43. Deciding whether to decide, or not.

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Some KFCs are quite opulent on the inside.

I’m hoping to acquire one of those official looking G4S-style jackets that parking inspectors wear, along with a peaked cap and mirror shades. The reason is, I live next to a school, and every morning the parking situation gets worse. The invention of the SUV has blurred the harsh boundaries of road, pavements and yellow lines and turned them into a mere probability distribution. There’s an Audi Q7 that behaves like a two tonne hippo, just setting itself down wherever it pleases. If I just stood outside, in my Parking jacket, maybe the madness would stop. Until I got arrested, anyway.

Parking properly is one of those skills, like cooking Yorkshire Pudding or wiring a plug, that 57% of people can’t do. Recently two surveys showed that modern school-leavers are no more literate than their grandparents were at the same age, and that they would lose a 100 metres race to their grandad. And that’s as he is now, aged 95, with advanced emphysema.

Surprisingly then, Britain, the country at the bottom of the skills league table, where only recent immigrants actually know how to do anything, introduced the Mental Capacity Act.

Luckily, like the parking outside the school, it is not enforced.

So called ‘mental capacity’ means that a person is able to make a decision. It depends to a large extent on how complicated the decision is as to whether the capacity is present or not. For instance a person could have mental capacity to choose breakfast, but not have capacity to make a will. In between these, somewhere, is capacity to have sex or get married, or both. If a person does not have capacity, they should first of all be suffering from a deficit of ‘mind or brain’. Then they must fail one or more of the following steps of decision making: Understanding the information, Retaining the information, Weighing the information up, and Communicating the decision.

Immediately obvious is the amount of greyness in the ‘weighing up’ part.

While the Mental Capacity Act makes it clear that making an unwise decision need not mean that the weighing up process is defective, it certainly leaves scope for an argument over the point where an unwise decision becomes irrational, and the point where irrational means lacking capacity.

Perhaps the intention of the mental capacity act was to give the illusion of clarity, while still leaving a huge judgement call to doctors or other professionals. The irony is that no professional person really understands the mental capacity act and certainly doesn’t retain it in his mind or communicate it well. The mental capacity act code of practice was written on the planet Zarg, in Zarg language, which is similar to Welsh.

So, only case law will reveal the dividing lines between unwise and irrational.  A series of judgements will set the goalposts for issues like leaving all your money to the scientologists, marrying your attractive but 70 years younger carer, buying a Porsche 911 to celebrate your 100th birthday etc.

For instance, last year, a judge ruled that an autistic woman with an IQ of 64 did not have mental capacity to have sex,

‘on the grounds she does not fully understand she could say no to such actions’.

Mr Justice Hedley said the 29-year-old lacked the mental capacity to consent to having sex, and made the order to protect her best interests.

He said she had to be protected from ‘potentially exploitative and damaging’ relations in the future, as she had already been involved in risky behaviour with people.

http://www.dailymail.co.uk/news/article-2096472/Judge-bans-vulnerable-woman-having-sex-lacks-mental-capacity-consent.html#ixzz28nA227ia

Would scientists or doctors have come to the same decision as the judge? I suspect that scientists would tolerate fuzziness better than lawyers, simply accepting that the person had some mental capacity but not as much as most other people. But the legal system is black and white, not grey.

Whether a person can choose to have sex or not soon becomes a question about how the mind and body work together. And this in turn leads to an examination of how the Automatic part of the Mind interacts with the Reflective Part. It would be nice to think that sexual behaviour falls to the Reflective Mind, but its association with the older parts of the brain and the older types of intoxicant means that it probably doesn’t. Whatever the IQ.

So rather than being a Parking Officer, perhaps I could be a Mental Capacity Inspector. Outside the school, armed with my new jacket, the Mental Capacity Act Code and the Oxford Dictionary of Zarg, it’s time to Stand up for Sensible.

Firstly, do these errantly parking motorists suffer from a disorder of mind or brain? Most of them look absent minded and some are clearly in a trance like state. Some seem distressed, shouting at their children. At least two are using nicotine. One appears to be wearing a dressing gown and slippers. In fact, none of them seems entirely well.

Then, have they really decided where they want to park? Do they know what yellow lines mean? Can they weigh up the ethical trade off between blocking the traffic and parking on the pavement? Would they know that squashing cyclists can hurt them?

Enforcing Parking Capacity is just the start. Irrational behaviour is going on all over town, much of it in the context of mind / brain dysfunction, such as Special Brew Disorder.

Firstly, the National Lottery till at the newsagent. Anyone who doesn’t understand Probability – a GCSE in Pure Maths with Statistics will suffice – should be politely turned away in their own best interests.

Then Ladbrokes. Look at these other customers – do they look like rich people?

The tattoo shop – this sounds silly, but do you know that won’t wash off? And KFC. It’s chicken Jim, but not as we know it.

The mental capacity act can only do so much, since it respects unwise decisions, or any decision made by someone of sound mind. That’s why we still need the Style Police and the Fashion Police. It’s vital these functions don’t go to G4S, even if they have the jackets already.

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17. Giving feedback without using the hairdryer.

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The characters seemed a little two dimensional and transparent in places.

For a long while, every time I filled the kettle with cold water first thing in the morning I thought I heard someone upstairs scream. I wondered at the time whether this might be an interesting kind of hallucination.

A ‘functional hallucination’ is a false perception that occurs at exactly the same time as a real perception, such as the sound of running water. I had assumed till then it only occurred in old German text books and multiple choice exam questions.

It turned out there was a more mundane explanation. The reduction in water pressure caused by turning on the kitchen tap caused the person having a shower elsewhere in the house to experience a sudden water temperature change, first quickly upwards followed by quickly down. The culprit was and still is a poorly operating thermostatic mechanism in the shower unit.

Although the shower over-reacted in terms of temperature control, I am careful to state that the showering person reacted completely appropriately.

The thermostat is our basic model of a feedback system. It senses the temperature of the water. If the temperature goes too hot or too cold, it responds by cutting or increasing the power to the heating element.

The same sort of negative feedback system occurs in most devices, throughout our bodies, and more generally through social systems.

It requires two prongs – a sensing device, and a device that effects a change.

When we come to try and understand the word ‘dysfunctional,’ that seems to describe certain behaviours or relationships – sometimes even applied to an individual – most often we are looking at a faulty feedback mechanism.

In British culture we have a great deal of trouble knowing how to react to things. For instance, it seems the height of bad manners to criticise someone directly. That would be like sounding a car horn. Instead, we tend to use a low key grumbling approach via third parties – like trip advisor, or writing a rude letter and not sending it.

There are a few exceptions, such as talent shows, and the army. If you want a more challenging annual appraisal, perhaps Alex Ferguson would oblige, using his famous ‘hairdryer method’.

But in general it is very difficult to get honest feedback.

If you write a reference for someone who is absolutely terrible at their job, the custom is to write a glowing reference with the tiniest hint of faint praise, e.g. ‘may lack ultimate commitment’.

One guide to how to behave in a crisis is watching drama. Millions watch soaps like Eastenders on a regular basis. How far do people model their social behaviour on such programs?

Whereas stage actors tend to exaggerate voice and gesture, movie actors have to play it deadpan. TV is somewhere in between, perhaps to do with the size of the actors face relative to real life. If shows get made specially to be viewed on a smartphone, they will probably star Brian Blessed.

Like actors in Greek tragedy, people with Depression tend to ‘catastrophise’ in reaction to events. Odysseus’s mother apparently committed suicide after hearing flimsy evidence that he had died.

In drama, Greek or Soap, no-one ever responds to a crisis by calling a helpline.

British people are more likely to under-react to a crisis. David Beckham found out one of his tattoos had misspelt the word Victoria, written in Sandskrit, as Vichtoria. History records that he was not unduly concerned, merely resolving to stick to Latin for further etchings.

A gentleman with OCD I used to know told me this story. One day he had taken his long suffering ‘good lady’ to the seaside, leaving early to avoid the traffic. Having driven 120 miles to the coast, he was confronted by a completely empty car park with hundreds of spaces. He drove around several times, unable to choose a space and eventually had a panic attack. After recovering, and still not in a parking space, he drove home again.

‘I’ve been a bit silly again’, he finally told me.

I should perhaps have anticipated this kind of eventuality and suggested a simple algorithm for parking. Recently I discovered that elevator systems in large buildings have just such a system for deciding which lifts should go to each floor.

Apparently, according to Mitsubishi Electric, a person becomes irritated immediately he presses the lift button and nothing happens. However, the level of irritation is proportional to the square of the waiting time. From this we can begin to understand how people can develop rage attacks surprisingly quickly.

Remember Christian Bale’s outburst on the set of Terminator? Apparently a technician walked across his sightline during a scene.

I know the feeling, from trying to talk to acutely psychotic patients in the same hospital room where builders are operating pneumatic drills and ripping up the lino with Stanley knives.

There are a number of ways to explain why certain people seem to ‘lose it’, experiencing an acute change in mood and behaviour.

Steve Peters would call it ‘letting the chimp out’, meaning a switch in mind-set, allowing a different set of brain pathways to take over control. Thankfully, Mitsubishi have not included a Chimp Mode in their elevator systems. Though Beko appear to have included a ‘Surrealist Mode’ in their washing machines.

A more neuroscience-based model still, is the possibility of positive feedback, or kindling, where the response actually goes the opposite way from restoring the norm. This is often called a vicious circle.

One theory of panic attacks uses a vicious circle model, where mild signals of distress from around the body are over-read, cause anxiety and thus further physical distress signalling, such as breathlessness, palpitations or chest pain. Finishing with a slightly embarrassing visit to the coronary care unit.

A behaviourist could explain ‘losing it’ in terms of social learning. Previous tantrums or losses of control have been rewarded by parents or others, either in terms of letting the upset person have his way, or by way of reducing ‘messing’ with that person. Having a ‘short fuse’ can be quite useful in certain situations. I once worked for a consultant who was completely benign 99% of the time, but the word about him was, ‘watch out, he goes berserk every now and again’.

One of the triggers seemed to be handing him a post it note with a poorly worded or scribbled message and a phone number. It was not that he had been hypnotised previously and made to react this way, although this is possible, knowing the hospital involved.

It was just that being handed a post it note is a metaphor for being handed a problem, but without the information needed to act on it properly.

I’d like to think that his reputation would have worked to reduce the number of post it notes he got handed, but I never saw any sign of this. Post it notes continued to flow like confetti. Perhaps he should have set fire to them immediately or eaten them.

In the NHS, feedback loops operate comparatively slowly, so it would have taken about 20 years to see the post it notes’ eventual downturn.

Remember the film, ‘Falling Down’? Here, the character, D Fens, is played by Michael Douglas, who is a screen actor and therefore tends to play deadpan. D Fens progressively loses it after a ‘rare morning’, ending up in a spree of violence across LA. The trigger event appears to be a shopkeeper refusing to give change.

An older theory of ‘losing it’ relied on the notion of a repressed or over-controlled person, which I think is what the director had in mind. D Fens had seemingly suppressed his anger by being extremely tidy and organised, never allowing himself to become emotional, and therefore never setting appropriate limits on people.

Here I suppose the systems analogy is the pressure cooker. This has a very primitive feedback loop, so that a massive degree of change from steady state is needed before the feedback occurs, in the form of opening a safety valve.

Here the feedback loop is too coarse to make rapid enough corrections, necessitating an external over-correction, such as being gunned down, albeit reluctantly, by Robert Duvall.

CBT is designed to improve a person’s feedback system: on the cognitive side to make sure the right information is collected; and on the behavioural side to make the appropriate responses.

Luckily the government has given us a new way to make sure we react appropriately.

We’ve been used to making a 999 call, for moments where we identified a very serious crisis. However, the 999 system is abused on a daily basis. One of the problems is that TV never shows anyone calling a helpline appropriately, so we don’t know what constitutes a 999 level emergency.

People have rung 999, for instance, to ask ‘how to dial 111’; because they were not being served in Macdonald’s; to try and obtain a laptop password, and to report the theft of parts of a snowman.

Now, to create a kind of crisis scale, at the milder end, we also have the 111 call.

That gives us the potential, provided British Telecom goes along with this, to fill up the numbers in between, 222, 333, etc, with a sliding scale of catastrophisation.

Let’s put in some examples to test the system.

You are Henry VIII, the most powerful king England ever had.

You have some marital issues, and in particular no male heir to the throne.

I’m thinking 333 would be about right.

Instead of which Henry over-reacts massively, dissolving the monasteries and the catholic church, divorcing his wife and executing some of his best pals.

There is no indication that the younger Henry was overly ‘buttoned up’, casting some doubt on the over-control theory. Although if he really had cerebral syphilis, that might have damaged some of his feedback loops.

Or try this one: Confronted with a pompous email from NHS management you write a reply you misguidedly think is witty, accidentally pressing the Reply to All button, so that every person in the whole NHS gets a copy.

555, agreed?

You eat a yogurt from your fridge mistaking the sell by date 2003 for 2013?

Not even 111, I don’t think. Yogurt never kills.

We are going to need an advisory panel of some kind as arbiters of how to interpret and assign a crisis to a number scale. This would be an efficient resource, especially if we can charge a premium rate for the crisis line. I hope the NHS is working on this.

Failing that I think Mitsubishi could run something up. For indecisive parking, press 111. For misspelt tattoos, press 222. For incorrect change, press 333…

What if the elevator seems awfully slow today? Press 444. Pressing using the fingers is sufficient. It is not necessary to use the axe.