Tag Archives: psychiatry

96. Watching their Rome burn.

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Sorry, I’ve not written anything for a while. The daily news has become so outlandish that the art of wry observation has been killed off. It’s like a weather report has been interrupted by an extinction event meteor strike.

People keep asking me to explain why the UK is shooting itself in the foot and I suppose the easy answer is that Britain hates itself deep down. Britain is one of the first industrial countries and is the first one to become sick of industrial endeavour. The jadedness is pervasive. No-one’s really facing it. Employment is historically at a high level, but most of what people do at work they freely accept is pointless.

If Britain turned up in outpatients we’d send it to the crisis café, where it would do breathing exercises and group drumming therapy. Britain is paranoid, but not in a psychotic way. Britain is using the primitive defence mechanism of projection to blame its problems on others, much as Gotham City eventually turned against Batman. Britain will not be given drugs and universal benefit; it will not be allocated to a care coordinator. Britain will be given a self help leaflet and ‘signposted’ to the Tuesday allotment project. Sadly there is no therapist designed to treat whole countries. Although we have Prince Harry ‘starting conversations’ and the government’s behavioural insights unit.

But will that be enough to rescue us from our angry self loathing? Or do we need a proper superhero? Or even a more universally hated enemy, now that ISIS is receding and Northern Rail have settled their strike?

Beneath paranoia lies a longing for there to be someone out there who is interested in us– preferably in a good way, like a guardian angel, or Nick Knowles from DIY SOS. If they care in a negative way, such as a stalker or the taxman, that is still better than the complete indifference of a dark, empty universe. If Brexit is a cry for help, rather than a death throe, it relies on someone taking notice.

We cannot rely on International Rescue since David Milliband took over. I seriously doubt whether David has got the time to monitor every radio network in the whole world 24/7 like the Tracey brothers used to do. The closest we can come to Thunderbirds is the Air Ambulance, which is why we love it so much and keep putting coins in the collecting tin.

Maybe the giant corporations will look after us. I know that Google Rewards checks up on me regularly, knowing which shops I have been into or near. Unlike my guardian angel or Nick Knowles, Google Rewards reveals itself to me regularly with short survey messages. At the moment it wants to know whether I have spent any money in the shops and in particular what means of payment I used. Quite often it asks me how I feel about Argos. I don’t think Google would come to my rescue in an emergency, but importantly it does pay a small fee for each bit of information I send in. It might only be 6p each time, but it means at last I can say I am a paid writer.

Up there somewhere, my imagination tells me, there’s a person at a monitoring station looking at a screen, looking at what I am doing, ready to beam me up out of any trouble spot – this is what I call the rescue fantasy.

If I break down in my car I will call the AA. If I’m in a road accident the ambucopter will arrive, circle overhead for a while and land in nearby school playing fields. If my tooth breaks off the dentist will fit me in the same day and fix it during the Ken Bruce Show on Radio 2, both of us muttering answers to the popmaster quiz.

The local GP surgery reached out to me recently, inviting me for my 5 yearly check up. It’s called Health Check with the Nurse, though it is a health check with a health care assistant nowadays. In some more prosperous parts of the world it’s maybe a Health Check with a Regional Dean of Internal Medicine, or an underemployed WHO ambassador like Robert Mugabe. Next time here I suspect it will be health check with youtube and a mirror.

Anyway, the point is there is someone out there who cares about you, even if they have ulterior motives, like targeted advertising or stopping you getting diabetes.

And we’ve looked upon our parliament and political leaders to take an overview and guard us from our own foolishness. In return for their efforts we scream ‘nanny state’. But now we find our elected leaders fighting among themselves. Our ambucopter has landed, only to reveal the pilot and paramedic beating each other unconscious in a fist fight.

Some good things are happening, like the minimum alcohol pricing in Scotland, limits on fixed-odds betting terminals and quiet carriages on LNER. The police are asking us to report motorcyclists without helmets, accepting they will be anywhere within a ninety mile radius by the time details have been taken on the non-urgent line.

If The Rescue Fantasy was a movie here’s how it could all still work out:

Prince Philip has a dream of a devastated Britain that looks ever more like the set of a Mad Max movie. No More Heroes by The Stranglers plays loudly in the background.

He sends for Harry and symbolically hands over the key to the Royal Land Rover and Harry’s old army pistol. ‘You’ve got exactly 40 days to save this country from its own danged-bone-headed foolishness. You’ve been talking a lot about starting conversations, Harry. (eyes narrow) Now I’m telling you to finish the conversation.’

Training montage of Harry ploughing through piles of books: Freud, Durkheim, Nelson Mandela; exchanging ideas with world leaders; mindfulness exercises with the Beckhams; in the lab with Brian Cox; and finally, on the firing range with Prince Philip.

Cut to Parliament. Just like in Crimson Tide, at gunpoint, Harry relieves the prime minister of command, ‘You’re unfit for duty madam. And that’s the end of the conversation’.

Epilogue scene, the truth and reconciliation committee, chaired by Ant and Dec, symbolically reunited, takes evidence from the perpetrators. Harry, in the background allows himself a half smile.

Brief shot of angry Putin, smashing his vinyl copy of No More Heroes.

The End.

Post credits shot of the new Nissan X Trail, made in Sunderland after all.

87. You know I hate to ask, but are friends electric?

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A patent magneto electric machine. USB C adaptor is $40 extra.

In August, I took an Australian visitor to Lincoln Castle for a good slice of History. Everywhere there were flamboyant characters in Victorian outfits and I soon realised Lincoln was hosting a steampunk festival and we were getting more History than just the Magna Carta.

Officially called The Asylum Festival, the event centred on The Lawn hospital, near Lincoln Castle, an early nineteenth century building which, until 1985, served as a mental hospital.

In this case, and in general, it’s easy to argue that steampunk is filling not just a building but also a cultural void at the Lawn vacated by psychiatry, at least in terms of celebrating the Gothic.

According to wikipedia, Steampunk refers to a subgenre of science fiction and sometimes fantasy that incorporates technology and aesthetic designs inspired by 19th-century steam-powered machinery.

Contrast with Psychiatry, which refers to a subgenre of medicine and sometimes fantasy that incorporates technology and aesthetic designs inspired by 19th century electrical-powered machinery.

Another attempted definition of Steampunk is ‘modern technology—iPads, computers, robotics, air travel—powered by steam and set in the 1800’s’.

Again, contrast with psychiatry, which is all about old ideas (mental energy, chemical deficiencies, mindfulness etc) set in a concrete building on a business park modelled on George Smiley’s HQ.

The point is, Steampunk celebrates the art of anachronism, whereas psychiatry regards it with a mixture of hatred and denial.

The Lawn was opened in 1819, which was before the reign of Queen Victoria, but most of the British Asylum hospitals were built during the Victorian period. Many of them were gothic in style, making them a suitable venue for wearing top hats and tinted goggles, riding round on penny farthings and racing steam robots.

Nowadays, psychiatry is shy about its Victorian heritage. The contribution of Freud and his colleagues is celebrated only in terms of a sprinkling of multiple choice questions. Freud’s early work would now be called Neuroscience and we know that he was intrigued by nerve tissue and would have taken a much more Electric road, if only he’d had access to multipacks of AAA batteries or a USB charger.

Freud knew that the brain was electrically powered – indeed this discovery went back to the end of the eighteenth century. He attributed symptoms like hysterical paralysis to mental energy short-circuiting down the wrong pathways.

Since the Victorian era of psychiatric treatment, electricity popped up as a treatment option at frequent intervals. Nowadays there are many people working on various kinds of electrical brain stimulation, such as deep brain stimulation, transcranial direct current brain stimulation (tDCS), magnetic stimulation and the original and genuine product, ECT.

This is not, you understand, the official penchant of British psychiatry, which by convention pretends to emphasise social and psychological approaches. You’re supposed to listen actively for at least five minutes before getting the talk round to tablets and quite a bit longer before mentioning the E word. That’s just a convention. I wouldn’t call it hypocritical, more, let’s say ‘dual mode’.

People say they want to be listened to more than anything else, but that stance also can be a little dual-modish. Quite a number of patients are in search of physical treatments of one kind or another and want to seek medical advice before buying batteries and sponges from B and Q.

Talking yes, counselling certainly, making a few changes to your life, I guess so, but hey, just tossing an idea out there, how about electricity?

Sadly, the custodians of ECT, psychiatrists and their colleagues in mental health trusts, have completely failed to market their product at all. The number of people prescribed ECT has declined dramatically over the years. Depending on where you stand on this argument, either it is being enormously under-utilised or you can’t believe it’s still going on at all.

Because the NHS mainly seeks to discourage people turning up to use its services, nothing much has been done to promote electrical treatments. The premises used are a bit drab and though they are strictly regulated, the ambience is a bit like the blood – doning centre, being a strange mixture of homeliness and apprehension.

After ‘One Flew over the Cuckoo’s Nest’ was made and shown to generations of students, the Royal College decided that ECT could never be made to look cool ever again.

Regulators like NICE narrowed down the number of indications and the treatment itself changed a lot subsequent to most of the controlled trials that were conducted.  A different anesthetic is used, the energy level has been reduced, the ECT box is not made of mahogany any more and some units don’t even provide free toast after treatment. Arguably, the toast issue has been the most damaging.Whereas 6 to 8 treatments used to be standard in the toast era, now it’s often 12.

I doubt if ECT will be hived off to the private sector, but it wouldn’t totally surprise me to see new departments of electro-therapy in different settings, like sports medicine clinics or the corner of Debenhams.

Unlike ECT, tDCS has acquired a better vibe, being used by the Air Force to keep people concentrating and allegedly by students to improve their performance in games and exams. Perhaps more psychiatrists should be looking at it, but they won’t hurry because they are still struggling with their electrical baggage.

Steampunks would be delighted with a treatment like tDCS that was invented in 1798, but psychiatrists haven’t yet learned to love and embrace the anachronisms of modern life. 

 

 

35. Winking at the Standby Light.

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Coming to terms with existential despair is a tough task. I find it quite worrying that many of my domestic appliances, even some of the ones made in China, are going to outlive me.

Some while back I caught the beady eye of my old Toshiba television. The little red standby light, the same one that had ruined the climate, seemed to be indicating: I’ll be here after you’ve gone. I took it to the Sense shop for recycling and I happen to know it went to a good home. They wouldn’t sell me any Sense though.

Similarly the Ivy all around my house waits patiently to make its big push. It can wait a hundred years or a million. In the meantime, Ivy has one great weakness, which is failing to armour plate its giant arterial stems. Possibly an even greater weakness has been its failure to develop a political wing. No-one is out campaigning to save the Ivy. Unlike its colleagues, Holly and Mistletoe, Ivy has refused to cash in on the Christmas market. I’ve a feeling it will never sell out.

For as long as I can remember, people have told me that the Psychiatric profession is about to go out of business. Psychiatry is a creation of the 20th Century and has probably been dying since the closure of the large asylums. Many reasons are put forward for this. On the one hand it is expected that Neuroscience will eventually explain what goes wrong with the brain when mental illness happens, so that problems like bipolar disorder and schizophrenia – the meat and drink of general psychiatry – will properly belong to the neurologist, along with dementia. The rest of it can be left to social workers and psychologists, if their time machine ever gets back from the seventies.

Another factor has been the massive reduction in the psychiatrist’s favourite habitat, hospital inpatient units (I nearly said hedgerows). And a third influence has been the rise of general practice based mental health care. So on the one hand more and more people are being diagnosed with mental health problems, yet on the other hand, very few of those people will ever see a psychiatrist.

I’ve tended to believe that these prophecies of doom have been overly pessimistic. After all the same has been said about the Liberal Democrat party, which is now part of the government. And similar predictions were made about some of the High Street chains, like WH Smith, which still seems to be doing very nicely, having occupied all the stations and airports.

So maybe I have become a little over-complacent. Woolworths’s demise should perhaps have sent us a wake-up call. And now the Royal Mail sell off is sending a message that nothing is sacred. And what about the public library? Are you a bit uneasy about the coffee machines and internet terminals, and the reduced number of books? When all books are e-books (next year?), why will we need a physical library building?

Uncannily, just after I wrote that sentence, we’re in Stephen King territory here, Look North just reported that 33 libraries are going to close in the county of Lincolnshire. I’m worrying that everything I write might come true. No-one likes I told you so.

Then there was MFI. Everyone joked that their sale had been going on since 1976. Until suddenly, like Marvin Gaye, it wasn’t going on any more.

Psychiatry is perhaps no more precarious than other venerable institutions. Recruitment has been very poor for many years – we have gone from being the Cinderella profession to the Ugly Sisters (no sexist remark is intended here). We are not yet in post-apocalyptic mode, like Mr Spock, or Dr Who, whose planets were destroyed, but it may be time to start wearing big leather maxi coats and stashing shotguns.

On so many occasions I’ve thought; this place is going out of business soon. This has occurred to me in pubs, restaurants, churches, shops of various kinds, launderettes, art galleries, zoos, theatres, even cinemas. In fact, especially cinemas. People said cinemas would close when TV became affordable. Many of them did, but more recently multiplex cinemas have opened in many new locations. They seem to operate with only one member of staff, the guy with night vision goggles who stops people filming the films and guards access to the Pullman seats.

So perhaps mental health will go the same way, returning in a new form, with VIP seating. In fact, premium products have done well in retail. Even Lidl have brought out a luxury range. Premium car brands like Audi and BMW seem to be gaining market share. Royal Mail will still be called Royal, which sounds better than Royal Yodel or Royal DHL.

What would a premium quality mental health service be like? Despite protestations by NHS Trusts and Private Hospitals that they offer such a thing, mental health services are often blue stripe basic. This is perhaps because the impact of mental health problems is often to reduce patients’ earning potential. In other words, most of our patients are skint. But if we can’t do premium, we can do Primark.

Along these lines, proper psychiatrists know that older mental health medications, which are incredibly inexpensive, are probably better in many ways than the expensive new ones. This is not something that GPs have discovered yet.

I have seen so many Psychiatric units close down. Including some that I saw open, with great fanfare and optimism. I remember one that even had its own carpet designer. Some fine new ones have opened recently, although nothing to compare with Victorian asylums, which had ballrooms, cricket pitches and farms.

Predicting their longevity is like a long range weather forecast. The main climatic system is social attitude. It feels like we are just starting a closing down sale. But I’m not certain yet that Everything Must Go. The outlook is probably somewhere between Royal Mail and FM radio. It’s still going but don’t bet your (Primark) shirt on it. Psychiatry is a bit like Toshiba, but it’s not all Tosh.

Everything Must Go was a Steely Dan album. Did they do another one? Like psychiatric medication, their earlier stuff was better.

3. It looks a bit DIY

Experts - do we need them?

Experts – do we need them?

There are surprisingly restrictive laws to prevent you doing bits of wiring and plumbing around your own home. Anything gas related is particularly strict, needing someone who is CORGI registered.

If you replace your gas hob, despite the fact that you can turn the gas off with a big tap, that the hob uses a simple bayonet joint, that gas is very smelly in case of leaks, that you have watched the CORGI man do it several times, that you don’t intend to do it with a lighted cigarette behind your ear – despite all that, if you disconnect it yourself you will be placed in the Tower of London for 100 years and tortured every Tuesday. Your crime is that you thought you knew better.

Surprisingly, when it comes to helping people with health problems, things are much looser.  There are professional bodies regulating the top end of the market – doctors, nurses, psychologists, but even here there is very little regulation of what types of therapy they actually do.

Lower down, blurring into the alternative therapy market, pretty much anything goes. This market is full of therapists who think they know better. Better, that is, than any evidence they can produce to support their work.

Its often fascinating, as a psychiatrist, to see how people have attempted to deal with mental health problems prior to ‘calling in’ the NHS.

We know people delay seeking medical advice for health problems. People tend to adjust to symptoms for a long while, often attributing them to random and coincidental events such as biological washing powder or a mystery virus.

Such accommodation to symptoms only breaks down if something happens – you notice specks of  blood over your white piano keys, like Chopin; your mum makes you an appointment for the GP. Or you are arrested in a public place under section 136 of the mental health act and taken to a place of safety.

Before we get to the point of needing professional advice, how long have things been deteriorating? In the case of psychotic and depressed patients, we know they have been unwell on average for many months before seeing anyone for help.

Some events are so traumatic that the person goes straight to hospital without passing GO or collecting £200. But the majority of medical events develop slowly, more like accepting a £10 fine, or, like Mr Huhne, taking a chance card instead. The first part of any illness is usually in our own hands to manage.

That means we have to consider health issues within the reflective mind, however much that part of the mind wants to sweep them under the conscious carpet.

When it comes to mental health problems there are times when we need an objective person to give advice. Another person can be a vital source of insight. Often just talking to another person helps us reflect better. Before we tell another person we are on our own and at the mercy of the limited perspective of the single view.

Even after we have convinced ourselves, and maybe our mums, that we have a problem, we encounter barriers around the health care system. These have been built good and high to filter out the excess demand placed upon a free health system.

The ‘culture of fear’ that NHS-managementism has created extends downwards towards service providers and users.

Firstly there is a healthy scepticism about what motivates the NHS  behind the scenes: 1. the nanny state; 2. targets that determine payments; 3. drug companies.

Then there are simple filters such as a permanently engaged phone line, KGB receptionists and a lack of appointments.

Perhaps more of a barrier for most people is just not knowing how to engage. What should you take to the doctor, how do you describe it, how do you present it? Should you take someone with you, should you write things down on a bit of paper, should you google it first?

Once into the mental health system we are very unlikely to find an ideal therapist we can relate to. One reason is that the demography of the NHS workforce nowhere near reflects the demography of the population it serves.

Another reason is the very small number of trained professionals relative to the number of people who suffer from mental illnesses.

For example, our GP has 2000 patients on average. Lets assume 3% of them (more later about the 3% issue) have severe depression – that’s already 60 people. Our local psychiatrist serves – again on average – 40,000 people. He or she will have a caseload of several hundred.

How many hours are there in a week? In the NHS, about 12, by the time we have allowed for bureaucratic intrusions, mandatory training, focus groups, and having our hair done.

Without wishing to denigrate anyone involved, or indeed undermine the foot-ware industry, the NHS mental health services are run on a shoestring. The negative halo effect that surrounds mental health issues also effects prioritisation and funding, relative to hotter specialities like Fever.

Having thought about all these barriers – starting with our own reluctance to think about our health, stigma, bureaucracy, shortages, shouldering our way into a system that feels like rush hour in Naples – its amazing that anyone gets treated at all.

Luckily, unlike with the CORGI fitter, a lot of it can be done by yourself. Often using equipment you can find in your own kitchen, such as another person.

But the first rule has to be: don’t think you know better (until you can prove it).

The second rule is: no cigarettes.