72. Falling back on homes under the hammer.

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Hull Trains are quite influenced by the Terminator series.

 

On the breakfast news there is almost always a mental health item. There are two types of mental health news reports: the short one and the long one. On the short one, the presenter merely reads out two statements, one from a survey and one from the health service.

First statement: a survey conducted by a charity reveals that there are no services for the mentally ill north of Milton Keynes and that depressed people in the north are simply rounded up and dropped down coal mines.

Second statement: more people are being treated than ever before due to increased investment in acronyms like IPT and IAPT.

You wait for a moment of analysis or commentary, a denial from someone in the coal industry perhaps, or an acronym buff, but in a blink, its over to the Midi dress. Should it really end at the thickest part of the lower leg?

The longer version of the mental health report is just the short one followed by an interview with a ‘service user’. Typically, the service user seems suspiciously mentally well, despite their long period of suffering and eventual escape from the coal mine. It took years of waiting, but eventually they reached the top of the Mindfulness Therapy waiting list, after which they were cured in a jiffy and made ready for TV.

This week, we just had the short version: One in six people attempted suicide while on the waiting list for psychotherapy, which is more than a year on average. NHS England says that there are more mental health services than ever before and even now new acronyms for services are being coined at their new DOA. (gettit?)

It is such a relief when the news stops and Fred Dibnah’s World of Steam, Steel and Stone finally begins, even though every episode is the same. Then there is a program where people buy a small house at an auction, paint it magnolia and rent it out. After that two people try and decide whether to emigrate to Australia, nearly go and then don’t quite go. Following on, a lovable cockney sorts out some dodgy builders in the style of Jack Regan from The Sweeney. Daytime television can seem massively interesting, but only under certain circumstances.

Normally these programs leave the viewer underwhelmed, but that all changes if you get ill. Once you are debilitated and a little delirious, daytime television takes on a whole different dimension. The level of stimulation the human system requires, or can even tolerate, is greatly reduced in cases of biological malfunction.

The key to successful television seems to be following a formula. Even though we’ve seen it a thousand times, we still love a plot that ticks along like a Swiss clock. To a very alert person, formula means repetition and repetition means boredom. To a stressed or unwell person, formula means familiarity and familiarity means comfort. Entertainment has a long history of formulaic productions, from Punch and Judy through James Bond to Strictly Taxidermy. Every time we are presented with a repeatable pattern, the part of the mind that ticks boxes is comforted.

I once asked an older colleague how people used to treat serious mental illnesses before the invention of antipsychotics. His reply was ‘Institutionalisation’. At the time I took this to be an attempt at irony, especially as institutionalisation had come to be regarded as oppression. Now, I realise he was giving a serious answer. Reducing stimulation and imposing regularity were ways of calming people. Perhaps it is just a coincidence that large asylums closed just as daytime TV began. Or perhaps, television just happened to hit the right level of stimulation to suit chronically ill people. One person’s stultification is another persons action thriller. On the acute ward, I noticed that really ill people hardly watched TV, not even football, but could just about manage old Top Gear repeats on Dave.

Disruption of biological rhythms is almost the hallmark of Depression and the first thing that psychiatrists ask you about. Sleep pattern, diurnal mood variation, bowel habit etc. Disruption of biological rhythms is also the hallmark of twenty-first century society, now that shops and the internet are open all hours, pubs never close and you can watch Dr Who whenever you want. I’m not saying the two are causally related, any more than fridge ownership is causally related to crime statistics (other than ice pick murders).

But possibly Stress is being met with De-Stress, in the form of Repeatable Pattern Seeking Behaviour or RPSB, as it will never be called again (too similar to the RSPB, who are a very powerful lobby). Accordingly I may have to forgive people who own pets or buy lottery tickets as simply stressed people in search of fixed schedules. Perhaps they just have nothing to do – besides panic – between Street Patrol UK and Cash in the Attic.

If you just don’t ‘get’ the Fast and Furious series, now you can understand why the same bits are in every film. Humans like patterns. Much of our brain is a scanning device and every cell has a system of time clocks.

Which is why, even before they had CAT scans, Interferon or Clozapine, Regional Health Authorities had their own carpet designers. One design was blamed for people hallucinating. Another type caused terrible friction wounds to frail people. Our own hospital replaced carpets with ‘abattoir-chic’ red lino. Cue carpet jokes: Where to sweep things now?

Like TV programs, carpet that can look fine – just a bit hectic – when you are fully conscious and alert, may look like a pit of vipers to a delirious person. Wetherspoon’s know this only too well.

Last time I was really sick, I remember thinking The Weakest Link was a brilliant program. But after taking a Zantac it suddenly lost all its appeal. It goes to show, if you are sick, you need to titrate your choice of programming carefully against your drug therapy.

Like hospital carpet design, there probably needs to be special programming for sick people. Or just accept that most television is aimed at people with impairment and should be run by Occupational Therapists. It already has?  DIY SOS, Blue Peter, Celebrity Master Chef, Come dine with me, Extreme Fishing…

TV is the new OT and we even have one on the ward.

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62. Displaying the pottery fish, with pride.

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My alarm clock rings to tell me it’s behavioural activation time, also known as Nike Therapy, which means just do something and think about it later, if ever.

My eventual aim is to re-write the classic publication ‘365 things to make and do’ in an updated style to suit these post-ironic times. Also, I’d like to add a 366th project before 2016, which is the next leap year.

Today’s project is to shred a few copies of the NICE guidelines for Depression, mix them with PVA and turn them into hats.

As I shred, I realise that these guidelines do mention the term ‘behavioural activation’ but don’t explain how to do it. They say nothing about arts, crafts, music or hats. Which is surprising, given that there is a long tradition of arts and music therapy in mental health.

My hypothesis is that people need to do something with their hands to feel properly human. Manual work, crafts and organised sport have declined, leaving the hands as mere vestiges of devices that once could dig or sew or fire an arrow. Most people still prefer a mouse to a touch screen, when there is a choice. Many people still prefer a manual gearbox, even though automatics are now superior in all respects.

I have another project coming along which is more complicated. This involves taking photos of bits of stained glass windows, printing them in different sizes, using all the different, clichéd image filters in Pixelmator (such as the ‘ennui’ tool), tearing them up and sticking them onto a collage, which in itself looks like a stained glass window.

For some reason I’m having trouble (as though it was the printer’s fault rather than incompetence on my part) getting them printed at the right size, so they are coming out like postage stamps instead of A4.

If I had to give this activity an hourly rating for mood improvement, I’d have to rank it slightly below checking the lawn for cat faeces, collecting it on a special trowel and flinging it over the garden fence onto the railway line. But it might improve.

Either the picture is going to be postcard size, saving a lot of PVA, or I’m going to have to ask a teenager how to resize the images. Or perhaps find an art therapist, just to check whether this whole activity is artistic or not.

There are no art or music therapists in my local area and come to think of it, none in the hospital where I work. This demise of arts and crafts based therapies has been insidious and largely unreported. This seems like a pity, and I wonder who’s to blame.

Somewhere or other, the mental health establishment has got the idea that ‘therapy’ has to involve a bus journey across town to speak to a person in an office for about an hour once a week for about 20 weeks. True, these activities are evidence-based to an extent. It’s just that the evidence has been collected along narrow strands of enquiry, being derived mainly from a ‘clinic’ context.

No-one has bothered to see whether listening to good music or watching football or making rhubarb crumble can treat Depression effectively. And imagine the practical difficulties in conducting such studies.

Therapies where numerical ratings are intrinsic, such as computerised CBT, have the advantage in terms of generating evidence of improvement. They have largely taken over from other modalities, leaving a long queue of psychoanalysts at Jobcentre Plus.

There’s perhaps a lesson to be learned from Interpersonal Psychotherapy, (IPT). This therapy was invented by Klerman, Weissman and colleagues in the eighties. It’s a standardised approach with a proper instruction manual, which makes it amenable to testing. In particular, it was tested against drug therapy – in those days mainly tricyclic antidepressants.

Its designers were highly scientific individuals with an excellent grasp of the various different ‘models’ of Depression: biological, family, cognitive, psychoanalytic, feminist etc. They knew how to fund and conduct controlled trials and publish the evidence properly. And thus IPT is one of the two types of therapy that NICE bother to endorse.

Compare that approach with a study by Mike Crawford in 2012, purporting to show that weekly attendance at a group arts project had no benefit for patients. I quote:

‘Members of activities groups were offered activities that did not involve the use of art or craft materials’.

My italics, meaning ‘why on earth not?’ It’s not the full Blue Peter, not without the sticky-back plastic.

This is what the new version of ‘365 Things’ should try and achieve – a standardised arts and crafts therapy manual. So we can finally show that meaningful activity is good for people. Each task should be spelled out clearly, like in Marguerite Patten’s 1000 favourite recipes.

And include proper materials like policy documents, shredders, glue and paint. For a long time the surest way to upset an occupational therapist was to mention basket weaving. Now, I say it’s about time for a raffia revival. And it’s time to display the pottery fish, if you’re lucky enough to have one.

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 Detail from Queen of Heaven, by M Healey, 1933, St Brendan’s Cathedral, Loughrea

29. Growing cress heads for no particular reason.

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This morning, the council came to collect the 3 bins I leave outside on Tuesday mornings, and I think they have brought another new bin – to dump your Guilt into. So much better to have it safely disposed of rather than giving it to another person. Guilt just doesn’t compost down.

I’m hoping for more metaphorical bins in the future, now that local government has taken over public health. In hospitals we have sharps containers coloured yellow, which is a safe place to put barbed comments.

Today, just as The Times reported that health checks for the over 40s were a complete waste of money, I received a letter from my local surgery asking me to come in for a health check with the practice nurse.

Though I am a supporter of evidence-based medicine, it took me less than a minute to make myself an appointment. I am also a hypochondriac.

To be honest, evidence-based decision making can conflict with common sense. Everyone knows that a stitch in time saves nine. As far as I know, there is no equal and opposite proverb to cancel this one out. My strict adherence to the evidence based approach probably doesn’t go much deeper than the occasional casting of nasturtiums on the alternative sector.

So many decisions we have to make are based on intuition rather than double blind randomised control trials. For instance, choosing what we eat. I start with the null hypothesis as follows: nothing that you eat – within reason – makes any difference to you. There are occasional bits of conflicting evidence, but in general nothing to disprove the hypothesis, which is based on the sound principle that the human body is a chemical factory.

I have yet to see any convincing evidence for the five fruits a day policy, nor the arbitrary alcohol consumption limit of 21 or 28 units per week. Which leaves me with a bit of a dilemma over what to tell the practice nurse about my lifestyle. I don’t want to come across as a fanatic of any kind. Like an NHS Trust, or Everton FC, its safest to be half way up the league table rather than at the top or bottom. But there is no real ‘gold standard test’ for lifestyle to pass or fail, apart from a few aspects of what we consume.

Like everyone, I find it very difficult to explain the increasing numbers of people who suffer with obesity. I watched a recent documentary attributing this to the corn syrup industry, but was not entirely convinced. Maybe it is a virus or other infection we have yet to identify. The concept of ‘food addiction’ has gained some adherents, certain products turning out to be incredibly ‘more-ish’, such as chocolate, pizza and ice cream.

Since obesity has increased rapidly over the last 30 years, we could attribute it to any or all of the social trends of the last few decades, from computer ownership to the decline of progressive rock. Psychiatrists have made their own contribution, in the form of atypical antipsychotics, which have doubtless added to the lard mountain.

My own hypothesis – no, really my own intuition, is that obesity is inversely related to pottering.

Pottering has been defined as: ‘to busy oneself in a desultory though agreeable manner’. Pottering behaviour should be largely unplanned, enjoyable, unhurried and diverse. Crucially, pottering does not derive from a work ethic, but from a natural tendency to interact with one’s environment. It’s roots are probably in thousands of years of hunting and gathering.

The habit of pottering has been hard hit by lifestyle changes toward electronic media and industrialisation, and away from localism, arts, crafts, hobbies, games and sport. Home made food is fast going the way of home made clothes.

What is surprising is the lack of a response, either from mental health services or the pharmaceutical industry, to the obesity epidemic. Surprisingly, there is a lack of evidence about what treatment to offer.

As anyone knows who has been on one of those treadmills with a calorie counter, you have to run about a thousand miles to counteract the effects of one Mars Bar. So its hard to see how increased activity alone could be the answer.

CBT does embrace ‘behavioural activation’ and ‘activity scheduling’ and mental health services do employ a small number of occupational therapists. We could begin to rehabilitate a pottering based lifestyle, but we need badly to find a new word for ‘potter’. It’s just too old-bloke-in-a-shed-based. And we need new pottering clothes, instead of tracky-bottoms and cardigans.

So here’s my five point plan:

Pottering should be re-named Freestyle Active Behaviour – fabbing, for short.

Village Shows to be re-named ‘Fabathons’

Stella McCartney / Adidas to bring out a new fabbing range, using a tweed / kevlar fabric mix.

A new talent show, called Britain’s got Knitting.

A new ‘more modern’ penthalon event, consisting of: repairing a stuck window, making a cake, learning the saxophone, growing cress in old eggshells with a face drawn on them and visiting granny.

(Yours may be different).

So far, none of this is evidence based, but neither, it seems, is going to the health centre for a check-up.