Tag Archives: psychosis

55. Saving the early intervention service, till later.

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An uneasy meeting at a fancy dress party.

It’s official. Children cost too much. Childcare costs more than a mortgage. If you have children they might stop you going to work, and they eat a lot too. Shouldn’t people be told this sooner? Worse than that, children don’t come with any kind of guarantee, and more of them seem to be going wrong. If Toyota had made them there’d be a recall. And soon a Commons Committee on young people’s mental health will start its proceedings.

Though there are rumours that mental health problems among teenagers have increased, there has not been a proper survey since 2004, when the world was very different. It’s hard to believe, but they didn’t even have Instagram in those days, let alone Whatsapp. People wore top hats and tail coats and travelled by horse, particularly the women.

There are lots of theoretical reasons why it’s got worse to be a teenager. Legal highs are widely available, the Harry Potter series came to an end, and no-one is far enough beyond suspicion to take over hosting Jim’ll Fix It, unless Desmond Tutu can be persuaded. Large numbers of youngsters have been sent to remote labour camps, or universities as they are now known. Employment opportunities as footballers and TV presenters, the only jobs worth having, have largely dried up.

Sadly, if a generation of teenagers became psychotic or depressed, no-one would really notice. Part of the blame belongs to British psychiatry and its strange tradition of age discrimination. For some reason we have different specialists for young, adult and older people, as though they were totally different forms of life – like eggs, caterpillars and butterflies respectively.

There’s a kind of reason for that, in that young people don’t really get the same kind of mental illnesses as adults. Psychotic conditions are very rare in children, or so we thought. ‘Early intervention’ services were an attempt to plug the gap, at least for older teenagers who seemed to be showing signs of schizophrenia. Early intervention was a laudable aspiration, but didn’t get much beyond that, since there was no litmus test for psychosis. The services were overwhelmed to an extent, by the numbers of children with emotional disorders, such as so-called ‘borderline’ personality; problems that,in a sense, flow from children being treated as commodities instead of people.

To cut a long story short, another tonne of anti-psychotics wended its way to the sewerage system, some of it via people. The early intervention services have been pruned back rather savagely, before they had a chance to flower. Doubtless the Commons Health Committee will come to regret this. In the meantime, services for teenagers are largely restricted to a skateboard area and free condoms at the library, for those who are brave enough.

When the large mental hospitals were closed down, some people warned that community services would be much easier to cut. It’s to do with visibility. Some of the asylum hospitals were the size of aircraft carriers; quite likely some of them had their own Harrier Squadron. They certainly had farms, ballrooms and cricket pitches. Everyone has noticed they’ve gone.

The coalition government has been quite tough on aircraft carriers, and luckily there won’t be one to send to the Crimea. But having a carrier with no aircraft to go on top is a major embarrassment. It’s like a Christmas cake without the marzipan, let alone the little decorative church and snowman. Similarly, having a hospital full of closed wards looks a bit wasteful. But if a care assistant only comes half as often, for half as long, or doesn’t visit at all, no-one really notices.

And if your psychotherapist turns out to have one years training at a community college, rather than the 25 year apprenticeship in Vienna and the multiple doctorates you’d expected, it’s hardly a big deal to anyone. Low tech services have a soft underbelly, as do many of the people who work in them – too much driving about eating petrol station sandwiches.

As the community mental health services are scythed back, we hear only a few muffled squawks from politicians. Nick Clegg (deputy prime minister and Britain’s answer to Al Gore) popped up in January, stating that mental health must be given parity with physical health. ‘We have got to take this out of the shadows’, he said. And we can expect a further survey on teenagers’ mental health, probably conducted by social media. But does the government have any coherent plan for teenagers, or are they considered, as a Bond villain might say, ‘expendable’? After all, they don’t vote and they don’t pay much tax. As a species, humans have a reasonable life expectancy at birth, which is a miracle, considering we ride bicycles, but perhaps this is set to change. It’s a bit ominous that youngsters are now being told that world war one was a useful outing.

With the demise of early intervention teams, there should be a move for adult and child psychiatrists to work together more closely, but I see no signs of this. They just drive a totally different kind of Audi.

During vacations I always got a child psychiatrist to cover my work, which he did brilliantly. I doubt whether I’d fare so well with his patients, unless he wanted half of them put on depot injections, and a tonne of complaint letters from parents. And I’m not sure if they still have sandpits to play in, so I wouldn’t know whether to bring my own bucket and spade.

Maybe a reverse takeover is in order, where children’s services take over and everyone is regarded as a child. This is perhaps the only way that children can get treated equitably. The danger is Ofsted staging a coup and taking over the government. And everyone would have to have a CRB check, just to meet anyone else at all. Treating everyone like children has worked well in lots of countries – you know who you are, nanny states.  Perhaps Nick Clegg could consider this. Otherwise, teenagers, like Hank B Marvin, are just going to have to ‘stay in the shadows’.

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52. Finding yourself and more importantly, your keys.

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A picture with a mental health sort of vibe, suitable for a leaflet, no sensible offer refused.

Two girls walk slowly to school alongside each other, both talking into mobile phones, possibly to each other.

A man in the public library, reading the newspaper, who moves his finger along the lines of print and whispers the words out loud.

An electrician, talking to his assistant, explains what he is doing as he puts in a new fuse box. He deliberately gives himself little electric shocks at times, explaining that this is something you should never do.

A man clutching a can of Special Brew, talking loudly, seemingly to no-one, as he staggers down the high street.

A kid, pretending to be CIA, talks into his sleeve at quiet moments during a history lesson.

I’ve been observing people talking out loud, and – heresy! – I’m just wondering if there shouldn’t be more of it.

Here’s another unpopular view – I always preferred the original release of Blade Runner to the subsequent versions, simply because of the Marlowe style spoken narrative. We’ve had ‘the final cut’, but I hope there will be more versions, for instance, a musical, with tap-dancing robots.

All this stems from the realisation that we are all several people in one. The idea that we are ‘an individual’ is handy for practical purposes, such as issuing passports and driving licences, but manifestly an oversimplification. Discarding for a moment oddities like multiple personality disorder, we spend a lot of our time in different modes of operation.

Dreaming, day-dreaming, fantasising, imagining for instance. Set on autopilot as we drive to work, often not remembering all the mini roundabouts and small mammals we drove over. Or reverting to chimp mode when there is a perceived threat.

In people who suffer from psychosis, this potential for multi mode operation has been called ‘double bookkeeping’. The ancient example is a patient who is deluded that he is the King, but is content to mop the hospital floor as a day job. Real life examples are frequent enough. One of my customers thinks he is the most senior officer in the British Army, but he is happy to work in the snack bar on a voluntary basis.

There is no need to be psychotic to indulge in double bookkeeping. The phrase ‘creative accountancy’ goes back a long way. Look, for instance, at the target culture of the modern regulated public sector, where information is routinely falsified. I even had trouble typing that word, falsified. I wanted to type ‘spun’ or ‘distorted’ or ‘laundered’, such is our reluctance to attribute malicious motivation. To call someone a liar is a serious insult and perjury can carry a jail sentence. Are all these managers and civil servants who cook the books consciously aware that they are lying, or are they using a series of mental mechanisms to justify themselves?

My hypothesis here is that it is easier to lie in a diagram or a document than it is to lie out loud. Speaking out loud seems to engage bits of mental functioning that are more careful and scrutinising. If you lose your keys, if you speak out loud the word ‘keys’, you are more likely to find them. Hearing yourself out loud seems to kick the awareness level one layer higher.

Apparently negotiations go better if you speak in the first person and include some ‘feeling’ words. If you happen to citizen’s arrest a former prime minister, be sure to mention you are disappointed with some of his bombing decisions and surprised that he thinks he can walk freely around Shoreditch, amidst Hipsters.

If you appear in court, and you hear yourself swear to tell the truth, the whole truth and nothing but the truth, you probably will. Talking to yourself is the new talking to someone else.

And that brings us to new technologies, like Siri and Google Now. If you hear yourself say, ‘is there a good japanese noodle bar round here?’ you will immediately realise that you are being silly. You don’t like noodles and you’re in Rotherham. You don’t need the latest phone, or any phone at all, you just speak into your sleeve.

That’s got implications for psychotherapy, and for the church, which has never successfully marketed its Confession product. If the magic ingredient is simply speaking out loud then you don’t really need the therapist or priest. You could dial 111 and explain your problems over the phone – just unplug it first.