ways of insuring against depression, without troubling the man from the Pru, or his modern day equivalent, lurking in the dark recesses of a Sunderland call centre. (Just redressing the north south balance, having mentioned Slough earlier on.)

Be Prepared, as Baden Powell advised. I am sure he meant this in a specific and practical way, such as keeping a spare credit card in your sock. Preparing for very unlikely events, such as a Harlem Shake breaking out in the library, or the invention of punk rock, is beyond the scope of ordinary scouting.

Can we prepare for Depression? I am referring to getting the roof of the house in order before the rain comes, as David Cameron would probably put it.

When depression hits, the mental functioning is decreased in certain key areas such as reduced concentration and energy levels. That means, if you are stretched to function properly even when you are well, then when you get depressed you may go under. That will lead to a vicious circle of more stress caused by failing to keep up, leading to worsening depression. Finally comes a crunch point where things officially go to Hell and High Wycombe.

That means if you are well at present you should be operating with spare capacity. What does that mean? I’m not your mum, but ideally:

You should keep at least a million pounds in your current account.

OK, that’s stupid, but: You should have a system for organizing and dealing with any paperwork including financial stuff. You should know where everything important is, like your birth certificate and passport. In particular some way of keeping the electronic passwords you need for online banking etc. You will never remember them if you get depressed, and you won’t even remember where you put the bit of paper you wrote them on. Then you will worry that you have lost the bit of paper or worse, someone has got the bit of paper and has taken your money. Morbid thoughts about poverty and ruin are common in Depression, and  suspicious ideas about others can occur.

So, strategy one is the tin box. Ideally take the biscuits out first and eat them.

Strategy two is more complicated, and involves working out your attitude to certain key issues. What is my policy on taking medication? What is my threshold for making an appointment with the doctor?

Strategy three is making sure none of the library books and dvds are overdue. Think how those fines could mount up.

It is clear that Risk Management is something of a myth when it comes to individuals. Actuaries – experts in statistics – work with very large sample sizes, for instance in predicting how long people will live. That makes it possible to run pension schemes and predict how much money will be paid out in future years.

When the sample size gets smaller, the effects of chance become much more significant. We have a similar problem when it comes to predicting the behavior of individuals. In particular we have been carried away with the idea that we can predict violence and self harm. We could probably predict a homicide rate for the whole population, but for smaller samples or individuals we might just as  well throw dice or read the tealeaves.

In fact a rather cynical movement has broken out within mental health work, which goes as follows: We are scientists of a kind, and we know that it is impossible to predict violence or suicide in individuals with an accuracy that could affect our practice.

Recognizing however that we work in a political context, we know that the standard on which we are judged will not be: Did a Homicide / Suicide occur? but rather: Was everything done, that should reasonably have been done, as judged by the man on the 7.15, to have prevented the tragic event?

Luckily, medical services tend not to give written guarantees, acknowledging that we are hardly in control of all the variables that predict how illnesses will affect people. Even Dixons, perhaps especially Dixons, do not guarantee that things will not go wrong. They only guarantee to fix or replace the  eg Beko if it eg explodes.

Patients cannot therefore expect infallibility, but only ‘reasonable care’.

Aware of the political context, clinicians have created an ingenious analogue of what looks like reasonable care, just in case something goes wrong. Take for instance the so called HCR20 scale, which purports to predict risk of violence.

It has a series of numerical scores, which must not be added up to make a sum total. The main function of the scale is that it shows you have considered the proposed risk factors and given some thought as to what might happen in a range of future scenarios.

Calling it ‘arse – covering’, as I heard an angry service user describe it this week, is inaccurate, as such a process is just as likely to create unexpected new buttocks.

Very few health managers and even fewer politicians are experts in statistics. It would be nice to see more actuaries in parliament. I can’t help thinking that actuaries need better PR compared with lawyers, such as a hit TV show. There was never a show called ‘Sun Life: Miami’, for instance. Or even ‘Canada Life: Canada’.

Based quite a bit on ‘Minority Report’ a theme could be a panel of (maverick) actuaries who have learned to predict actual events – sudden deaths – in individuals, rather than just rates in large populations.

Using the dark arts of prediction – going against the fuddy-duddy regime at the Institute Of Actuaries – they would race round to the person’s house just in time to stop the victim poking metal forks in the toaster, or mistaking the Paraquat for Green Chartreuse.

The hero would be called Pendleton I think, and he would drive a lightweight trail bike or use parkour to beat the inevitable traffic jams.

In the first episode Pendleton would skim a CD copy of Microsoft Excel disdainfully into the river.

Each episode would end with a party at Pendleton’s cool loft apartment, and include a minor accident he had foolishly failed to predict, such as a champagne cork hitting someone on the forehead, or someone breaking a tooth on an olive.  ‘I never saw that one coming’, Pendleton would chuckle.

Health managers and Inquiry panels would announce, ‘what we need here is a Pendleton’.

Preparation is not the same thing as insurance.

Both depend on subjective assessment of risks and putting documents in a tin box, but for insurance you need to haggle with another person and give them money.

Its quite likely that subjective risk assessment is impossible beyond simple and likely events in the very near future. Beyond that we might as well use random number tables or a horoscope (which are the same thing).

By the way, there’s a free copy of Excel floating in the river.  And is that a trail bike I can hear in the distance?

8. The age of Sprocket Man.


Is the modern world inherently toxic to our bodily systems? Niall Ferguson included Work Ethic as a killer app for society. It is certainly a killer, but in a more literal sense.

The body uses countless timing devices to regulate itself. Obvious examples are the night and day cycle, the heartbeat and brain waves.

Systems theory teaches us that everything has a point of equilibrium or natural balance. Most things have a natural frequency at which they like to vibrate. Some cars like to cruise at 50 mph, some like to cruise at 90 mph. Generally, the more German the car, the faster it likes to go.

Many systems have a feedback mechanism of some kind that puts them back to their default setting. On the road system, large potholes have been left like landmines to deter overenthusiastic driving.  Inspired by the ‘safety car’ concept in Formula 1, our government has paid an army of older gentlemen to drive at a constant 42mph all over the country, to keep speeds down. As a uniform, they wear trilby hats. These are only worn when actually driving at 42 and never outside the car.

Farmers have received grants from the EU to bring their otherwise redundant farm machinery out onto the major highways at peak times, similarly to check undue haste.

In our neighbourhood we have learned to beware a vehicle we call ‘the Stealth Renault’. Painted black, this innocuous 1980s model is driven by an extremely old person (or a person disguised that way), in second gear at a constant 30 mph. His trick is to give you the impression that he will stop or is stopping at your pedestrian crossing.

He never stops though. Like Sandra Bullock in Speed, he maybe believes a bomb will go off if he drops to 29.

He is a road safety bogey man. He never ratified the green cross code. He is there to teach children never completely to trust traffic lights. He may in fact be a dummy, the car actually being driven by remote control from a university psychology lab, as part of a learned helplessness experiment. Or maybe by the authorities, to keep us a little on our toes.

After all, we may be getting a bit complacent. Such close encounters with terrorists like Stealth Renault are relatively rare nowadays. It is surprising how routine most activities have become. The post office queue stands patiently, First Capital Connect arrives on time, the Sky box records your favourite programs. I appreciate that other societies and parts of the world are different, but the UK, with the possible exception of Doncaster, has adopted a ‘no drama’ policy.

Isaac Newton taught us that every action is met by an equal and opposite reaction. Every time I turn the heating control down another person will come and turn it up to a point slightly higher than it started originally. The body has a similar system in the hypothalamus, which can be used if thermal underwear is not available.

In larger systems, such as the NHS, an attempt to make a change will be resisted with significant force. Employees in large organisations tend to work like small cogs in a gearing system. If the small cog gets out of line the whole gearing system will crush it back into place, a few splines missing, but still turning.

A lot of ‘choice architecture’ is set up this way, large systems with high moment of inertia. Franchised models and low variance operating schedules ensure you will find the same shops and restaurants in every town.

Why not put the Hugo Chavez T shirt away and just coast along with things? People are living longer after all, and the television screens are getting bigger, sharper and cheaper all the time.

Why is it then that so many people seem to be unhappy? A recent survey by Unicef suggested that children in the UK are among the unhappiest people anywhere.

‘Pressured and commercially vulnerable, our kids are the most miserable in the industrialised world’ spoke the Guardian. People have blamed a mixture of possible causes, from inequality to the demise of the nuclear family.

Blur titled an album ‘Modern Life is Rubbish’ and I find myself quoting that to people whenever there is a spectacular system failure, such as getting stuck in a 20 mile traffic queue, or trying to pay for parking using a mobile phone.

Another line I find myself saying is ‘everything is relative’. There are many compensations in modern life.
It is the best time ever for ease of communication. Even Captain Kirk did not have a smartphone.

Food is at once the best and the worst it has ever been, depending on whether and how you choose your ingredients. I went to the Turkish part of London yesterday and had an amazing breakfast for £5.

A car made in 2013 is undoubtedly, objectively and measurably superior to a car made in any earlier period. It is faster, stronger, safer and more economical than before, and it is never mustard or beige coloured.

This is probably not the best period for music composing, which peaked in the classical period. But it is the best time for listening to Beethoven or Mozart, or any other music, because we have fabulous sound quality in concert halls and from hi-fi systems.

The best novels ever were probably written in the nineteenth century. But we can read them all free now on a device that weighs half a pound.

The renaissance period gets the prizes for painting and sculpture. But they did not have antibiotics or dentistry.

Teaching was probably better 50 years ago than it is now. And, as we know, History ended in 1989.

Different systems peak at different times. It s hardly likely that all systems will peak at the same time. That’s having your cake and eating it; or finding the M25 is completely clear all the way round.

If you happen to be lucky your system suits your natural frequency, and you will run smoothly. Your system will mesh with other systems and you will spin freely on your bearings.

If you are unlucky, like most UK children apparently, you are not in tune with your system.

For instance we know that children function better if they start school at 10 or 11 am, but our local school makes them start at 8am. The problem for children is that their system runs subordinately to every other system, so that they are made to fit in with adults rather than the other way round. The more your system is subordinated to others the less chance you will be in your own element.

The advancement of the system devoted to economic productivity has marginalised children, along with the old and sick, to the bus replacement services of life.

Children cannot vote, after all. They are just lucky that they don’t have to sweep chimneys any more. Worse than chimneys though, we have breakfast club and afternoon club, not to mention the dreaded school bit in between the clubs.

David Cameron said today that he wanted to place himself on the side ‘of hard working people who want to get on in life’.

What about those people who yearn for a life of recreation and entertainment? Shouldn’t all those machines and mechanised systems have made it possible not to work so much?

A big category of mental health diagnoses is the so called Adjustment Disorders. These come in various forms, including depression and anxiety. They are usually mild and transitory and reflect what many people loosely refer to as stress.

They can be seen as a wrench caused by a change of system, much like ‘frozen points at Guildford’ delayed Reggie Perrin by 11 minutes each morning. If frozen points cause a complete derailment, then the Adjustment Disorder is upgraded to a more serious diagnosis like Depressive Episode. A lot of depressive episodes also seem to follow adverse, or even positive, life events, which have caused a crunching in the gears.

The concept of mental health problems being stress related is attractive and easy to understand. But it only tells a part of the story. Most people are robust when it comes to negotiating changes.

Perhaps they have a wider tolerance to a range of operating conditions, so they are more often in their comfort zone.

A comfort zone is supposed to be a behavioural state where we are happy and confident and working reasonably well.

Some people work on their comfort zone more actively than others. Attributed to golfer Gary Player is the phrase: ‘the harder I practice the luckier I get’. Specifically referring to shots played out of sand, Player mastered the shot to the extent that he was equally comfortable in the bunker as on the grass.

Round about the time Player made that quote, in the sixties, psychologists developed the theory of Learned Helplessness.

Psychology nowadays keeps a bit quiet about these sorts of experiments -suffice it to mention the words electric shocks and dogs.

Later on, with the move from behaviourism to ‘cognitivism’, the negative effects of helplessness turned out to be more to do with a person’s pessimistic explanatory style than the actual experience of not being in control. This led to the idea of hopelessness, and the relationship of that state to suicidal thinking.

The issue is not so much whether we really have control over what happens to us, but more whether we think we do.

Studies in Ireland have shown that patients with Depression like their therapist to take an upbeat and optimistic stance with regard to whether and how much recovery will take place.

I remember a moment when, as junior doctors, we observed the arrival of a very senior colleague, in a severely dilapidated Ford Escort. It was trendy at the time for the psychotherapy – orientated type of psychiatrist to drive ‘crap cars’, such as this one or the Austin Maxi (mustard colour). As we watched, another SHO colleague put this scenario to me:

‘Imagine you’re in the depths of despair. You have been tried on every type of antidepressant. You’ve tried counselling and psychotherapy. You’ve had herbal medicines and homeopathy and transcendental meditation. The GP finally arranges a visit from the leading specialist at the teaching hospital. You watch through the window, and you see in the distance the Professor arrive in his Escort, which has large furry dice dangling from the mirror. Is that not the moment when suicide seems inevitable?’

Harsh perhaps. Equally, people might like to see someone eminent arrive in a non pompous vehicle like a 2CV covered in stickers or an original Beetle with vase. I can’t remember any specific training on what vehicle to drive, although an older colleague insisted that consultants should only ever have Michelin tyres, ‘never Goodyear my boy’.

To return to the point, the feeling of having a choice matters a lot, even if in the wider scheme of things, the biggest choice we really get is between Diet Pepsi and Pepsi.

The comfort zone is largely a place where we choose what happens to us. A lot of people want to move us out of our comfort zone.

It’s true that we will be more productive if we are challenged just a little. Coaches know that a mixture of support and challenge can bring about superior achievement. The same approach can work well in therapy, for instance treating a phobia. If the comfort zone has got too narrow then it needs to be carefully increased.

Unfortunately, in most organisations, the challenge is greater than the support. The pressure is always on to squeeze a little more out of the system. Supermarkets want to get the milk off the farmer for a few pennies less. The farmer turns the cows up to 11, giving them more food, or playing them some Led Zeppelin at milking time.

The effect of the larger and more dominant system on your system is felt as disharmony, or being slightly behind the beat, or as a little ping in the ears. Your system might be different.

Interestingly, this is exactly the kind of disorientated feeling that makes us purchase something – retail therapy – or consume some alcohol – drug therapy. The work ethic is all about ‘must’ ‘should’ and ‘ought to’.

It all depends whether we want to make superior achievements or just be happy with what we have. It’s not a choice we seem to get very often. Even the illusion of choice is worth a lot though. Turkish breakfast. Mozart. Thomas Hardy. And, today I think, Diet Pepsi.

The comfort zone is equivalent to driving at 50mph.

It’s better than 42. It might even be better than 52.


PS: It looks a bit like this one.

5. Knowing what to call things


An early classification system for depression, using cake.

Doctors and psychologists have invented a huge vocabulary of jargon. The downside of this enterprise is that non- experts are artificially excluded from participating. The upside is that at least we have a name for practically everything that might happen.

For instance – what do we call that thing – you know, in catatonic patients, where you pull their finger gently and you tell them to resist your pulling, but they follow your pull anyway without resistance, is there a word for that? How about mitgehen?

What about that thing where people mix up a coincidental event with a causal event? How about attribution error?

What’s that part of the wrist called at the base of the thumb? How about the anatomical snuff box?

How can we describe a loose pattern of findings that might include aspects of subjective history, observed behaviours and objective measurements, without necessarily implying a causal agent? How about a syndrome?

Depression has been described and categorised in so many different ways. We had reactive, endogenous, melancholia, major, minor, neurotic  and many more types. We have dysthymia and neurasthenia, we have bipolar 1 and 2. As stated by medical man, comedian and philosopher, Harry Hill, and an excellent catch phrase and running gag: ‘you’ve got to have a system’.

We are often accused of inventing diseases, for instance ‘medicalising’ ordinary human problems such as poor attention. More accurately though, we try and classify problems rather than invent them.

Classification is hugely important to doctors, partly because we have a geeky fondness for lists and tables, but mainly because all of medicine operates through a process of Pattern Recognition.

What we call each pattern doesn’t fundamentally matter, but it may matter a lot for social or political reasons. For instance if we diagnose ADHD or Asperger’s Syndrome, rather than identify a certain kind of character, that might mean extra funding and help at school for someone. Diagnosis could make the difference as to whether someone who offended got sent to jail or hospital.

These issues largely flow from the way society is organised and what part the medical community has come to play within the processes of maintaining social order, rather than whether the Pattern is a genuine entity.

There are lots of ways of describing Patterns of behaviour. If there is a recognisable Pattern then there are a few things we need to say about it. Take a simple example, no, lets take a really complicated example – Anorexia Nervosa.

Psychiatrists have defined this illness so that there are three necessary components -the person should have lost a lot of weight, stopped having menstrual periods (if they had them before), and have a certain set of views about their body size. Both the first two aspects are easy to measure, the third one not too difficult to find out if the person will speak to you.

Anorexia seems to be both a valid and reliable diagnosis. By valid, we mean there is a real problem that we can identify and measure, by reliable we mean that people would agree on whether someone suffered from Anorexia Nervosa.

But is there truly an illness called Anorexia Nervosa? Only perhaps in as far as that is what we agree to call a certain type of problem. Diagnoses in Psychiatry, for the most part, are conventions between us regarding what Patterns should be called.  Are there people we meet who seem to fit the criteria for Anorexia Nervosa? Yes.

Our health system, be it the NHS or private sector, will demand that we make a diagnosis. We have to use a system such as the International Classification of Disease or the Diagnostic and Statistical Manual. In the UK we tend to use the ICD10. That will give you a number code, such as F10, if you drink too much alcohol. The codes can be quite detailed if we use more digits, e.g. F10.4 if we drink too much alcohol, stop drinking for a day or two and get delirious. If we had an epileptic seizure during this we will get F10.41.

Are there people we meet who get Delirium Tremens some of whom have a seizure? Yes.

But why bother to label certain types of life problem and include them in a list of supposed Psychiatric conditions?’ I am not a number, I am a human being’, yelled Patrick McGoohan in The Prisoner. ‘Pigeon holing everyone’ – that is something Psychiatrists are accused of all the time, along with another favourite: ‘pumping people full of drugs’.

Ironically the interest in tightening up diagnosis in Psychiatry came as a result of a fascinating series of studies, the international pilot study of schizophrenia, or IPSS. The IPSS looked at the use of the term Schizophrenia in different countries including USA, USSR, UK, India and Nigeria.  This study seemed to find that a larger number of people were receiving the diagnosis of schizophrenia in certain countries (USA and USSR).  The American and Russian psychiatrists were calling a larger proportion of their patients schizophrenic.

At that time popular belief in the West was that the Soviets were falsely calling political dissidents mentally ill and locking them up in asylums. Whereas in the USA the disparity was put down to the way Psychiatrists traditionally understood the concept of schizophrenia.

It was soon recognized that it would be pretty difficult to do research into the causes or treatment of any disease if we could not even agree who suffered from it in the first place. Hence a huge amount of work sorting out a valid and reliable diagnostic system – DSM in the USA and ICD for the rest of world. The current versions – ICD10 and DSM4 are very similar in day to day use. So we can be reasonably sure that someone with Anorexia Nervosa in Milan has got a similar type of  problem to someone with Anorexia Nervosa in Birkenhead. So if we find Cause X or Therapy Y in one place, it might prove useful in any other place. Such is globalization.

Much  of the criticism of diagnosis in Psychiatry is based on what happens to people, and society, as a result of diagnosis happening. But criticizing diagnosis itself is as foolish as suggesting that it is impossible to classify colours of the rainbow or garden flowers.

The point is, sound diagnosis can be liberating as well as restrictive, it all depends on what we do with it. The danger is in poor quality diagnosis, or the misuse of diagnosis. These are the same dangers that occur with any tool, cordless curling tongs in particular.

How does this affect the depressed person in their kitchen?

Your subjective experience needs putting into words if you have to tell another person how you are feeling. You are free to create your own diagnostic scheme for Depression, but to be useful it needs to chime with someone else’s scheme.

In the case of Depression, even experts who normally know exactly what to call things, have failed to create much of a system. The ICD10 for instance gives up on classification much beyond the level of severity:  Mild/Moderate/Severe. Its unlikely that mass protest and civil disorder will break out in response to this categorisation.

There is only one thing worse than labelling people, as Oscar Wilde definitely didn’t say, and that’s not labelling people.

And there’s only one thing worse than pumping people full of drugs… (an inquiry was told).

1. The War on Depression Starts Today

Car parks can be beautiful if you look at them the right way

 Don’t be frightened – it’s only a car park.


The War on Depression: where is the enemy weak?

These pages are mainly about Depression. The starting point is to understand how Depression comes about and the finishing point is dealing with it better.

As an individual psychiatrist it may not be possible to make much of an impact on the wider problem of Depression, which affects so many millions of people.

But there are many fronts to fight on, outside the hospital.

There are a few themes to these pieces. One is to do with how toxic modern life has become. One is to do with how the mind works and in particular how people make choices. And a third one is to explain how health systems such as the NHS operate for (or sometimes against) people with mental health problems.

However we regard Depression, as an illness, as wear and tear, as a reaction to loss or as a social barometer, there is always another perspective to take.

Rather than ask the question, ‘why do some people get depressed?’ we might just as well ask why everyone isn’t depressed all the time.

Lets get the bad news out of the way right now: people get older. Generally when they get older they get more ill, and (don’t say it, please) eventually die.

In some ways that fact, the D word, is a potential party – pooper, even when we are young and have a fabulous future to look forward to.

Worse than that, even younger people can get ill, and they certainly can be subjected to terrible events (such as school).

Its been said that all political careers end in failure. Partly that’s because of the scoring system in politics, which tends to be ‘sudden death’, either by way of an election, or by way of sudden death.

But the same is not true of most sportsmen and women, who are somehow able to retire at the right time. In boxing, that’s while the brain is still working. For the rest of us, its a matter of recognising changes and adjusting to them .

If we adjust too much too quickly we are hypochondriacs and wimps. If we adjust too late we are foolhardy and in denial.

Life is very complicated and dangerous and a lot of us don’t make it, either in terms of quality or quantity of life. Some of us spend a lot of time ‘off the road,’ on the hard shoulder of life, but that doesn’t make us burned out ruins.

In seeing Depression as a wear and tear or stress related illness, we are not really explaining it very much. I prefer to see it as a natural phenomenon that is also an enemy, like rust. Or, at times, Gravity. Black ice. Wind. Electricity. Biscuits. Etc

All necessary but dangerous when out of control.

Depression happens when the system that controls mood is defective. The system has failed to calibrate correctly, or feed back on itself, or stay at a level. Most of what we do in treating Depression, one way or another, is to try and get the control system working better.

Often that’s a matter of seeing the situation differently: reflecting, reframing, resetting, recalibrating. (4 Rs. Much better than 3.)

The way we see Depression, in its widest contexts, affects very much how we deal with it. Depression is a very isolating experience, both in terms of reduced social contact, and reduced range and quality of thinking.

But if Depression was inevitable, or even an overwhelming likelihood, why is it that many people never get depressed, whatever happens? Do they have a very sophisticated chemical control mechanism? Or do they reflect upon the world in a different way? Or do they have some protective factor, like a guardian angel?

After this length of time, over 50 years of antidepressant and drug therapy, it doesn’t look as though we have a breakthrough solution, at least by way of a tablet. It would be nice to think a magic bullet would get discovered, much as saltwater killed the Triffids in one of the Day of the Triffids films, or the Common Cold killed the Martians in War of the Worlds.

While we wait to find the enemy’s weak spot, we continue to fight on all fronts. Depression’s Achilles Heal is in fact the thing that makes it strong, its incoherence as a diagnostic concept.

Could Depression fall apart under the weight of its own complexity, like the coalition government?

More to follow.