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.


25. Taking a creative powder.


The golden age of pharmacology.

There is probably a link between bipolar disorder and heightened creativity, but this occurs mainly during the periods of elated mood. One of the first things to go when the mood dips is concentration. For creative types that’s a major hazard.

There’s only one solution for writer’s block. And that’s to write about it.

I just checked with the local NHS and apparently there is no rapid response team for this problem, unlike, say, blocked drains or blocked arteries.

The mental health service is interested in ‘thought block’, but only in the context of schizophrenia.

What I’m envisaging is a group of experts, probably led by a retired army major, who would arrive in a pimped day van, set up their equipment and get to work straight away.

The first thing to do is to remove any loaded weapons and / or bottles of whisky from the writer’s desk.

Next comes a thorough examination of the writer’s body, particularly the orifices, just to check he has not begun ‘disappearing up himself’. If there are signs of this, a Dyson cleaner makes an ideal suction device.

That also includes checking his ego boundaries, to ensure he is still able to separate himself from his characters. Clues to this can include wearing a flying helmet or shoulder holster while he types.

Psychedelic drugs should be removed, keeping samples for the lab, except for science fiction or fantasy writers, when they should be cautiously continued and titrated with Bourbon if necessary.

There are no NICE guidelines for writer’s block, though the author is probably poised over his keyboard and has been for years. But there is some expert guidance on the subject.

Dan Brown for instance likes to hang upside down in gravity boots. This could explain some of his thinking, in terms of reduced cerebral blood flow. Lots of writers prefer to be horizontal when they write, and many others like to pace up and down. Some are quite obsessive about stationary and pens. Others like to chew their pencils. It’s important to ensure they put the right end in their mouths.

Having attended to posture, the team looks toward some kind of psychological jolt. Firing a gun is often helpful, and if there is space, the team like to set up a row of porcelain figurines to use as targets. Royal Doulton seems to work best.

Coercion, blackmail and torture don’t seem to work. This is probably because anxiety levels have gone just beyond the optimum level for concentration. Writer’s block is mainly a result of ‘performance anxiety’. It is when the automatic mind makes the mistake of calling in the reflective mind for advice. Whether it’s writing, sex, walking a tightrope or putting, self monitoring can be catastrophic. The interventions are mainly to create a distraction.

For instance, waving a wad of cash under the nose brings about a rapid reaction similar to smelling salts. Not only does money talk, it speaks most eloquently.

Claims are made for psycho-stimulants and antidepressants which some people think enhance performance. Thomas Hardy might have benefitted from a little light turbo-charging, for instance. I’d like to have seen more of an action thriller conclusion to Mayor of Casterbridge, possibly involving Farfrae and Henchard shooting at each other with blunderbusses, from hot air balloons.

More useful is a gentle workout for the parts of the brain that write. A trip to a gritty location such as a Ladbroke’s in Rotherham might bring just the change of emotional tone that’s needed, but obviously the danger is melancholic overload.

Sometimes a little ‘power pottering’ is necessary, such as re-organising the tea bags or melting a vinyl record to make a flower pot. An encounter with an overloaded kitchen sink has helped many angry young men keep it real.

The most difficult thing is finding an ending, if that’s where the block has happened. If all else fails, a revision test can serve as a makeshift conclusion, e.g

Which blockage is not a medical emergency?






Which endings are valid?

Reprising earlier parts of the piece

Suddenly dying of TB

A dream sequence with exploding figurines

Throwing a badge into San Francisco Bay

Reader, I married him.