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The RSM’s Global health and human rights film club launched on 8 September 2011 with a screening of director Mark Hopkins’ Living in Emergency.

Filmed in the war-zones of Liberia and Congo it follows four volunteer doctors providing emergency care under the aegis of Doctors Without Borders/Médecins Sans Frontières (MSF).   The film’s urgent title is borne out by its content.   The doctors work in chaotic overcrowded clinics, there is limited diagnostic equipment and often they have sole responsibility for the lives of all the patients they treat. 

The stress of this situation runs through every frame and every line of dialogue.  “The demand is pretty much infinite” says Dr Christopher Brasher.  “It’s just a matter of choosing what you can do”.  The film shows that the inadequacy of what MSF’s doctors can offer is in direct contrast to the enormity of the task with which they are faced. 

Brasher, a veteran of several conflicts, wants out but wonders where he should now call home.  American surgeon Tom Krueger works in Monrovia’s only emergency hospital and is on his first assignment, having grown disillusioned with the contribution he could make at home.  He appears to cope the best, but struggles to live with his inevitable mistakes. 

Davinder Gill, 26 years old and working in remote bush, is overwhelmed and exhausted by his responsibilities.  His irascibility makes him the most compelling character, his frustrations leaving him unguarded in front of the camera.  Perhaps inevitably Chiara Lepora, the head of the Liberia mission, compares him to Conrad’s Kurtz, driven mad by the insanity that surrounds him.    Like the majority of MSF doctors who never make it beyond one 9 month mission, Gill is unlikely to volunteer for a second time.

When conflicts end, healthcare needs remain and the film sensitively shows how difficult it is to leave.  Also here are the gore, personal conflicts, and difficult compromises that day to day MSF work entails.  This is no recruitment film for MSF, but a forceful character study of people close to their emotional limit. 

It’s a shame that couldn’t have gone a bit deeper, as its subjects’ back stories remain untouched.  A more serious omission is total lack of any local viewpoint on MSF interventions or volunteers.  Without this, their suffering becomes a mere backdrop for the disillusionment of Western idealists.

Living in Emergency press page for further reviews

Also published on BMJ blogs

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I was asked to review this book for the British Journal of Psychiatry.  For various reasons I wrote two different reviews of which this is the first; the second will appear in the journal and anyone keen can compare the viewpoints for subtle differences.

When critics state that psychiatry lacks both a firm logical foundation and a grounding in psychology and neurobiology, Prof MacKinnon thinks that they have a point.  In addition he considers that psychiatrists have no clear concept of ‘the mind’, the organ we treat.  This is in contrast to other medical specialties; whilst a psychiatrist would struggle to explain what ‘mood’ is for, a renal physician could easily relate the dysfunction of a diseased kidney to its proper physiological function. 

It is these failings that Trouble in Mind seeks to address.  The unorthodoxy of its approach is to build up, from first principles, a functional model of the mind (‘a function of brain’) and to place psychiatric problems within this working system.  With the brain’s shape and structure as a starting point, three further levels of increasingly complex cerebral activity are examined in detail.  At each level adaptive function is linked to the dysfunction seen in mental disorder

Trouble in mind threatens to be a classic of non-mainstream psychiatric thinking.  It has a novel approach that makes intuitive sense.  MacKinnon’s influences are clear.  McHugh and Slavney have been colleagues, and he cites their classic The Perspectives of Psychiatry (amazon.co.uk / amazon.com) several times.  As an ‘introduction’ it is cunningly aimed at trainees who may be open-minded enough to pick up and run with its ideas.  But alas it ultimately fails to deliver. 

The concluding chapter ‘psychiatric mind’ is problematic.  This is dedicated to the treatment of mental illness as a problem of the adaptive mental functioning the book describes.  As the book’s crucial denouement one might expect this chapter worthy of detail but curiously it is only twenty pages long and MacKinnon’s argument is left underdeveloped and unfinished.  The reader is left without adequate guidance as to how a disciple of these insights might integrate them into everyday practice and research. 

Perhaps a second edition could address this shortfall.  I hope so, as MacKinnon has a good point to make, a clear command of his subject and this book is well written and never dull.

Book website

(Smile or Die -  UK edition / Bright Sided - US edition buy at Amazon.com)

Smile or Die is social critic and author Barbara Ehrenreich’s examination of the stronghold that positive thinking has on America.

She first encounters this close-up when diagnosed with breast cancer.  She is encouraged to be positive about her condition, almost to the point of considering it a gift allowing spiritual growth.  Rather than embrace this way of thinking, she finds it sinister, and the pink ribbon she is offered infantilizing. 

Looking further afield, Ehrenreich finds that the notion that positive thoughts lead to positive outcomes is pervasive.  She can find no scientific evidence for this, but regardless the notion has become the basis for several best selling books, including The Secret.  The threat is, Ehrenreich writes, that if you do not think positively then you will not thrive.

Ehrenreich says that positive thinking has also percolated into the work sphere.  She identifies this as a source of social control.  People who are laid off are told this is an ‘opportunity’.  This then feeds into the current American paradigm whereby misfortune is never the fault of the system, but rather in an individual for not thinking positively enough.  How could social inequality be important if you can become rich simply by thinking about it?

The solution?  Ehrenreich would like to see herself as a realist, not someone who champions despair.  Instead we should try to see the world as it really is. 

By a stroke of luck that’s what I’ve been trying to do for many years. 

Links

Guardian review 9 January 2010

BMJ review 18 December 2009

RSA animate video

 Interview on R4 Start the week 11 January 2010

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Anna Minton’s book, Ground Control, is about the relatively recent phenomenon of the privatization of public space in the UK.  In city centres, what might once have been public space is now privately owned and managed.  Although seldom noticed, this provides a very different culture and environment; certain behaviours and people are encouraged whilst others are seen as undesirable and excluded. 

Minton traces this trend back to the 1980s, when London’s Canary Wharf and Broadgate centre were built.  Since then private ownership has become a template for all new city developments.  Similarly, most new houses are now built as gated developments.  Although the perception is that only the wealthy live in these high-security environments, in fact it is equally prevalent in social housing. 

The result, Minton argues, is a more divided and security conscious population and environment.  Paradoxically, she writes, increased security actually makes us feel less secure, as security is as much an emotional and physical state. 

One of her conclusions is that this pervasive fear over safety is linked to overall population well-being.  Levels of UK unhappiness have been reported to be twice those of continental Europe and Minton writes that this is due to their stronger civic life where the ‘architecture of fear is the exception to the rule’. 

Minton’s book is interesting, and it remains timely as her ideas can now be reread in light of the recent UK-wide civil disturbances.  Whilst I do find her overall conclusions somewhat speculative, she illuminates an issue that is rarely acknowledged or discussed.

Ground Control synopsis

Anna Minton on Start the Week R4 (she’s the last guest)

Anna Minton website

The London River Park: place for the people or a private playground? Observer 13 November 2011

Published in 20-27 August BMJ

How does the biggest trial unit in Europe balance the individual needs of hundreds of patient volunteers with the demands of participation in studies of treatment? Stephen Ginn reflects on a two part radio documentary

Of all maladies, few so occupy human fears and efforts as cancer. This is not without justification because many of us will eventually receive this diagnosis. For an individual, cancer brings uncertainty about the future and places strains on close relationships. In many cases the disease will progress and be accompanied by failing health and prolonged treatment. Western societies, which venerate youth and are on uneasy terms with death and decay, provide little preparation for a terminal diagnosis.

The complexity of the disease is perhaps why cancer and its treatments are imbued with metaphor. Although many nuanced concepts are understood in more familiar terms, cancer is unusually well suited to be described in this way. The martial metaphor is the most common. A patient (a soldier) fights cancer (the enemy) with chemical, biological, and nuclear “weapons.” Another metaphor is that of a journey. This is more applicable when thinking of cancer as a chronic disease, where the trajectory through life is diverted, leading to new goals and redefined definitions of progress.

Responses to cancer are the subject of Behind the Scenes at the Christie, a two part BBC Radio 5 documentary. Based in Manchester, the Christie is the largest cancer treatment centre in Europe, treating 40 000 patients a year. It is also the largest early phase clinical trials unit in the world, and at any one time 200 treatment trials are taking place.

In the programme, presenter Geoff Bird interviews the patients, doctors, and nurses who take part in the Christie’s trials. Although there is a lot of interesting factual content, the exploration is primarily emotional as Bird focuses on the motivations and challenges that face the patient volunteers and staff. What emerges is a portrait of an institution with a clear sense of mission, and touching emotional portrayals of patients.

It is a remarkable thing to take part in an early clinical trial of a cancer treatment. The sacrifice is substantial because participants undertake to spend a substantial slice of their remaining life span in clinics, and to be given potentially harmful treatments from which they are unlikely to benefit. Yet their contribution is essential; all cancer drugs currently in use have started life as trial treatments.

The challenge for the Christie’s staff is to ensure that patients feel valued while maintaining the rigour of their trials. Managing patient expectations is also vital because there are no “magic bullet” treatments (another metaphor). A common complaint from trial participants is that they dislike the possibility of being placed in a study control arm. I was interested to learn that different types of cancer bring their own challenges. Patients with lung cancer experience a lack of sympathy as a result of the perception that they are responsible for their own condition. Progress in breast cancer is slow because current treatments are fairly effective, and ethical approval for a trial is hard to obtain. Brain research has a lack of funding; patients with this cancer are often too disabled to fundraise.

Bird’s style is gentle and empathic, and the interviews that result are moving. His discussions with his patient subjects rarely venture far beyond their condition and relationship with the Christie, yet we also learn much about their lives and families. It is clear how much cancer becomes part of patients’ lives and how vital family support is to their recovery.

The motivation for a patient to take part in a trial with such a low chance of success is not what you might immediately expect. Some patients are holding out for a cure, but the narrative that Bird elicits is that participation in the Christie’s trials has lent them renewed purpose. In many cases trial inclusion affords them the opportunity to redirect the narrative of their lives from that of victim to pioneer.

Which metaphor best suits the Christie and its trials as portrayed in these programmes? With the martial metaphor the Christie could be an “experimental weapons division.” Bird may agree with this because he describes one patient as acting with “a quiet heroism.” Finding new sources of strength and purpose is more consistent with cancer as a journey. One story of transformation after treatment at the Christie is almost magical. Richard Jackson’s metastatic melanoma, which was advancing rapidly, disappeared after treatment with ipilimumab.

The approach of thinking about cancer in terms of metaphors has its limitations, and likewise this documentary leaves some stories untold. Patients for whom trials hold no appeal are mentioned only in passing. Similarly, the programme only occasionally profiles patients for whom treatments have failed. Bird’s interviewees are largely positive in their outlook, despite their prognosis, no doubt in part because of the practicalities of recruitment of interviewees and the requirement for reasonably upbeat radio, I wonder to what extent they feel obliged to behave in this way, a situation recently criticised by Barbara Ehrenreich in her book Smile or Die.

Of course no two hours of radio can do justice to a subject as complex as cancer treatment, and omissions are inevitable. These quibbles aside, Behind the Scenes at the Christie intelligently covers essential and unsung sacrifice.

BBC page

Amazon.co.uk link / Amazon.com link

Epileptic is a memoir of childhood and disease, and also tackles the dreams and fantasies of emerging maturity.  When Pierre’s brother, Jean-Christophe, develops epilepsy age 11, his family is profound affected.  In a search for a cure his parents seek the advice of all manner of alternative therapists, mediums and communities; but alas any improvement is often short lived.  Pierre seeks solace in drawing elaborate battle scenes and as an adult becomes the acclaimed cartoonist David B.  In contrast the adult Jean-Christophe becomes demoralised and distant, his life dominated by the side effects of his medication and his still constant seizures.  Central to the book, the relationship between Pierre and Jean-Christophe remains complicated.

Amazon.co.uk link / Amazon.com link

Less a graphic novel than a picture book on an adult theme, I had a black dog is Matthew Johnson’s visual articulation of what it is like to suffer depression.  Borrowing Churchill’s sobriquet for his dark moods, throughout the book’s pages Johnson illustrates a man bedeviled by an ever-present black dog: it’s his reflection in the mirror; it lies between him and his partner at night; it sits on his food.  Johnson’s illustrations have a dark wit, but also a serenity as he charts his subject’s journey from despair toward insight and respite via professional help. 

A sequel of sorts, Living with a black dog continues the theme, focusing on the challenges faced by partners and carers of people effected by depression.  Amongst the subjects covered are how to recognize depression, good and back things to say, and how carers and patients alike can access help. 

I had a black dog and its companion project homogeneity onto what is in fact a very heterogeneous patient body and mostly shun any discussion of the complex ways in which people arrive and are maintained in this state of mind.  This reductionist quibble aside, their accessible approach and common sense advice make them a good place to start any discussion on this common disorder. 

Amazon.co.uk link / Amazon.com link

‘Couch fiction – a graphic tale of psychotherapy’ is an illustrated tale of fictional psychotherapy sessions between James, a successful barrister, and Patricia, a psychotherapist.

Despite his wealth, James has a penchant for petty thieving and troubled relationships in his present and past.  As the therapy sessions develop both his emotions and motivations and the nature and peculiarities of the therapeutic relationship that develops with Patricia are explored.  Perry presents the therapeutic process as helpful and special, but also addresses the imperfections of the process.  For different levels of interest or expertise in psychotherapy Perry has provides two texts in parallel.  The graphic strip contains the narrative where we read the characters thoughts and speech, whilst footnotes underneath are more didactic and unpack the therapeutic techniques at play. 

For the uninitiated especially there is much to discover from this book about the process of psychotherapy.  However the dialogue is rather wooden, and the illustration is not particularly accomplished or interesting.  I also found the dual approach to narrative unsatisfactory, as it’s jarring to read both simultaneously but neither is fully satisfactory on their own.   The ability to innovatively combine words and pictures is one of the strengths of graphic novels so the decision to opt for a dual approach is perhaps a missed opportunity. 

Finally, although she is at pains to present realistic characters, Perry does yield to the temptation to give her story a resolution, whilst never conceding that one of the great frustrations of psychotherapy is that full resolution of the difficulties of the subject of therapy is rarely achieved in the neat way she presents.

This post will be published in the June RCPsych London Division newsletter

The Almeida Theatre has, of late, been concerning itself with the wider aspects of psychiatry, mounting a number of strong productions on the theme of mental illness. The Knot of the Heart, a new play written by David Eldridge, is no exception. With its well-drawn characters and sharp dialogue, it is also, arguably, its finest on the subject. The play is about addiction; the compulsion, the self-destruction, the relentless careening towards rock-bottom, the loss, the bewilderment, the relapse, recovery and relapse again. It is also, crucially, about our need to understand why people become addicts. It is to the play’s credit that it offers little in the way of answers.

Lisa Dillon is superb in the role of Lucy, which was written specifically for her, and plays her as self-indulgent and spoiled but also charismatic and frank. Lucy is a young woman on the brink of her dream career as a children’s TV presenter caught smoking heroin in her dressing room. She loses her job and ends up living with her indulgent mother in posh house in Islington. Their enmeshed relationship is tenderly portrayed with Lucy shown to be both manipulative addict and loving vulnerable daughter. As Lucy moves quickly onto injecting heroin and selling her body to pay for it, her mother acts as intermediary, ‘facilitating her addiction’ by seeing dealers on her behalf. Margot Leicester handles the role beautifully as a bewildered caring mother put in a dreadful bind by one beloved daughter whilst subtly dismissing the other, Abigail Cruttenden, as hard and functional, despite expecting her to sort the whole thing out. The play follows their complex family dynamics as Lucy’s addiction plunges them into debt and despair. Lucy spends several spells in rehab and her many healthcare encounters are realistically executed.

Addiction is portrayed as a complex phenomenon, full of moral dilemmas. The confusion and difficulty they have in making sense of their situation is palpable. In one striking scene Lucy is found by her mother half-collapsed in the living room and asks desperately ‘Why?’, ‘Because the rest is background now’ Lucy offers weakly, the best non-explanation she can find. The reality of addiction is never glamourised nor is its often sordid consequences used to shock. In one notable scene, her mother finally realises the full extent of Lucy’s addiction, ‘How did you get the money for the drugs darling? ‘You know Mummy’, ‘How did your friend die?’ ‘You know Mummy’. The sinking terror is conveyed in the spaces between what isn’t said.

There are suggestions within the play of what might have predisposed Lucy to becoming an addict; her father’s death from sudden alcohol withdrawal, her mother’s difficulty in boundary setting, their enmeshed relationship, her mother’s alcoholism and her mother’s high expectations. However, these are all, I believe, shown additively to have rather weak explanatory power and I think this is a real strength of the play.

The Knot of the Heart is well-paced, taut, expertly crafted and clear in its aims: addiction is a heady combination of unfortunate exposure, bad luck, poor choices, and, importantly, something that could touch your life too. As is often the case in real life, Lucy is left with hope but no concrete answers and, alas, no happy ever after.

By Dr Lisa Conlan

There’s an article by Dr James Arkell, who is the ‘in house’ psychiatrist at the Almeida theatre in the December London Division newsletter

In February 2002 journalist Patrick Cockburn received a call from this wife.  His student son, Henry, had nearly died swimming across the Newhaven estuary whilst fully clothed and had been admitted to a psychiatric hospital. 

Henry is diagnosed with schizophrenia and ‘Henry’s Demons’ is an account of the Cockburn family’s experiences of the next nine years.  Henry is unable to finish his degree and spends a majority of his time under section as his behaviour often puts his life in danger.  Despite this he is often at large for days at a time, having escaped from locked wards with an ease that dismays those that care about him.  He does not accept his diagnosis and will not take any medication, as to do so would mean that everything he thinks is wrong.  The hallucinations he experiences are for him beautiful and revelatory, not a sign of illness. 

Whilst the majority of the narrative is related by Patrick Cockburn, Henry Cockburn also contributes several chapters to the story in which he is so central a figure.  It is not just that his viewpoint is different; his story is strange and disjointed as he recounts being driven by forces that few understand.  To the frustration of his family neither in his writing, nor in his life does Henry take responsibility for his actions and nor does he show remorse for the emotional distress these cause. 

“It was about this time I had my first vision.  I had borrowed a book on meditation and was sitting on a beach in Brighton in the lotus position, trying to meditate.  It was only for a few seconds but I saw two birds fly across each other, and where they crossed, I saw a golden Buddha in the sky.  I was wearing shoes for once, but I took them off.  I started to climb the earth embankment by the sea because I thought the Hanging Gardens of Babylon were on the other side.  Later, I felt I wanted to stare death in the face and started to climb on top of a high wall overlooking the railway track.  People shouted at me to get down and when I did so one of them bought me an orange juice.  But they also called the police, who asked if I was trying to kill myself.  I said I just wanted to get a better view of Brighton.  They also asked me ‘have you seen things?’ I did not tell them about the golden Buddha.  The police were good to me, though I thought it was a bit much to be arrested for having bare feet.”

Patrick Cockburn’s writing is more journalist: it’s fluid and obviously polished; he often turns his journalist’s skills of observation towards the professionals he meets.  He is critical of the closure of the asylum system where he considers that ‘one could safely behave bizarrely or even madly without derision or persecution’.  He is also particularly unimpressed by the breadth of psychiatric knowledge:

“Ironically doctors often noted that Henry had lack of insight into his disorder, which mean that he did not acknowledge that there was anything wrong with him.  But the insight of professionals was also limited.  Over the last century psychiatrists and psychologists have proved singularly unsuccessful in finding either causes or cures for mental disorders. “

As a document of the difficulties faced by a family affected by schizophrenia this book invites comparison with Tim Salmon’s recent Schizophrenia: who cares?  The Cockburns’ dual narrative is an obvious difference and in addition is also a gentler read with less of a sense of vented anger than is Salmon’s work.  The two books complement each other, and are both worth readings, but there is surprisingly little overlap.