This is a block of 44 days of personal musings about mental health. They may help readers to understand nidotherapy better, but, if not, I just hope they entertain and amuse. Readers of this website are invited to join this group if they wish to be involved. If you are interested in reading more send an email message to firstname.lastname@example.org .
Wednesday 13th May. Social prescribing is likely to become an increasing part of the mental health services in the future, and we expect this to blossom in the wake of the COVID pandemic. A piece on the subject is being published in Lancet Psychiatry very shortly. Here are two sections from the paper:
‘ “Social prescribing” may not be a good couplet for an intervention that has the potential to transform services. It implies the dispensation of interventions, probably of the drug variety, in settings where there are many people present. This is not an attractive notion, implying casual disregard of professional conduct, and is of course misleading. Yet it has now been embraced fulsomely to the extent that there is now a National Academy of Social Prescribing, launched by the Secretary of State for Health and Social Care, Matt Hancock, the UK on the 23 October 20191. It is too late to change the wording at this stage in its life, but a much better couplet would have been ‘collateral interventions’. They are interventions because this word covers a much bigger range than ‘prescribing’, and collateral because they reinforce rather than challenge conventional pathways. So, when someone with long-term depression who has not improved after 20 years of antidepressants meets a community pharmacist, talks about ways of improving her life and, as part of social prescribing, is given the suggestion of taking up a vacancy at a local allotment. If she returns six months later to see the pharmacist, says that she has stopped the antidepressants and gives a large allotment-grown cauliflower in thanks for the intervention, we can then say social prescribing has been successful.’
Unfortunately, social prescribing has been poorly researched and comes under the general heading of ‘absence of evidence is not evidence of absence. It is likely to be of value but many questions arise about its process, which currently concentrates on trained link workers:
‘There are three important questions to answer.
- Who should be referred?
The initiatives in social prescribing are focussed on primary care and supported by the use of link workers. Presently, the referrals to link workers will come from general practice, but in the near future any community resource can refer. Without guidance it is likely that link workers will be overwhelmed.
- Do linkworkers have the necessary skills and support to be effective?
This question cannot be answered at present, but it is unlikely to be positive. With such a large range of people eligible to refer it is easy to envisage a Pandora’s box of problems being presented that go far beyond the abilities of a single worker to solve. There is little in the guidance about the necessary skills and training of link workers and the only common requirement is that they should have extensive local knowledge.
- What back-up is available for social prescribers?
At present there is a good internal network proposed for social prescribing link workers with regular meetings, supervision from more senior staff, and events for outside speakers. But is this enough, particularly when there is going to be no filter on referrals and more severe problems are bound to be encountered? The level of feedback between link workers and referrers also needs to be tightened up as at some point the process of referrals will have to be constrained.’
Social prescribing and nidotherapy are highly relevant for children as well as adults. Today I gave a talk on the subject to London child psychiatrists. It was linked to a general theme about the diagnosis of personality disorder in children and adolescents. Some people find this notion abhorrent, but one of the principles of Mental Health Unblocked is plain common sense. Nobody disputes that personality is set down in childhood so disorder must arise then also. Pretending it doesn’t exist until adulthood is nonsense. If any child and adolescent mental health professionals want to be convinced I can send them the PowerPoint presentation.
Thursday 14th May. People have often asked us if drug treatment can be part of nidotherapy. It most certainly can. But it works in two directions. Anthea, the first person to be described in detail in the second edition of nidotherapy (she gave full permission to have the raw story set out in full) was determined to avoid taking drugs for her schizoaffective disorder (one of the schizophrenias). She had very good reasons for not taking the standard antipsychotic prescription drugs given for this condition – saying they made her feel so awful life was intolerable – and so for 17 years she had oscillating admissions as she stopped taking these drugs whenever she was outside hospital. But when assessed for nidotherapy, where collaborative treatment is paramount, we were forced into trying a form of management without drugs. As the account in the book demonstrated, it worked like a dream, as we found out her episodes of psychosis could be condensed into a few days if she walled herself into her flat and avoided contact when unwell, and no drugs were ever needed. There is a journal which used to publish a series called The Patient Who Changed My Practice, and I wrote about her there and gave her a copy. ‘ I am glad you were finally able to see sense’, was her short reply.
But with other people the collaborative approach sometimes leads to people appreciating the value of drug treatment, as it can lead to more favourable interaction with the world. A scary frightening environment can suddenly become friendly and supportive if the appropriate drug is given. In this type of situation taking the right dose of drug at the right time is the key, and guidance towards this goal can be given by the joint nidotherapy approach. Persuading doctors to allow their patients to be flexible in their use of drug treatment can often be difficult, and here the skills of the nidotherapist as an advocate can come into play. It’s all in the second edition of Nidotherapy: Harmonising the Environment with the Patient, and for those reading this piece from Europe, there will soon be a German translation to read.
Friday 15th May. Some critics of nidotherapy follow the standard argument of ‘new wine in old bottles’, maintaining that what practitioners in mental health practise nidotherapy all the time in their work. They also claim that the positive effects we achieve are limited and short-lasting. These people ought to read the article by our colleague in Prince Edward Island, Canada. Dr Ben Spears: Spears B, Tyrer H, & Tyrer P (2017). Nidotherapy in the successful management of comorbid depressive and personality disorder. Personality and Mental Health, 11, 344-350. (If any reader wants a copy please let me know). This describes the mental health suffering of a woman with alleged borderline personality disorder and severe depression who tried to end her life countless times over a period of nearly 30 years. Since a major nidotherapy initiative organised by Ben in 2012 she has completely recovered. Any sceptical readers can be put in touch with her if they have any doubts. She attended the Annual Meeting of the British and Irish Group for the Study of Personality Disorders in 2018 and I trust all were convinced then that she was genuinely better.
Saturday 16th May. ‘It is a truth universally acknowledged’, as Jane Austen would have said had she lived longer, ‘that the quality of relationship in the treatment of nerves far exceeds the power of the intervention’. This is indeed universally acknowledged by all who practise psychotherapy but nobody has nailed down exactly what this quality is. There are dozens are hard-working highly informed psychotherapists who are hopeless at helping people, yet others who with minimal training who are conspicuously successful. Many like to attract all comers by arguing that they practise ‘holistic’ or ‘eclectic’ psychotherapy but this too covers the range from utterly useless to extremely effective.
We have just finished a 30 year study of the most common mental condition in Jane Austen’s novels, anxiety/depression (equals ‘nerves’), in which three kinds of drug treatment, cognitive behaviour therapy and self-help advice were compared initially in a trial, and the patients then followed up at regular intervals. After 30 years it is clear which treatment was the most effective of them all – cognitive behaviour therapy given by competent therapists. This was first reported after 2 years (Kingdon D et al (1996). The Nottingham Study of Neurotic Disorder: influence of cognitive therapists on outcome. British Journal of Psychiatry, 169, 93-97). These findings have been reinforced by comments written at follow-up in the section marked, ‘which treatment has helped you most over the last 30 years?’ ‘The CBT I had at the beginning’ frequently appears, often with the named therapist, but only when the therapist was assessed as competent. When the results of all the CBT patients are included there are no important differences between the outcome of CBT and other treatments.
We would like to think that good nidotherapists would also be regarded as competent CBT ones. They concentrate on getting the right quality when they get to know people at the beginning of treatment. This is done in a way that creates trust and respect and so allows true collaboration to follow afterwards. But measuring this is very difficult. We have nidotherapy fidelity scales but they only scratch the surface. But we must keep trying.
Sunday 17th May. We are often asked which organisations across the world practise nidotherapy and do they have any special characteristics. A list will follow in another post, but to begin with here is the account of a Swedish group headed by Susanne Bejerot, where nidotherapy was included as part of a training programme.
Kognus is the name of the programme, and Susanne and her colleagues, in introducing it, latched on to an important omission in current psychiatric practice. This is the almost complete lack of mental health training for the large number of people, many without any formal qualifications, who care for people with chronic mental illness and intellectual disability. The full account of the programme is described in: Bejerot, S., Lindgren, A., Rosén, J. et al. Teaching psychiatry to large groups in society. BMC Medical Education 2019, 19, 148. In summarising it I will concentrate on the parts relative to nidotherapy.
Currently we are only too well aware of these carers, as they have come into the spotlight in the COVID-19 pandemic. In the United Kingdom we are very proud of our NHS and its staff and give them justifiable praise for their heroism and commitment during the crisis in our health services. But we also need to be giving equal thanks, support and encouragement to our unsung health carers, who have had twice the death rate of NHS staff in the UK and are in danger of being forgotten again when this crisis is over.
Susanne and her colleagues list the expectations we pass on to these tireless workers. ‘They are expected to support clients with regard to various matters, including household work, paying bills, picking up drugs from the pharmacy, and making appointments with doctors, social services professionals, and social insurance personnel. They are also expected to motivate passive clients, comfort sad clients, and calm anxious and psychotic clients. Consequently, they need to understand and handle clients with diverse and possibly severe and comorbid psychiatric disorders.’
So the aim of the Kognus programme was to upscale training. (I do not much like the word ‘upscale’ but as a verb it describes the process of improvement and as a noun it describes high quality, so in this context it is accurate).
The Kognus programme was to provide education that is ‘interesting, relevant, useful, and affordable and preferably result in heightened professional status….for large groups of professionals with different backgrounds. The project had a patient-centered approach. The project sought to enable professional advancement, with a focus on its usefulness for society and minimal administrative requirements’. It began its work in Stockholm but extended to Malmö, Skellefteå, and Mölnlycke, and then nation-wide.
The third part of the programme concentrated on nidotherapy, with the aim of making each participant a good nidotherapist. ‘The task of the nidotherapist is to explore possible concrete areas that can be improved for the patient according to his/her wishes (i.e., not necessarily the wishes of the professionals). The nidotherapist assists in implementing these changes over approximately 9–12 months. Collaboration within the client’s network, to which the client consents, is crucial to achieve success. The client is an active partner to reach the selected and attainable goals.’
The training was carried out over one year. ‘The participants represented a variety of professional backgrounds, such as working at psychiatric outpatient units, nongovernmental organizations, and employment services. No costs were involved. The first session of the course provided participants with a free textbook on nidotherapy. In the second session, their knowledge on nidotherapy was examined in a multiple-choice test.’
Some examples of treatment were also described in the article. ‘ Examples of problems included organizing the home, finding ways to finance and purchase a dishwasher, and accompanying a client who was afraid of vomiting on the bus. Notably, the nidotherapist trainee did not treat any psychiatric symptoms. At the end of the course, the trainees were examined with extensive written and oral examinations. Each participant received a score (ranging from 1 to 10) for each of the following five areas: (i) gaining trust, (ii) perseverance, (iii) flair (i.e., lateral thinking), (iv) pacing (i.e., moving forward at the right pace for the patient), and (v) collaboration.’
Kognus was a funded initiative with a fixed budget and so could not be maintained. But there is no reason why it should not continue and flourish, and when we all have to reassess our priorities after the COVID-19 crisis is over perhaps the best organised and most sensible country in the world can think again.
Monday 18th May. One of the common comments that follows an account of someone who has been helped by nidotherapy is, ‘you can make that happen because you’re a professor. Its very different for people like us.’ This is 90% untrue. The changes made in nidotherapy are owned and enacted by the person being treated, not by anyone else. The other people who are the most appropriate to acknowledge are the key people practising nidotherapy, be they relatives, friends, front-line key workers, or other health professionals. Professors and senior staff are there to help develop the treatment plan, and sometimes to act as advocates when something gets stuck. But this is just the final 10%.
Being a professor is often a handicap. Shortly after I was interviewed for an upgrade to professor from senior lecturer, not a promotion I had asked for, I had to see a new patient at home. I wrote to the person concerned, a widow in her early 60’s, and gave the date of my visit. I duly arrived, possibly a few minutes late as I have a tendency in that direction. She let me into her house, was excessively cautious and over-polite, and escorted me into her front room.
‘Just wait there a minute I’ll be with you shortly’, she said, just a little bit oilily. Nothing happened for a few minutes and I began to get a little perturbed. Then I heard a voice in the hall. I got up, moved towards the door and opened it a fraction. The woman was speaking. ‘Could you please come as soon as possible’. She was on the ‘phone. After a short pause she said again, ‘please come as soon as possible, this man is an imposter’.
I returned to the ample armchair which I had been offered previously, trying to work out what was going on. Within a few minutes she came back with an elegant tray, jug of milk and cup of tea. ‘There you are, professor. Drink that up and I’ll see you soon’. By now I was getting a little alarmed and, while sipping my tea, I think it was Earl Grey, I tried to work out what was going on. I had to have my credentials handy if I was to prove myself.
Within five minutes, it could not have been longer, a policeman arrived and was brought into the room where I was now perched uneasily on the edge of the chair. ‘This is the man, officer. He said he was a professor, but professors don’t go around seeing people in their homes. Could you arrest him immediately.’ But I was prepared. I produced both my academic and NHS badges and quickly convinced the policeman, who was by now a little nonplussed, that I was whom I said I was.
The policeman reassured the woman and said there was nothing he could do. ‘That’s not good enough. I’m going to report you to your senior officer’. We both protested but it was no good. She grabbed her coat, ushered us out of her house, and stalked off to the police station 400 yards away.
So I cannot say that professors of community psychiatry are favoured people. Professors in general are getting a hard time of it at present. One of the common criticisms in social media by people who take on the mantle of expert opinion makers is to refer to this group as ‘so-called professors’ as though they had acquired this title by underhand means. I never read about ‘so-called health-care assistants’ or ‘so-called consultant physicians’. So what have we done to offend?
Tuesday 19th May. The best evidence of the efficacy of a treatment is determined by a large randomised trial – one that is free of bias and follows a predetermined protocol. We do not yet have these for nidotherapy; only two trials have been completed and both were relatively small. As a consequence a Cochrane review – the well-regarded independent group that assesses randomised trials – concluded that nidotherapy should be regarded as an experimental treatment only (Chamberlain IJ, Sampson S. Nidotherapy for schizophrenia. Schizophrenia Bulletin 2013, 39, 17-21).
But there is another trial that was not included for obvious reasons but in which nidotherapy might have played an important part. This was the UK700 trial of intensive versus standard case management published in the Lancet in 1999. In this study four hospital groups were involved, one of which was St Mary’s and St Charles Hospital in west London.
The primary outcome of the trial was the number of days spent in psychiatric hospitals over a two year period after randomisation. The expectation in advance of the study was that intensive case management (with 10-15 patients per case manager) would lead to fewer admissions than standard case management (30-35 patients per case manager), as more frequent follow-up and supervision anticipated fewer admissions. Bu the results contradicted this ; intensive case management led to a mean of 73.5 days spent in hospital compared with 73.1 days in those allocated to standard case management (Burns et al, Lancet 1999; 353, 2185-9). Although this was unexpected a similar earlier study had shown that applying more stringent follow-up criteria (care programme approach) led to more admissions (Tyrer et al, Randomised controlled study of close monitoring of vulnerable psychiatric patients. Lancet 1995; 345: 756-9).
But examination of the data from the different sites did show differences. At three of the four sites there were more days in hospital in the intensive care group compared with standard (St George’s Hospital – 10.5 days, Manchester – 19.5 days, Kings College Hospital – 0.9 days), but at the St Mary’s site there was a big difference in favour of intensive case management (65.7 days for intensive case management and 90.9 days for standard management). In combined studies like this you are not allowed to cherry pick results afterwards, so nobody commented on this finding, but the fact remains that if the 201 patients at the St Mary’s/St Charles site had been analysed alone there would have been a significant finding in favour of intensive case management.
But why the difference compared with other sites? The staff we had on the project had all worked together and been trained in the principles of nidotherapy, even though at that time the exact content of the intervention had not been properly formulated. So you could argue, but not with an intense level of conviction, that the significant difference at S Mary’s/St Charles was the consequence of intensive case management plus nidotherapy versus standard case management. This conclusion was to some extent supported by a later trial showing that nidotherapy plus assertive case management led to a 63% reduction in psychiatric hospital admissions with cost savings compared with assertive case management alone (Ranger et al Cost-effectiveness of nidotherapy for comorbid personality disorder and severe mental illness: randomized controlled trial. Epidemiologia e Psichiatria Sociale, 18, 128-36).
So whether there are two or three trials of nidotherapy published I will leave for you to decide. But the data are beginning to stack up and cannot be ignored or brushed away too easily.
Wednesday 20th May. Here is the list of organisations that list nidotherapy, either as one of their central tenets, part of their services or just encapsulated in their philosophy:
Cardinal Clinic, Oakley Green, Windsor
Recovery Village, Palm Beach, Florida, USA and at Umatilla, Florida, USA
Charlottetown Nidotherapy Group, Prince Edward Island, Canada
Mahatma Gandhi institute for Comprehensive Mental Health Care, Guntur, Andhra Pradesh, India
Horton Rehabilitation Services, Horton, Surrey, the very latest addition. This will be one of the venues for the Nidotherapy 2021 Workshop as we have international visitors again for this meeting. There will be more on this subject at a later date, and of course we can make no definite plans at this stage.
Thursday, 21st May. One of the important aspects of treatment in nidotherapy is to take all statements made by people in treatment as seriously as those made by a good friend. So in deciding on environmental changes remember not to dismiss too readily. Herman (this is his real name but he does not mind its disclosure) was a man with an apparent psychosis who believed that, after he was forced to leave his home, he was being placed in substandard accommodation out of personal spite. We helped to get a new flat and at first he was very satisfied. He also had a garden and we had a great time changing the colour of his hydrangea flowers from red to blue by adding acid fertiliser to the feed.
But after a bit he became dissatisfied, mainly about the noise in the house next door. He said he was frequently woke in the middle of the night by heavy objects being moved across the floor. ‘Almost always its at 1 o’clock in the morning, just when I’ve got off to sleep’. We found this hard to believe – ‘another of his paranoid delusions’ was the common response – but on investigation we found out he was correct. The house next door was occupied by the business associates of Billy Bragg, the well-known singer song-writer and left wing activist. Billy is a prolific artist and in the song-writing industry you are always under time pressure. A large photocopier and the equipment was often being moved around in the early hours of the morning and this is what made Herman wake up in annoyance. Fortunately the Bragg Ensemble were able to operate more quietly after we expressed our concerns and we were able to report back to Herman that he was correct after all.
And this was the start of Herman’s renaissance. Within two years he had joined the cast of The Teaching of Edward, an operetta based on the experience of Edward Elgar as the bandmaster at the Worcester County Asylum in 1879. Elgar has been playing for the staff at the asylum, as indeed all good bandmasters did at that time, but the patients, led by Herman as their ‘union organiser’, persuade Edward to play for them as well and force him to do so, despite all his reservations, in a noisy chorus:
‘And if the lines don’t seem like a music theme but dialogue from a madcap scene,
Please don’t mind as you will find, that we will follow right behind,
Just – take it as it goes
We’ll make sure it flows
From the tops of our heads
To the tips of our toes
This – is the path we’ve chose
Take us where the music goes’
Take us where – the – music – goes
And that is precisely what Herman did, for over 20 performances. So in nidotherapy when you do not jump to conclusions and keep a completely open mind, you never know what might happen.
Friday 22nd March. ‘One division of mental health conditions that the general population has picked up on is the apparent distinction between mood disorders and personality disorders. Those of us who, like me, have suffered from the effects of bipolar disorder like to congratulate ourselves on the purity and constancy at least of our personalities. The illness, we say to ourselves, is like the weather. It comes from outside of who we are. We might be made alarmingly enthusiastic, exuberant, grandiose and overconfident when in the grip of elevated moods, or grumpy, silent, morose and pessimistic when depression descends on us like a leaden cloud, but inside we are ourselves, all right and tight. Personality disorders, that is what the boogeyman suffers from, they are dark and dangerous territory. To be told one suffers from such threatens our sense of self and the very ownership of who we are. ‘
Who wrote this? You may have guessed, Stephen Fry. It is part of the foreword to Taming the Beast Within: Shredding the Stereotypes of Personality Disorder, 2018. Stephen, with a great interest, but no actual training, in mental health has nailed it in one. We do not like to have our personalities messed about by others; they are part of us and if you say I am personality disordered you are attacking the core of my being. This is the main reason why most people with personality disorders do not want treatment. Only those with ‘borderline’ personality disorder ask for it repeatedly, and this is one of the reasons why my colleague, Roger Mulder in Christchurch, New Zealand, and I, argue that it is not a personality disorder at all (look out for a book exposing all the kernel of personality disorder without the chaff, to be published shortly).
So not long ago we assessed people with personality disorder using a scale to find out their views on treatment. This was carried out in a tertiary psychiatric service – one which one of the members said was ‘the last chance saloon’ . We found that only one in three was Type S (treatment seeking); the others were all treatment resisting (Type R)(Tyrer P, Mitchard, S., Methuen, C. & Ranger, M. (2003). Treatment-rejecting and treatment-seeking personality disorders: Type R and Type S. Journal of Personality Disorders, 17, 265-270). Even in the group who were the most severely personality disordered, people being assessed in the Dangerous and Severe Personality Disordered (DSPD) Programme in England between 1999 and 2005, only 57% rated their personalities as Type S, even though they were on an agreed programme to try to alter their personalities (Tyrer P, et al, (2009). Assessment of dangerous and severe personality disorder: lessons from a randomised controlled trial linked to qualitative analysis. Forensic Psychology and Psychiatry, 20, 132-146). And it will come as no surprise that in a normal population a study carried out by one of our Trustees found only 13% had Type S personalities (Gardiner C, et al (2010). Associations of Type R (treatment resisting ) and Type S (treatment seeking) personalities in medical students and their clinical implications. Personality and Mental Health, 4, 59-63.
So you can see why the diagnosis, or ‘label’ if you wish to be more critical, is so despised by some. Perhaps this is the origin of stigma. ‘If you tread on my personality you tread on my soul’.
Saturday 23rd May. Critics of the term ‘personality disorder’ often refer to the instability of the diagnosis as a reason for dispensing with it. ‘Personality is enduring so how can it disappear. QED, Personality disorder does not exist. It is just a term of criticism.’ The problem in accepting this argument is that it contradicts science, or if you want to be more specific, empirical science. Investigators, with no particular bias or preconceived ideas, have shown over and over again that personality disorder, measured in its hundred different ways, is unstable over time. In some it persists for years, in others it fluctuates, in others it disappears altogether. We need to find the reasons for these differences, but one key one, linked to nidotherapy, is environment. If someone with personality disorder, no matter how severe or apparently pervasive, chooses, or happens to be placed in, the right environment for their particular disorder, harmony can be created. There is a fit between the person and the environment that is specific and may be unique. This is why we refer to nidotherapy as ‘reverse Darwinism’. It is not a particularly clever or apt term, but instead of all competing for the same place in the sun – survival of the fittest – nidotherapy competes for the most different places under the sun – survival of the adapted. The myriads of different physical, social and personal environments that exist in this planet allow all of us to have this choice. The problem is how to choose, and this is where nidotherapy comes in.
Sunday, 24th May. The treatment of personality disorder is unduly complicated, super-specialised and ridiculous. It has increasingly generated a complex self-serving mix of psychodynamic interpretation, didactic teaching and expert worship that has not helped practice.
It is also unnecessarily long. The evidence that longer term treatment is required is very flimsy. When the NICE guideline for personality disorder was going through the relevant data between 2007 and 2009 there were many studies published showing the benefit of courses of psychological treatments varying between three months and one year. In our recommendation at the end of this analysis we concluded that ‘brief psychotherapeutic interventions of less than 3 months’ should not be given for the condition. But the only significant trial (480 patients) that had tested out such a brief intervention was one for which I was chief investigator, the POPMACT trial (Prevention of Parasuicide by Manual Assisted Cognitive Behaviour Therapy). The CBT given showed only marginal benefit for CBT although it was cost-effective (10% cheaper than standard care)(Byford et al (2003), Psychological Medicine, 33, 977-986), but those with borderline personality disorder responded Iess well and cost more (Tyrer et al, 2004, Journal of Personality Disorders, 18, 102-116).
But the treatment given in this trial concentrated only on preventing self-harm. It was not focused on personality disorder. Of course you can say the two conditions overlap but there are differences that should not be ignored. So the field was wide open for other studies of short-term treatment and I am glad to say that these are now being published. And the results are encouraging. In Canada a stepped care approach showed that most patients could be treated successfully in a three month programme (Laporte et al (2018), Personality and Mental Health, 12, 252-264) and a similar study in the UK using Structured Psychological Support showed similar benefit (Crawford et al (2020) BJPsych Open, 6, e25).
What these treatments do is to take away the unnecessary fluff attached to previous treatments. Shaved down, Structured Psychological Support involves some of the elements of nidotherapy. It is ‘a person-centred approach that allows therapists to determine the exact number, frequency and duration of sessions based on clinical judgement and patient preference. During the first two sessions therapists assessed the patient’s mental health, personality difficulties and existing understanding of their problems and coping strategies in order to formulate a treatment plan, including a crisis plan.’
So this is a collaborative exercise, not a top-down model from the heights of Olympus. It needs to be known more widely. Without it we will continue to have long waiting times, great frustration and, for far too many, denial of treatment. Read Joel Paris in the latest early view of Personality and Mental Health, Access to psychotherapy for patients with personality disorders, 9th May, 2020) for the clarion call to better access.
Monday 25th May. Today is International Personality Difficulty Day. Why not? There was a Care Day on 21st February, an International Nurses Day on 12th May, and World Mental Health Day will be held on 10th October, as it is every year. The main purpose of these named days is to draw attention of the public to subjects that need greater awareness, and what could need more attention than personality difficulty. At least 2.5 billion people in the world have personality difficulty, more than any other physical or mental disorder, as further study of the new ICD-11 classification will show. Personality difficulty is best summarised as intermittent interpersonal social dysfunction. This is necessarily polysyllabic in order to fit into four words but it can be shortened to ‘environmental antipathy’. People with personality difficulty only show the problems of poor social interaction in specific situations such as formal meetings, visits to strange settings, crowds, public speaking, communal eating, competitions, large family gatherings, forced social interactions, hierarchical events (where everyone has to know their place), and assessment interviews. This covers a large range and most people with personality difficulty are able to manipulate their lives in such a way as to avoid these negative interactions. But sometimes they cannot, and every year in the United Kingdom there are reports of otherwise respectable neighbours squabbling over subjects such as the height of a garden to such an extent that homicide occurs. The forced interaction of neighbours is very difficult to avoid, and can quickly escalate.
Personality difficulty is generally mild in its effects but there is no reason why International Personality Difficulty Day cannot include all others with personality problems of any severity. I always introduce my discussions with people having any of these with a comment like ‘this suggests you may have some personality difficulty in…..’ as I find this does not offend or annoy, and can readily lead to a constructive discussion. So all those who have the capacity to lead good lives, enjoy liberty and pursue happiness, but fail to do so as completely as they would like because of the brakes imposed by their personality difficulties should be celebrated on this day. They deserve respect, encouragement, and, dare I say it, praise, for their efforts. There is no reason why their struggles should not be acknowledged every year on 25th May, when the darling buds of hope are still awaiting the opportunity to open to their full splendour.
Tuesday, 26th May. William Sargant is not a familiar name to most reading Mental Health Unblocked. But 60 years ago he was one of the most prominent psychiatrists in the United Kingdom. I first came across him when deciding which medical school to go to after completing my first degree at Cambridge University. My mother, starting a psychology career at the time, insisted I must go to St Thomas’s Hospital as ‘William Sargant is there and he’s the most optimistic psychiatrist in the country’. Indeed he was, but encountering him both as a medical student and in my first psychiatric post as his House Physician (the only one in the country entirely devoted to psychiatry), I learnt that optimism had its drawbacks. Like Donald Trump, he would never admit to failure, and so if one prefrontal leucotomy failed to relieve symptoms he was quite happy to recommend a second or third. But because of his inveterate optimism, he was popular with most of his staff, including the Nightingale nurses of the hospital, and indeed most of his patients. One of them I saw 40 years later, long after she had her third leucotomy. She was still completely convinced that ‘Will’ as she called him, with these operations had saved her from a life of constant misery.
But William Sargant was definitely a polariser, a true Marmite character. It was difficult not to choose between either loving or loathing him. What some regarded as therapeutic determination to do everything possible to help a patient, others saw as reckless adventurism, using treatments that had no basis of evidence other than his own clinical experience. He regarded all psychotherapy as limited in efficacy unless it was attuned to Pavlovian conditioning, and was convinced the way forward for psychiatry was to embrace physical treatments, singly, together, or in any other combination, until the patient was better, or at least said he or she was better. But Sargant had a cop-out. He only claimed success in people who had goodpreviouspersonality. I run these words together as he always said them very hurriedly as though they were one word. But I never saw him assess a personality in a way that was commensurate with practice at the time, so I concluded, possibly infairly, that it was an escape route to explain failure.
But personally I found him easy to work with. You could argue with him and win your point, provided it was not a major one, and I have always felt I learnt more from teachers who went beyond their brief instead of sticking rigidly within it. And although I do not like Marmite on toast or bread, I just love it when I can put a full teaspoon in a cup of very hot water and sip it till I reach the tiny bit of the brown sediment at the bottom, where it tickles my palate with a salty tang. That was the legacy of William Sargant, an old salt who sometimes got into rocky seas.
Wednesday 27th May.
I have been helping Swedish academia recently as an external referee. I was hoping that it might lead eventually to an invitation to join the Nobel Scientific Committee for Physiology and Medicine. I envisaged the letter on crisp Nobel notepaper: ‘We feel that it would now be important to have a psychiatrist on our Committee as mental science has been under-represented in our discussions.’ But of course I will never receive such a letter. Quite apart from the many other disqualifying reasons I am not a member of the Nobel Assembly at Karolinska Institutet nor the Swedish Academy and it is they who choose.
The only psychiatrists to receive the Nobel Prize for Medicine were Julius Wagner-Jauregg and Egan Moniz. Wagner-Jauregg, an Austrian psychiatrist, received his prize for the development of pyrotherapy, the deliberate infection of patients with syphilitic dementia with malaria to create a high fever, and Moniz for the invention of leucotomy. In retrospect these were not major advances, some would call them retreats, and even at the time they were awarded they were pretty small fry. Wagner -Jauregg was a Nazi sympathiser and President of the Austrian League for Racial Regeneration and Heredity. He recommended the forced sterilisation of people considered to be constitutionally inferior. Jeffery Lieberman, in his book, Shrinks: The Untold Story of Psychiatry, now told, considers that the Italian psychiatrists Cerletti and Bini were more deserving contenders as they introduced ECT.
It seems to be particularly difficult for psychiatrists to be ever in the running for a Nobel Prize as they rarely make cut and dried new discoveries. Many feel that Tim Beck is deserving of such an honour for his discovery of cognitive behaviour therapy but despite the impact of this treatment being a thousand times greater than Wagner-Jauregg’s and Moniz’s discoveries this is unlikely to be considered groundbreaking enough for him to become a Nobel Laureate. Perhaps the nearest contender is Sir Alec Jeffreys, of the University of Leicester, possible in tandem with Jeffery Glassberg (who later devoted his time to preserving butterflies (not in pickle but in the open air)), for discovering DNA finger-printing. This has done more for forensic psychiatry and psychology that the thousands of barristers and forensic experts have ever achieved and if Arthur Conan Doyle was alive today Sherlock Holmes would have carried a mobile DNA fingerprinting kit with him everywhere (in Dr Watson’s medicine chest of course).
So I suspect we will have to wait a long time for another psychiatrist to win the Nobel Prize for Physiology and Medicine. But serendipidity owes allegiance to no discipline, and it may place itself munificently on a psychiatrist who least expects it.
Thursday 28th May. A postscript on Nobel Prize winners. I have only met two of them. One, J D Watson, was one of the three winners of The Nobel prize in Physiology and Medicine in 1962, for discovering the structure of DNA. Rosalind Franklin, who had done the key work on X-ray diffraction should have been included too but she died in 1958 from ovarian cancer. Watson supported her for the Nobel Prize in Chemistry posthumously but failed. I met James Watson in 2014 at Cold Spring Harbor Laboratory during an international meeting on borderline personality disorder. I quite liked him. You knew exactly where you were with him. He was not especially impressed with the meeting and said do in earthy language. I challenged him over this, but he said that, being brought up in Chicago, he could never forget the language of his past and was proud of it. He was particularly bothered over what he called ‘this obsession with borderline personality disorder’. ‘Why can’t they look at the others, what’s so fxxxing interesting about borderline?’
The other Nobel Prize winner was John Nash, winner of the Nobel Prize for Economics in 1994, long after his famous discovery, linked to game theory. In between he had developed paranoid schizophrenia and divorced his wife, Alicia. But she was an amazing woman, as despite being divorced, she recognised the original non-schizophrenic John would not have divorced her, so she stuck by him and brought up their son on his own and kept in touch with him. His university, Princeton, also helped by allowing him to still come into the library and get involved with students. After 40 years divorced she remarried him in 2001.
When I met the family, John was remarkably well, by contrast with his son, who had also developed schizophrenia and was very keen on talking about his medication. I suggested to Alicia that John’s improvement might be related to her constant support and encouragement and suggested it might be an example of nidotherapy at work. But when I asked her straight she was quite clear. ‘It was the Nobel Prize that got him better; that was the key’. I could not but agree, but I still think there was an element of nidotherapy somewhere.
Friday 29th May. Green health
Not a day goes by in our lockdown world without gardens being given credit for both preserving and improving mental health. But what is the evidence for this? I would like to think it is considerable, not least as garden options are often frequent choices in nidotherapy. I’ve looked around but almost all the fulsome praise allocated to gardens is based on qualitative research and simple before/after comparisons that tell you very little. And of course you have to specify exactly what you mean by a garden, its size and format, and indeed its exact contents. In one study it was postulated that the most mentally healthy gardens were ones that provided a canopy so that people were surrounded not only on all sides but also above by greenery. (Zhang L & Tan PY (2019). International Journal of Environmental Research and Mental Health, 16, 578). Now you have a good research design. Vary the components of greenery systematically and measure the results in terms of mental health and function in a well-organised trial.
Saturday 30th May.
One of the most unpleasant tasks of a psychiatrist is to detain people against their will when no other intervention is possible. I have never found this satisfying and, almost invariably, it leads to a lessening of trust that is almost impossible to remove entirely, even after a gap of several years. We are all taught and trained to use as little coercion as possible yet the paradox is that we are using it more and more. Richard Bentall, a harsh critic of psychiatry but definitely not an anti psychiatrist, gives two and a half compelling reasons reasons why coercion is wrong (Bentall R. Doctoring the Mind, 2009, New York University Press, pp 272-3). The first is that coercion can be justified if the coercer (psychiatrist) really knows what is in the patient’s best interests and that is never true. The second is that coercion is unjustified if the treatment is ineffective, and the third, expressed baldly, is that ‘coercion is intrinsically damaging to mental health’. I agree completely with the third, but only three-quarters with the first two. It is perfectly possible for a doctor to act in a patient’s best interests, and it is not true that all interventions linked to coercion are ineffective. When I placed a patient with hypomania on a section after she told me she was going out to have sex with as many people in Soho as possible ‘this afternoon’, and insisted she took an antipsychotic drug instead, I think most people would agree I was acting in her best interests.
But all too often we use coercion because it is in ‘the system’s best interests’ rather than that of the patient. And despite our liberal ideas and earnest guidelines, we are using coercion more and more in psychiatry; it is increasing by around 5% every year in almost all western countries. Just in case you need reminding, but if you have got this far a reminder is highly unnecessary, nidotherapy is a collaborative venture. It never, ever involves coercion.
Sunday 31st May.
I have been pilloried for writing my book, Taming the Beast Within: Shredding the Stereotypes of Personality Disorder, with comments like ‘this is a deeply stigmatising book, with extremely outdated views on ‘personality disorders’, among others that contain significantly more abuse. Sometimes when I get criticised I can accept the merit of the comments and am prepared to row back a little, but on this occasion, with twenty coordinated diatribes posted within a few days of each other I just blink and wonder whether the critics have been reading Silence of the Lambs rather than Taming the Beast Within. (And Silence of the Lambs is indeed a stigmatising book, as Thomas Harris, with no prior knowledge of psychopathy, read every book, report, court proceedings, biography and review on the subject before combining them all cleverly in the form of the completely fictitious, and essentially unbelievable form of Hannibal Lecter. And why give him the name of Hannibal, who was very kind to his elephants and his rag-tag army as they crossed the Alps before anyone had heard of motorways).
Back to the book, what is it that is so stigmatising? After puzzling about it for two years I think I know the answer. Because ‘borderline’ is not a satisfactory diagnosis – I would describe it as a paraphernalia of symptoms, most of which we regret after showing them – it is being tossed around willy-nilly in practice. So if I go to the doctor’s surgery, as I did recently, and arrived five minutes late for an appointment with a nurse, and then have a tantrum because she refuses to see me as it is her lunch break, as ‘this is a health and safety issue’, I can be described as ‘a typical borderline’ as I have shown some of the key features of this mythical condition. But if I have a significant personality problem I am also a ‘typical borderline’ and can be treated in the same way as I was by the nurse I saw, with contempt. It is even worse if I am not seen with my problems at the time but instead told ‘I will make a referral; you will hear from X, Y and Z in the next two weeks’. I am being ignored in a different way and yet I want help pretty urgently.
I see dozens of patients who have personality disorders and when I explain to them that abnormal obsessionality, conspicuous detachment, or chronic anxiety may actually constitute a personality condition they usually accept this readily and, if not, we at least have a useful discussion to settle the matter. These people do not accuse me of stigmatising them. If I do come across someone with emotional dysregulation I usually say ‘ I suppose others say you have borderline personality disorder but you can be assured that I will never do so, as I think it does not exist.’ This sets the scene harmoniously and we do not discuss the subject again.
Monday 1st June.
People often ask me what is the scientific basis of homeopathy. Rather than going into describing the ridiculous theories of Samuel Hahnemann that ‘like cures like’ and so infinitesimally small quantities of a toxic substance simulating disease can stimulate a cure, I merely say ‘it shows the power of placebo’. And placebo not only has immense power, it does this without the presence of any adverse effects, and so is safer than any active drug. Years ago I carried out a trial of the monoamine oxidase inhibitor, phenelzine, against placebo in phobic anxiety. The tablets were bright vermilion in colour, both phenelzine and placebo, as this was a double-blind study. Phenelzine turned out to be superior, but only after several week’s prescription, but this delay suggested it was a drug effect, not a placebo one. One of the patients in the trial asked to continue on her tablets as they had been so effective. We decided not to break the code and so she persisted on the same tablets as originally prescribed. She continued to do well but we had to break the code – she had been on placebo the whole time. But still she wanted to continue, so all the placebo tablets were packed and sent to her. But when she had finished all of them she had a withdrawal reaction. I would like to think this was not an adverse effect but a consequence of suggestion, but later I concluded it was a nocebo reaction as we found a similar effect when patients were withdrawn from placebo while thinking they were on the benzodiazepine, diazepam..
So game, set and match to placebo. It cures pain, anxiety, depression, bodily symptoms and lots more. It deserves respect. But why can’t the homeopathic physicians admit it? Because belief in a crazy system of dilutions is one way of adding extra power to the placebo. And despite the House of Commons concluding ten years ago that homeopathy was no better than placebo it has proved to be the hardiest of perennials. When Thomas Wakley, the founder of the Lancet medical journal, fulminated against the English Homeopathic Association nearly two centuries ago, claiming the Associaiton was ‘an audacious set of quacks, noodles and knaves, the noodles forming the majority, and the knaves using them as tools’ (Wakley T, Lancet 1842, 2, 246) he doubled the circulation of his journal, but homeopathy still survived. Perhaps it’s something to do with the power of dozens and dozens of dilutions of criticism.
Tuesday, 2nd June.
January 9th, 1945 was quite an important day in my life. I was taken with my twin brother to my first school at a town called Adlington in Lancashire. I remember it well. Because as we were left by mother we, like many children at the age of four, were distressed at being parted and burst into tears.
‘You know what we do to stop boys crying?’ said the battleaxe of a teacher. She may not have been a battleaxe but to us she was a plundering Viking having absolutely no mercy. ‘We put their heads under that tap’. She pointed to a washbasin in the corner. This threat was not sufficient to stop the crying so we had both our heads dumped sequentially in the wash-basin and very cold – I mean very cold – water filled until we spluttered. (January 1945 was one of the coldest months on record). I remember feeling very annoyed, rather than distressed, at the time as there seemed to be no logic in this particular sequence of actions, and I was at an age when logic mattered. I also remember my head feeling very numb afterwards; my crying stopped, no doubt as I now had something else to be concerned about. But it clearly cannot have had much effect on the rest of the day as my father’s diary for the 9th January has a short entry – ‘Twins first day at Adlington School – they loved it – came home afterwards’.
I am interested to know if this experience qualifies as an ACE. This is an unfortunate term imported from the United States as it misleads. It is not one of merit or success. Adverse childhood experiences (ACEs) are potentially traumatic events in a child’s life that can have negative and lasting effects on health and well-being. These experiences are usually remembered throughout adult life and are defined as occurring before the age of 18. In the United States it is estimated that nearly half of all children have experience an ACE and it you have four or more ACEs you don’t win any jackpot but instead are much more likely to have chronic mental health problems in later life. I do not think my experience was an ACE. But some people could make it out to be. In my book Taming the Beast Within I describe my own personality difficulties in the first chapter, one of which is to behave very badly when confronted by people in authority. Could I not claim that this was a direct consequence of my basin-dunking experience at the age of four? It all depends on the word ‘potentially’ in italics above. I leave it for others to decide.
Wednesday 3rd June.
My friend and colleague, David Nutt, has been researching the potential therapeutic value of psychedelic drugs for many years. It was not a popular subject when he began his research and has still remained on the fringe of respectable scientific enquiry. But through dogged determination and an entrepreneurial spirit – involving among others, funding from Channel 4 and crowdfunding – he has established a world-respected scientific group that is doing valuable work in establishing exactly what goes on inside the brain when you take one of these mind altering (should now be brain altering) drugs.
But David was preceded many years earlier by a colleague with whom I worked in Southampton in the 1970’s, Dr Ronnie Sandison . Ronnie was not your typical psychiatrist. He was a Shetlander, and retained that streak of independence and rugged obstinacy that is characteristic of those islands. He started his psychiatric career as a consultant at Powick Hospital in Worcestershire in 1951, was appalled by the lack of initiative and shabbiness of the institution under its mean-minded director, and introduced many new ventures, including the use of LSD in clinical practice. But when the dangers of LSD became known it was shut down and some patients received compensation. But Ronnie always maintained there was value in using LSD therapeutically and he would have praised David Nutt’s work.
I remember having an argument with Ronnie about psychotherapy when we were in Southampton. ‘Can you really give me one instance where you can show me, without question, that psychotherapy is an effective treatment?’
‘I’m not in the treatment business, Peter. I’m in the Growth and Development business’.
This may be where psychedelia is going too, but we shall see. And one of Powick Hospital’s former alumni, its bandmaster when it was called Worcester County Asylum in 1879, Edward Elgar, would have approved of that statement also. His first composition was for the Asylum, just when he was developing.
Thursday 4th June. After discussion and debate with colleagues and our United Nations Rapporteur for Human Rights, Dainius Puras, we have concluded that May 26th is much better entitled International Personality Spectrum Day. This reminds us that all of us, whatever our abilities, deficiencies, assets and failings, we are all on the same personality spectrum, some nearer to one end than the other. This is the best way of emphasising that we are all in the personality pot together, and what could be a better way of removing the stigma that so many attach to the subject. So spread the word around and look forward to May 26th, 2021.
Friday 5th June. A large number of counsellors and psychotherapists whom I meet say they practise holistic or ‘whole-person’ therapy. I think I can understand what they mean, but these attempts to be sensitive to individual needs is almost always arrogant. Homeopathic specialists are fond of these terms also. The reason it is arrogant is that any therapists who think they can understand fully the workings of someone else’s mind (and body) after a short period of contact are deceiving themselves. We attempt in nidotherapy to get to know what environmental needs are wanted by understanding all the factors that come into these complex choices, but never think we have in any way understood the whole person in making these assessments.
What so often happens in counselling is that the therapist has a limited number of interventions available, beyond that of developing a good rapport with the patient (or client if you prefer), and these are then fitted to the problems being presented. There is nothing wrong with this as long as it is approached honestly. You do not have to say to the patient (client) ‘I only have a very limited idea of your problems but approach B in my repertoire often seems to work with people like you, so I am going to plump for this’, but you can say it to yourself. This is the best defence against overweening confidence and self-importance.
About a year later I arrived at work and noted a carefully hand-written stiff envelope addressed to me. Inside were a plethora of £10 book tokens and a bright thank you card with delphiniums, sunflowers, lupins and hollyhocks bursting off the page. There was a small note at the back of the card. ‘Thank you for helping me through the night’, followed by her signature.
Saturday 6th June.
Many years ago, when I has just been appointed as a consultant and senior lecturer, a depressed woman was referred to me by a colleague. I was initially flattered to be thought competent enough to see her but as I assessed her over several interviews it was clearly going to be a difficult task to make any improvement. But I continued to see her, quickly abandoning the thought that there might be a hidden antidepressant I must have previously overlooked, and always saw her at the end of the day when I had a half-hour to spare. But the progress made was very tiny, and I only continued because she insisted her interviews with me were of help. Eventually, as I was being relocated to a somewhat different area, I had an excuse to discharge her. She accepted this, not with any enthusiasm, and I wrote my discharge letter to her GP with some relief.
About a year later I arrived at work and noted a carefully hand-written stiff envelope addressed to me. Inside were a plethora of £10 book tokens and a bright thank you card with delphiniums, sunflowers, lupine and hollyhocks bursting off the page. There was a small note at the back of the card. ‘Thank you for helping me through the night’, followed by her signature.
I thought this was a very eloquent tribute, even if undeserved, and realised afterwards that it might have been inspired by, if not taken from, the pop song ‘Help me make it through the night’. But I have often thought of this at times since when I don’t seem to be making any progress with patients and blame myself for being less than competent. Psychiatrists can help by sticking with their patients, and just by being there you can be a stable rudder on a storm-tossed boat.
Barbara Taylor, in her book The Last Asylum, gives a very good example of this in her account of a roller coaster, emotionally rending, journey of an illness that seemed to cross many diagnostic barriers. It involved several periods as an in-patient in Friern hospital in north London. Throughout a period of 21 years she continued to see her psychoanalyst (even when an in-patient), whom she never identifies but who is clearly a Saint, and she gives most credit to him, and also to the reassuring ‘stone mother’ of Friern Hospital itself, for her recovery. Having stable reliable props around when you need them can be very therapeutic.
Sunday 7th June. Further discussion has led to a new form of awareness; International Personality Spectra Day for next year on May 25th. Lee Anna Clark from Indiana has reminded us that there are many spectra of personalities and we need to acknowledge them all on this special day. Now the task is to let all the movers, shakers and influence makers know about the importance of this day and its subject. Nothing could be less stigmatising than International Personality Spectra Day. It is a reminder about the most magnificent quality of humankind, our diversity.
Monday 8th June. What has nidotherapy got to do with the COVID-19 pandemic? Not much, I expect most people will say. But we are all going to be forced to make big environmental changes in the next year or so, some which we should have made long ago and never got round to implementing them, and others which could never have been anticipated a year or so ago. For some of these we will lack any choice and will just have to lump them, others will sort themselves out over time, but others will require much thought and reflection, and this is where nidotherapy may come in. There is no need to insist to yourself that these difficult decisions are to be made by you alone. Help will often be needed, and whether you call it advice, counselling, brain-storming or nidotherapy does not matter, all that matters is that the right decisions are reached. This advice is not just ‘mom and apple pie’; it needs to be said.
Tuesday 9th June. I have just realised that the day we selected for International Personality Spectra Day, May 25th, was also the day in which George Floyd was asphyxiated by an eight and a half minute police knee on his neck and three others on his back. The world-wide reaction to his death has been a refreshing wake-up call for compassion and equality at a time of international division. And, in keeping with the spirt of personality spectra, the reaction to George’s death has also celebrated diversity, and this is right in the middle of our wish to have the variability of personality, in all its forms, celebrated in the same way as variation in all other areas of life.
Wednesday, 10th June .
The impostor syndrome is a curious condition that almost became a diagnosis in some psychiatric classifications. It describes the feelings of doubt and uncertainty that affect many successful people who have the fear that they are basically inadequate and at any time they may be exposed as a fraud. It was first described in women but the assumption that it was less common in men now has been challenged. One of its curious aspects is that it is really a misnomer. An impostor is someone who pretends to be somebody else in order to deceive them for some gain; the impostor syndrome is the opposite. It is an impostor-fearing syndrome.
What has this got to do with nidotherapy. The answer lies in the environment of the sufferer. If you excel in a specific field, say at the sport of cricket, and are praised accordingly you do not suddenly feel you are fooling everybody and have no ability. You, if you are like Marcus Trescothick and Jonathan Trott, may have great troubles with anxiety and depression that impair your performance, but you do not suddenly decide you are a cricketing impostor and have never played the game well.
But if you were placed in a completely different environment where you felt completely inadequate it would be quite understandable to feel like an impostor if you had not specifically chosen that environment. I put these words in italics as it is perfectly possible to switch environments successfully if you make the choice. Greg Rutherford did this in Celebrity Masterchef recently after being one of Britain’s most illustrious long-jumpers; the link to both is the mastery of detail.
So my advice to any who feel they have the impostor syndrome is to look around. Are you where you want to be? If not, please move.
Thursday 11th June.
The Plague (La Peste), written by Albert Camus in 1947, describes an outbreak of bubonic plague in the Algerian town of Oran. It begins with a simple description of a run-down town that Camus always despised, interrupted by the appearance of hundreds of dead rats, at first ignored and then followed by the deaths of many citizens. An expression of fatal acceptance permeates the book, and yet Camus also says ‘there have been as many plagues as wars in history; yet always plagues and wars take people equally by surprise’, so atlthough we expect it we are always unprepared.
I understand the book has sold millions of copies across the world in the last three months. Why? Because we are as unprepared as the town in The Plague even thought all our public health experts tell us the plague is going to happen. I think the reason why so many are attracted to the book now is that we are in a similar position of semi-suspended animation, or existential angst as some will have it, not knowing if we are next for the slaughter or will escape unscathed. It is the helplessness that is most disturbing. This, for those who may be interested, is not a strong theme in Poleaxed, my novel about an epidemic being published in October, and if you want to get a flavour of its optimism you only have to read it. It may not compare with Camus, (what can?) but it will not leave you feeling depressed.
Friday 12th June.
My colleague, Roger Mulder, and I are writing a new book on personality disorders. This will be very different from other recent books on the subject, as worthy though these may be, they are written for the personality specialist. But this group represents a tiny proportion of the health professionals who need to know more about personality disorder. So we are writing for the generalists, not the specialists, in our book, as the latter are now highly sated.
But we need to ask ourselves why so few people outside the specialist field know about personality disorder? The reason, we believe, is stigma. We are dealing with personality disorder in the same way in which the population dealt with mental illness 500 years ago. We deny them legitimacy, we pretend they do not exist unless they offend us, and though we no longer burn them at the stake as witches, we still demonise them in a different way, pushing a tiny proportion into a box with the label ‘evil’ permanently engraved on top, and pretending the others either do not exist, or conclude they are all suffering from early rejection and trauma, so to suggest their personalities are abnormal is itself a manifestation of stigma. So we have a double pronged attack, stigma of avoidance and stigma of usage. So this explains why such a tiny proportion of people are actually diagnosed as having personality disorder in mainstream practice. We ignore them and pass by on the other side. Let us hope we can all celebrate International Personality Spectra Day next year and move on.
Saturday 13th June.
I am not a particular fan of Woody Allen. This is not his fault. It is just that for the last thirty years I have tried to get the medical public to treat hypochondriasis seriously, and he always spoils it with his barbs of self-deprecating humour, so people continue to think the subject is a joke. My favourite: ‘Its not that I’m afraid to die. I just don’t want to be there when it happens’.
Of course it is a joke against him too, as he is the most publicly health anxious person on the planet. But like many chronic health anxious people he has learned to live with it, and now is thriving at the age of 84.
But at present I have considerable sympathy with him. He knows he will go to his death, not as a great, or even reasonably good, film director, but as a paedophile. This, to put it bluntly, is not true, or even partly true, or at least this is the way I read it. Of course, nobody can be absolutely sure what goes on behind domestic closed doors but everybody accepts the following facts (in italics) and background:
- Woody Allen did not have a great upbringing but there was nothing abnormal in his childhood experiences except that he was great at magic tricks.
2. He started a relationship with Mia Farrow, a well-known actress, in 1979. She was previously married to Andre Previn in 1970, the third of his five marriages. During this marriage they had three children and then adopted three other children; Vietnamese infants Lark Song and Summer “Daisy” Song and Soon-Yi Previn, a Korean child. Farrow starred in several of his films and became even more famous as a consequence, as they were good films.
3. They separated in 1992, after which Farrow claimed Allen had sexually assaulted their 7 year old adoptive daughter, Dylan, which Allen denied. The Yale New Haven Hospital Sexual Abuse Clinic stated ‘no credible evidence was found that the child had abused or maltreated’. Farrow retained custody of Dylan afterwards. They also had an adopted son, Moses, and a biological one, Ronan. Neither Ronan nor Dylan have had contact with Allen since separation. (This is the critical point in the whole saga, but, as is so common in these situations, there is no way of resolving exactly what happened, whether it was imagined, exaggerated or misconstrued, or whether some abuse took place.)
4. In 1997 Allen married Soon-Yi Previn, who was then 27, but admitted he had been having an affair with her for five years before this. They have since had two further children.
5. In March 2020, Allen’s autobiography. Apropos of Nothing was about to be published but Ronan, now a journalist, managed to suppress its release. ‘Woody Allen is a living testament to the way society fails the survivors of sexual abuse and assault’, he wrote, and so the publishers, no doubt thinking of Harvey Weinstein, caved in.
6. Allen has been defended strongly by his wife, Soon-Yi, now married to Allen for 28 years, rather longer than Farrow’s marriages to Frank Sinatra and Andre Previn (total 9 yrs) by Moses and by former actors he worked with including Diane Keaton and Scarlett Johansson, who feistily said, “I have been very direct with him, and he’s very direct with me. He maintains his innocence, and I believe him.”
8. Woody Allen’s autobiography is now going to be published after all. People say it is very funny. His latest film, A Rainy Day in New York, a typical Allen title and literally true in that all the action takes place over one day, also went down a storm in Korea – well done, Soon-Yi.
9. Allen has never been charged with any offence. He admits it was unusual to marry his adopted daughter but the affair started when she was 21 so any talk of paedophilia here is not appropriate.
Now, unless some other factors come to light, it does seem as though Woody Allen is being pilloried unfairly. But as he says with his usual laid back style, ‘I assume that for the rest of my life a large number of people will think I’m a predator’. But his roots are in Lithuania, where they have a detached and fatalist sense of themselves, Apropos of Nothing I suppose.
The main purpose of repeating this curious saga, in which the Allen/Farrow household must have seemed more like a refugee centre than a family home, is to be more careful in what you believe when abuse is tossed around. It can be an indiscrimate weapon.
Sunday 14th June.
Yesterday evening I saw the film Goodbye Christopher Robin. It was a salutary reminder of the perils of what can be called unnecessary name fame. The film was more complicated than it needed to be. All that was necessary was to show the extinction of the innocence of childhood by the success of the mass publication of Winnie the Pooh and his friends. By introducing the name of the author’s son, Christopher Robin, into the stories, his father branded him for life. Everyone wanted to see and talk to Christopher Robin; after all he was the only real person they could talk to, and it appeared as though he was actually the author who had more or less dictated the story to his father.
So why on earth did his father, AA Milne, decide to place Christopher Robin into the centre of his stories? Was he wanting to make them more realistic, was he trying (very unwisely) to give credit to his son, or was he merely trying to be honest in describing the Hundred Acre Wood, with correct descriptions of Winnie the Pooh, Tigger, Kanga and baby Roo, Eeyore and all the other toys in the tales? I think there was a more complex motive. AA Milne was Alan Alexander Milne but never used his first names. He was not like AA Gill, the well-known restaurant critic, who deliberately kept his first two initials to remind others that his life would have led to early death but for Alcoholics Anonymous. So for some reason Milne did not like Alan Alexander, or once labelled and promoted as AA Milne he found it difficult to change. Every author likes to be remembered properly, if only as an afterthought, and by boldly putting Christopher Robin into Winnie the Pooh’s adventures Milne thought he had done a service for himself as well as Christopher Robin. But of course, by so doing, he blighted his life and regretted his decision countless times before he died.
Monday 15th June.
In June 2007 I attended a lecture by Professor Colin Blakemore, then head of the Medical Research Council. Colin is a brilliant communicator. He has the knack of talking to you, quite informally, but very clearly and in simple language, as though you were meeting together with a glass of port after a good meal. And you cannot help liking him, unless you are a convinced animal rights activist, but no more of that here.
Colin is also an honest communicator. He does not flannel his words. And what he had to say on that evening of 20th June I had to write in my diary afterwards;
‘We have a weakness in our current UK mental health portfolio. There is a relative lack of research into the most common psychiatric disorders, anxiety and depression’.
Of course he was absolutely right, but I was still surprised that he, as an expert on visual communication systems, should have been so much aware of this deficiency. I also wish his views had been shared by other colleagues at the MRC who later that year turned down my application for a long term follow-up study of anxiety and depression, together, not apart, despite good reviews. (But the reviews were very helpful and they did enable me to get funding from elsewhere, so I owe them some gratitude). Colin has also done more since in the seven years he had left at the MRC to improve matters, and in this he has been helped by the highly sensible Chief Medical Offiicer, Sally Davies, who can pick up a dud miles away even if it is enclosed in flowery language. Nevertheless, those who do research on the most common mental health disorders still need our fair share of support. The fancy and the exotic attract the news-lines and the attention but the mass of suffering is elsewhere.
Tuesday 16th June.
Many psychiatrists now avoid the subject of what we will soon be calling personality spectra as it seems to lead to trouble. But this was not true of the most influential psychiatrist in the United States in the first half of the 20th century. He was Adolf Meyer, the Swiss-born psychiatrist who moved to the United States at the age of 26 and rapidly rose through the ranks till he was offered the post of medical director at the new Henry Phipps Psychiatric Clinic at St Johns Hopkins Hospital. Although Meyer was highly influential and a good administrator, teacher and medical leader his writing was opaque and boring, and nothing he actually wrote can be repeated as memorable. But he had good ideas, and once you are able to process his prolix Germanic sentence construction important messages lie beneath, as I found out by going through the three volumes of his collected papers (available at the Royal College of Psychiatrists Library).
He coined a term that, unsurprisingly, nobody remembers, called ergasiology, the study of mental illness viewed as a consequence of disordered personality rather than pathology of the brain. This complicated diagnosis greatly as he considered every individual to have a personality derived set of responses to stress and disease that were described as reaction types (ie individual reactions rather than disease exposure).
This was unmanageable as a psychiatric system, and when Meyer combined them with psychoanalytical additions they became even more unhelpful. But we need to acknowledge that Meyer’s ideas are still with us, and if he had concentrated more attention on variations in personality he would have had a greater influence. His teaching programme of making every student assess personality in themselves and in others could still be used profitably in practice today.
Wednesday 17th June.
Jim Wight was a vet in Thirsk, North Yorkshire. He would have been remembered just as a friendly highly competent vet but for the fact that he wrote. Everyone now knows him as James Herriot, a top-selling writer with his books based on his veterinary experience in North Yorkshire. He based his books on his day to day experience of looking after pets and farm animals, and these were not only newsworthy as an illustration of veterinary practice but were also very amusing. Ever sense reading the books and looking at TV series like All Creatures Great and Small I have mused about the equivalent in mental health practice. The difference is that you can write about the lives of vets and their families and get away with just a little sensitivity and only minor changes in names. The main characters are the animals, and they do not have the wherewithal or the inclination to issue writs for libel, so they can be described exactly as they are.
But of course psychiatrists cannot do this with the same abandon as they have their patients’ sensitivities, and those of many other people, to consider. Nevertheless, I am ready to have a go. In this set of disparate comments on mental health I am going to make a James Herriot break for candour and have already included a snippet or two . Here is a third.
Some years ago I was involved, as the consultant in a multidisciplinary team in treating a very uncommunicative patient, whom I will call Jean. I was trying to introduce the idea of nidotherapy to her but she never stayed long enough to have any form of proper discourse. What was even odder, although she never expressed interest in any material things, she had the habit of going into fashion stores, picking up garments without paying for them, and then leaving without trying to conceal what she had stolen. So of course she was arrested and we had great difficulty in keeping her out of prison.
Eventually she was detained in hospital under a section of the Mental Health Act. But because she was as quiet as a mouse most of the time she was often left unsupervised. So it was not difficult for her to escape. Shortly afterwards I received a call on my mobile phone from the team leader to say that she had left the ward and was now at her parents’ home in a town not far from London. This was a town like Saffron Walden but wasn’t, as I cannot be as accurate as James Herriot. At the time I was phoned I happened to be in a town not far away, so after after a few minutes on the phone I said I would go and pick her up from her parents’ house and bring her back.
I was preparing my journey when I was called again. The team had just met for a risk assessment and I was expressly forbidden to go and pick up Jean. I was not used to being in this position and was somewhat taken aback. Then my personality difficulty took over and I said that I was going to ignore this instruction. My reasons were (i) Jean was unlikely to refuse to come back with me in the car (I knew her well enough for that), (ii) I had already met her parents as I had given a talk at a meeting near their home and knew they would prefer me to see her than have police and an ambulance outside, (iii) I would have the bonus of an uninterrupted car journey with her and might find out something new, (iv) it would save the NHS and the police service a considerable sum of money if I took over their responsibilities.
Now I would like to think that I performed a rescue as dramatic as James Herriott at his best, and that I could report a breakthrough in Jean’s case. But I didn’t. I arrived at the parents’ house, was given tea and cakes and found that Jean was relieved to see me rather than a policeman. She happily came with me in the car and it took nearly three hours to get back to the hospital as we travelled through London’s rush hour. So I did have a long and relatively uninterrupted conversation with her and only found that her view of the world was pretty bleak and she had no ideas for changing it that could allow me to think of a nidotherapy programme. But I did save the NHS quite a bit of money by my actions, and I repeatedly point out that it is cost-effective, even if the cost sometimes trumps the effectiveness. One other decision I made that day – that I would retire from community team activities. I was, as so many of my patients used to remind me, past my sell by date.
Thursday, 18th June .
When people become psychotic they often develop grandiose ideas. Believing yourself to be an important figure from the past is an extension of this distorted belief system. In my experience, for reasons I can only guess, Napoleon Bonaparte and Jesus Christ are the most common figures from history to enter into this delusional system.
I had an unusual problem when I visited the in-patient ward of the hospital for a regular review. ‘We’ve got a real problem on our hands. There are now two patients on the ward who both believe they are Jesus Christ. Its causing havoc on the ward. They keep shouting, each saying he’s the real Jesus Christ and the other is an impostor, and they’ve almost come to blows’.
This is not a problem discussed in psychiatric textbooks so it required a little lateral thinking. After a short time contemplating I arranged to see each patient separately in the doctor’s office and gave the same talk to both of them. You could almost call it a sermon.
‘If you are Jesus Christ you need to behave like Jesus Christ. Where in Bible do you hear about Jesus shouting and cursing? Nowhere. He was gentle and believed in kindness, peace and charity, and commanded us to love our neighbours as ourselves. I do not know which one of you is the real Jesus Christ, or if either of you are, but the best way to show this is by showing me how much you love each other’. It worked, at least for long enough for their mental states to improve. They went back into the ward and became excessively polite and attentive, not only to each other but to all the others on the ward. Some began to believe at least one of them was telling the truth.
Friday 19th June. Acronymania.
This piece is about a serious condition that appears to be highly infectious. I refer, of course, to the accelerating use of the disease of first-or-sometimes-other-letters-being-joined-together in unlikely and usually forgettable capitals, known as acronyms. When I was growing up there seemed to be no place for acronyms. Of course, this was not entirely true, but acronyms like RAF and RN were so well known we saw them as ordinary friendly words; at least everyone knew them. Now it is impossible to read any article in what is commonly called a ‘learned journal’ without coming across dozens. Perhaps the word learned is used because you have to be very clever to understand what these acronyms are all about.
This completely spoils reading. Typically, you cannot remember the acronym and so are forced to go back to the part of the text where the full name is given (it sometimes isn’t, so you have to guess) and then hope that you can retain it in your head for long enough to fit it in to the place you had just left. Every large research study has to have an acronym now. The best ones are those that cheat by using words that already exist, so the very large UK Biobank just takes the generic word ‘biobank’ (a biorepository that stores biological samples for use in research), adds UK and everybody knows what it means.
People spend hours thinking up acronyms for research studies. I used to be considered a good case of acronymania, but I am not sure if it indicates a severe case of the disease or just a somewhat warped sense of humour. So when I thought up the acronym BOSCOT – A Randomised Controlled Trial of Cognitive Behavioural Therapy in Borderline Personality Disorder (note BOrderline Study of COgnitive Therapy) it went down well with my colleagues. The head of the investigating team was a highly organised Scottish psychologist and some people saw a connection (sorry Kate, it never entered my mind).
We have just finished an 8-year study called CHAMP. There are others studies with this acronym but I felt ours was the most accurate (Cognitive behaviour therapy for Health Anxiety in Medical Patients) as this is precisely what it was. But we did even better with our patient support group that was called CHASSIS (Committee of Health Anxiety Sufferers Supporting Increased Services). My colleague Mike Crawford is very skilled too, so a study of treatment in bipolar disorder had to be called LABILE.
But I have found the disease is most prevalent in Chinese research workers. Perhaps it is related to acronyms being part of their upbringing from an early age. Recently I was in Chengdu in Sichuan Province helping young, very enthusiastic, ambitious students write their first scientific papers. One of these papers had me running round in every descreasing acronymic circles. Here are some of the acronyms used (some were not even translated and are omitted):
AHC (Avoidable Hospitalisation Conditions)
ACSC (Ambulatory Care Sensitive Conditions)
AHRQ (Avoidable Hospital Research Questionnaire)
E2SFCA (Enhanced Two-Step Floating Catchment Area)
NRCMS (New Rural Cooperative Medical Scheme)
PPAP (Precise Poverty Alleviation Policy)
TPA (Targeted Poverty Alleviation)
And these are English – what would have they looked like in Chinese?
It was Mark Twain who showed the importance of brevity in authorship. ‘Writing is easy. All you have to do is cross out the wrong words’. The trouble is, most people don’t know which ones they are, but acronyms would make a good start.
Saturday 20th June. O tempora, O mores
I have just been catching up on memories by looking at a replay of the Brtish General Election in 1970, which Edward Heath won somewhat unexpectedly. Compared with today it was all pleasantly amateurish to see election results announced like prizes at a low cost auction and terse comments made in cut-glass accents – ‘you’ve got it quite wrong. You’re thinking of me as a military man. But I’m not a military man any more. I’m a politician, So if you continue to treat me as a military man you’ll go wrong’.
But what struck my attention most was an interview carried out during the results interval between Cliff Michelmore, Robin Day and Janet Fookes, who had just been elected as MP for Merton and Morden in south London. It is so grossly sexist it looks like a parody, but it definitely happened and at the time nobody blinked an eyelid, apart from the two male interviewers, who could not take their eyes off her.
“Now we have to welcome a lady MP”, says Robin Day. “Mrs, or rather Miss Fookes; she tells me that no-one has ever plucked up the courage to ask. Now that might represent a challenge to any bachelor in the House of Commons, one in particular. Are you interested in sailing and music, Miss Fookes?” Now the unperturbed Miss Fookes did not walk out or slam back “am I here to answer questions about politics or titillate your fancies? My impression is you are a sexist scumbag and I think I will leave now.”
No, she smiles graciously and seems completely unperturbed, then adds ‘Mr Day, are you starting a matrimonial agency?’.
He then asks her how old she is. “Must I,” she replies. ‘Yes you must’, says Robin the Gauleiter.
“Well I must say you don’t look anything like that. Miss, what are your interests? “
At this point the unperturbable Miss Fookes decides she is being chatted up. Just to check she asks, “politically or personally?”. Robin pauses for a second; he really wants to say ‘personally’ but he realises he mustn’t and so replies, “politically and professionally”. Then, just in case you had any doubts that you were looking at the Miss General Election Beauty Pageant rather than an election night results programme, Cliff Michelmore then adds, “ Miss Fookes is the most gorgeous redhead. If you are seeing this in black and white, it is something you are missing”. He wanted to add “next we will see Miss Fookes in her swimsuit” but was unfortunately interrupted. Baroness Fookes, as she is now, after a career including the position of Deputy Speaker of the House of Commons, has looked at the old film clip and explains her equanimity by saying ‘I was just so pleased to be elected as an MP, and women at that time were not expected to fulfil the roles they do now’. Well done, Janet, you were part of the process that made these roles happen.
Sunday 21st June
Are authoritarian rulers personality disordered? This is not an easy question to answer. A great deal depends on your political beliefs. If you are liberally minded you will tend towards a positive answer to this question. Authoritarian rulers deny free speech, suppress opposition, and rule by coercion, not consensus. ‘If you want want a vision of the future – imagine a boot stamping on a human face, forever’, wrote George Orwell in 1984, the most awful contemplation of the liberal mind. But of course, if you are conservative, a supporter of good law and order, and like to have both your life and that of others regulated properly so that chaos and uncertainty are kept away, then the authoritarian approach, provided you personally are left alone, has considerable attraction.
When people search for individuals to label as the most severely personality disordered they often pick on the most authoritarian of authoritarians, Adolf Hitler and Joseph Stalin, not least as they were responsible for the deaths of more people than any other people on earth. But if you look at their early lives, when our adult personalities are set down, even if not manifest immediately, we come across contradictory facts. Adolf was a somewhat strange isolated boy but he was good at painting. He was determined to be aprofessional artist, and if he had succeeded in passing the entrance examination of the Academy of Fine Arts in Vienna in 1907, or even at the second attempt in 1908, would we have seen the Third Reich? I doubt it.
His views about race were set at any early age but when my colleague, Desmond Henry and I, interviewed a person who knew Hitler and his background, for personality assessment, these views were said to be typical of the area where the Hitler family originated and not that abnormal (Henry D, Geary D and Tyrer P (1993). The personality of Adolf Hitler: a reassessment. Irish Journal of Psychological Medicine, 10, 148-151). But as an artist he would never have had the power to inflict on others later.
Joseph Stalin was even more atypical of personality deviation. When I visited his home town of Gori in Georgia recently I visited the Joseph Stalin Museum, seemingly staffed universally by his avid supporters, who tried to put me off reading a book by Robert Service in the Museum library by saying it was too biased (it is actually one of the more favourable biographies). I was told, and shown, all the details of Joseph’s early life, how well he did at school, how much he did for his village and helping others, and found it hard to believe this was all propaganda. In his late teens he also discovered poetry, and in giving talks on personality I sometimes read one of his poems, To the Moon:
Do not hang your head
Scatter the mist of the clouds
The Lord’s providence is great
Gently smile at the earth
Stretched out beneath you
Sing a lullaby to the glacier
Strung down from the heavens’
Not bad for a callous psychopath responsible for the deaths of 4 million Ukrainians. Nobody ever guesses the identity of this poet with his lovely metaphor of a glacier strung down from the heavens. They only think of his glacial indifference to the deaths of others.
So here we have a lonely artist and an inspired poet maturing to be psychopathic monsters. It just shows the power of the environment.
Monday 22nd June.
You know when a government appoints a Minister of Mental Health that psychiatry has suddenly become key. After all, you never get a Minister of Orthopaedics or a Minister of Sexual Health, although they may be equally important subjects, and it would be quite interesting to see questions in the House on these subjects. It was Australia, I think, that led the way in creating Ministers of Mental Health for each of the states in the country. It is very good for public relations, and when I was talking in New South Wales a few years ago it was rewarding, if somewhat surprising, to be welcomed by a mental health team from government, and even though there was nothing novel in their speeches it made international visitors such as me feel unjustifiably important.
In the UK, Scotland was the first part to have a Minister for Mental Health, initially combined with sport and health improvement – why not indeed, they interleave. The current minister, Clare Haughey, has been a mental health nurse and before being appointed was the nursing manager of a mother and baby unit. In England, Jackie (Jacqueline) Doyle Price was appointed shortly afterwards with the title of Minister for Suicide Prevention. Now that is a poisoned chalice indeed. Nobody actually knows how to prevent suicide apart from economists and warlords, as it is only military and economic catastrophes that alter national suicide rates. We try as psychiatrists, we really do try, but we only seem to tickle the edges of the problem. Poor Jackie was a supporter of Theresa May and left the government when Boris Johnson was appointed. She was succeeded by Nadine Dorries, a highly colourful MP, ex-nurse and author, who always reminds me of the firework I particularly liked as a child, the rip-rap. This was an unpredictable explosive device that jumped in the air when the touch paper was first lit. You then thought it had finished performing but no, it jumped again very shortly afterwards, took a different direction, and continued doing this several times before fading. Nadine Dorries is a rip-rap. You never know when, or where, she is going to cause an explosion. Her job role now includes mental health, suicide prevention and patient safety. For a rip-rap the last is very important.
Tuesday 23rd June.
I used to work at Mapperley Hospital, a mental hospital built in 1880 and closed in 1994. Of course, it did not start life with this name, it was the Nottingham Borough Lunatic Asylum, and the whole town knew it. When I used the play the fool with my children and went too far, they used to whisper ‘shall we send for the yellow van’ (‘shall we’ almost always replaces ‘will we’ in Nottingham). I ignored this, thinking it had no significance, but found out later that it was the ‘yellow vans’ that used to carry patients to Mapperley Hospital.
Mental hospitals in the 19th century were traditionally built in the countryside – the out of sight, out of mind philosophy – but as the asylum had to be built within the Nottingham boundary there was little choice, so it was placed on a steep hill just below the northern perimeter of the city.
Mapperley Hospital achieved a justified degree of fame in the 1950’s by being the first hospital in the country to unlock all its wards, this being achieved as the instigation of Duncan MacMillan, the far seeing and determined Scottish Physician Superintendent. When I was there it was a little dilapidated. I worked in the North Wing of the hospital, the less favoured part as a spanking new academic unit was in the South Wing, but eventually, when the hospital closed the North Wing got its reward and became the new Duncan MacMillan Centre. It was beautifully refurbished; what a pity the patients never saw it.
Despite Dr MacMillan’s achievements the hospital remained stigmatised – the yellow van mentality was slow to die – and I found patients much preferred to see me at the new general practice clinics springing up all over the town.
The hospital itself was a friendly and welcoming, if at times a little stodgy. In the room above the office the old records of the hospital were stored. At idle moments I used to look at these, and what surprised me was the degree of ritual that dominated the lives of everybody, and this extended to the time of Duncan MacMillan, who even use to open the junior doctors’ post and insisted on all staff acting charades on Christmas Day.
So the life of the average patient in 1890 was a pretty stultifying one, with an early rise at 6am, breakfast at 8am, work in the gardens or the hospital until 12.30pm, with afternoon work until the 5.30 pm bell, dinner at 6pm and bed at 7.30pm. I tried the envisage the job satisfaction of the night attendant in the early 1900’s, who wrote the same words in copper plate writing: ‘All inmates slept well, Nothing to report’, for each page of the records, repeated month after month with only the handwriting becoming a little more wobbly as the attendant aged.
We now think of these buildings as anachronistic remnants of our history but they had much in their favour. They offered space, occupation, acceptable food and clothing (not quite so good on the clothing) and, for many, they offered security, perhaps too much as they often did not want to leave. Barbara Taylor, in her fascinating story of life through extreme emotional instability (The Last Asylum, 2014) came to respect Friern Hospital, one of the largest mental hospitals in the country, as a ‘stone mother’ when she was at the limits of despair. She comments that it would be difficult to get this support today. ‘Wards are overcrowded, jammed up with people who do not want to be there. Staff is overstretched; patients overlooked; the atmosphere is often very fraught. The result is an acute-care system described as ‘broken and demoralised’, with some wards so chaotic and frightening that people badly in need of care will not enter voluntarily’ (pp. 254-5). Barbara is dead right – I’ve been there too.
So perhaps it might be time to look again at the positive aspects of the old asylum. The stone mother is not yet done.
Wednesday 24th June.
I have recently joined a Webinar with Philip Pullman, who reminded all prospective novelists that they were absolute despots before their books were published and so could write anything they wished, but once the books appeared in print complete democracy took over. Anybody could say anything they liked about the book and the author could do nothing about it, unless it was libellous. Of course when you think about it this has to be true. It is even true of non-fiction books, as although reviewers assess early segments the author is then left to get on with the remaining 90% without interruption or change.
This is not true of published articles in peer-reviewed journals. Here the peer reviewers can completely macerate the original text, spit it out and make the author write something completely different. David Owen, former foreign secretary, wrote his first scientific paper for over forty years (on the hubris syndrome as an acquired personality disorder, (Owen D. Clinical Medicine 2008, 8, 428-32)), followed shortly by another, and said how surprised he was by the directness of reviewers. They take no hostages, spare no criticism if harshness is due, and are often blatantly rude, and for someone used to the public niceties of government correspondence this was quite a shock.
So you would think that that most scientists would want to put their thoughts into books rather than into competitively published journals. Not a bit of it. We all rush into journals like Gadarene swine, take all the rejections and rudeness that is going, and come back for more. We only reserve writing our books for times when we have more leisure, even though they are the proper legacy of our scholarship, written in our own words, without interference or word limits, ridiculous constricting author instructions, or artificial deadlines.When will academia come to its senses and realise that good books are the answer; good journals are just back-ups.
Friday 25th June.
‘Go on, analyse me.’
This was the instruction most commonly given when I first became a psychiatrist and had to admit my profession at those awful social occasions where I knew nobody. I never felt able to respond to this adequately, particularly when it was followed by ‘have you got a couch?’ In the end I concluded that it was only intended as jest, even though it only qualified to be at level one on a ten-scale joke meter. But at least there was a coherent response in this instance. Often there was no answer at all when I admitted my occupation, just a strangulated grunt or a badly suppressed guffaw.
That was a very long time ago. Things began to improve a little in later years but I have to admit I often felt embarrassed about admitting what I did in my working life. When I became a community psychiatrist I found it difficult to explain exactly what I did and used to chicken out and say, ‘I’m in community health’. This led to useful discussions about prevention and wellness so I did not need to explain further.
The word ‘self-stigma’ is often used to explain the behaviour of psychiatric patients who feel they are undervalued and misunderstood and so lose heart in trying to overcome their problems. I think in these early years I was carrying a little self-stigma around with me too. I felt I was in a different profession, less important than others, and just had to get on with my work, expecting it to be under-valued.
In the last ten years there has been a big change. Now everyone wants to talk about my work, what it feels like, and whether it is fulfilling. So we have moved a considerable way along the parity of esteem pathway. But will we ever get to the end of this tortuous road, at the point when newly qualified doctors can boast to their colleagues that ‘I’ve got a job in psychiatry’ and be envied? I think not, at least not for 200 years.
Friday 26th June.
My first ‘post’ in psychiatry should have been in Rubery Hill Hospital in Rednal, formerly Birmingham County Mental Asylum. ‘Post’ is put in quotes as I was only 18 and cycled there after I had finished my schooling nearby and a long summer lay ahead.
I arrived at the front entrance and introduced myself. ‘I am hoping to become a psychiatrist and would like to start as a volunteer here if it were possible’. This was clearly not a common request. I received a curious look, almost as though anyone wishing to work as a volunteer at this particular hospital must have a completely different motive quite separate from volunteering. But, after confirming that I was not an escaped patient or up to some other mischief, I was escorted to a room next door to one of the wards at the hospital and asked to wait. I remember the chair. It had a soft pad in the middle but this was very thin and after being prodded by hard wood I kept on getting up and walking around before seating again. I could not help noticing that the room and the ward nest door, which seemed very somnolent, were both very clean.
After what seemed to be about an hour but must have been shorter, a man looking like a surgical attendant with a white coat came in.
‘I’m sorry. This has been discussed with our union representatives and they feel it would be out of keeping for you to work here’.
But, I protested, ‘I promise not to get in the way. I just want to see what everyone does’. This was not helpful. They probably saw me as a reporter now.
‘No, there is no room for discussion. You should leave now’.
So that was my first encounter with psychiatry. Many years later I found out why everything was so clean at the hospital. The physician superintendent, Thomas Greaves, also a surgeon, was a strong advocate of the focal sepsis theory, the hypothesis that much of mental illness was caused by rotting teeth, grumbling appendices and other putrid sites of infection. So he brought dentists and surgeons into the hospital and many patients with sever mental illnesses like schizophrenia were treated by surgery, not any form of medicine or psychotherapy, the last of which Graves abhorred. But he was not regarded as an outsider. He was regaled as a psychiatrist who was bringing the subject back to medicine. He was elected President of the Royal Medico-Psychological Association in 1940 and held the position throughout the war. He was obsessed by cleanliness in his hospitals (he ran three) and only retired in 1950, just nine years before my abortive visit. I do wish in retrospect, I could have been at the hospital for a short time and seen the scars of these surgically treated patients and found out what they really felt about this focal sepsis business.