Archive for the ‘Books Films Television’ Category

Ground Control by Anna Minton

Monday, August 22nd, 2011

Buy on Amazon.com

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

Metaphors for malignancies

Thursday, August 18th, 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

Graphic novel review – Epileptic

Friday, July 1st, 2011

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.

Graphic novel review – ‘I had a black dog’

Friday, July 1st, 2011

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. 

Graphic novel review: Couch Fiction

Friday, July 1st, 2011

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

Review of ‘Knot of the heart’ Almeida theatre by Lisa Conlan

Friday, April 29th, 2011

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

Review of Henry’s Demons by Patrick and Henry Cockburn

Friday, April 15th, 2011

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. 

London Division March Newsletter

Saturday, March 26th, 2011

This month’s London Division newsletter is edited by me and also has a new and exciting layout.  Here’s the editorial:

Never think of the future”, said Albert Einstein “it comes soon enough”. Predicting the future is a thankless task but for this issue four contributors have been willing to take on the challenge. A voice from the future Prof Hamish McSalter reflects on a time when ‘death became the last true resort of sanity’. Dr Derek Summerfield stays with the present day and frames the future in terms of what has come to pass thus far. Dr Trevor Turner stays with this theme: where psychiatrists have seen their future in the past is informative in guiding our current path. Dr Michael Maier’s focus is on the current difficulties with training and Dr Kevin Healy sees our role as ‘doctors of the body and of the mind’ a role set to be strengthened by scientific progress. Finally with a related theme Dr Ian McClelland has taken a look at Anthony Clare’s seminal Psychiatry in Dissent 30 years since it was published.

Elsewhere in this issue there is topical comment with a report by Dr Abby Seltzer on the Winter academic event and an analysis by Dr Angela Hassiotis of the new government mental health outcomes strategy document. We have a report from Dr Isabel McMullen about her placement with the London Deanery and one from Dr Kostas Agath about being a medical governor. I’m also pleased to publish two prize essays from medical students and to have a contribution from Roxanne Keynejad, who has been involved with the successful King’s Psychiatry society and shares her experience with us

Report on the arts has long been a strong suit of this newsletter, and this issue is no exception. Dr Lisa Conlan reports on a recent exhibition at the Wellcome Collection; Dr Nick Dunn recommends books for trainees; Dr Sarah Jones reviews a book from Roy Porter’s canon. We also have a feature on the treatment of psychiatric issues by graphic novels. Dr Issy Millard provides an overview of this subject and Dr Greg Neate and myself lend a few reviews. This is something I hope we can return to in the future.

Interview with Tim Salmon author of ‘Schizophrenia: who cares?’

Tuesday, February 8th, 2011

Tim Salmon, author of Schizophrenia: who cares? has kindly agreed to be interviewed by the Frontier Psychiatrist blog. 

FP: Please tell us about your motivation for writing the book.

TS: I wrote the book for several reasons. First, I wanted to tell the world something about schizophrenia. Whether the world will pay the slightest bit of attention is of course another matter! Most people, unless they have had personal experience of the illness, have no idea what it means, what it does to people, what a devastating and truly tragic effect it has on the lives both of those who suffer from the illness and those who love and try to care for them. If they have thought about it at all, they think it has something to do with going berserk and wielding axes or having some kind of what they think of as a split personality.

And I decided to tell my story because I knew, after attending meetings and listening to other people’s experiences for twenty years, that my story was everyone’s story: we were all in the same boat. I also wanted to expose the hopeless inadequacy of the provisions made in our society for the care of people with schizophrenia: the ridiculous, illiterate and contradictory nonsense talked by those supposedly in charge of the system and its continuing failure to provide the things that the government told us we could expect from it. For twenty-five years we have been told that the involvement of carers was of primary importance. Am I informed of the dates of Care Plan review meetings? Have I met the “new” consultant who has now been in charge of my son’s Care Plan for three years? No, and that in spite of the fact that I have bullied and pushed and agitated for more than twenty years.

My local Trust is now planning to close half of its remaining in-patient facilities on the grounds that Care in the Community has been so effective that they are no longer needed. A likely story, I say, when Care in the Community for my son means a fortnightly injection and an occasional cup of coffee with a CPN. Does anyone know what he eats, when he last changed his underclothes, his bed sheets, what is growing out of his sink? Actually, he is doing pretty well – at last, but I don’t think the “system” can claim much of the credit.

FP: I know you would like to reply to some of the comments I made in my review

TS: Yes, firstly, I am aware that some people with schizophrenia “can hope for a much better outcome…” Rethink, for one, never ceases to tell us so. But while I quite understand that there is no point in being only pessimistic, I feel strongly that the people who “can hope for a much better outcome…” are lucky, are a minority, and, in a sense, are not really the ones we need to worry about. My experience – not systematic, I admit – suggests that the majority languish somewhere between more or less stability and more or less acute illness: in a kind of limbo, where many sort of manage without coming anywhere near leading the kind of life that could have been expected for them before the illness. They are, in short, the people whose plight prompted John Pringle to set up the National Schizophrenia Fellowship, ancestor of Rethink, in 1970. These are the people I am concerned about; these are the people who need looking after. These are the people who truly suffer from schizophrenia and I do not see any evidence that their numbers are diminishing. Rethink still has some 150 support groups and, I believe, some 8,000 members, most of them inherited from its days as the NSF. If the chances of good outcomes had significantly improved, I do not think we would still be attending these groups.

It was to highlight the plight of these people that I wrote the book. Responses from readers largely confirm that my story is, as I had suspected, also theirs. And given that there is as yet no cure, no truly effective treatment, for the illness, this is surely what one would expect.

You express surprise at my lack of sympathy for the vulnerability of ethnic minorities. Vulnerability to what?

If it can be shown that ‘Albanian-ness’ is in some significant way relevant to a person’s susceptibility to schizophrenia or to the way in which the illness should be treated in that person, then I have no objection. As far as I know, no one has been able to show that this is the case. My strong impression is, on the contrary, that talk of ethnicity and minorities in this context is merely part of the ill-thought-out and currently fashionable discourse of political correctness, aka the positive discrimination/affirmative action movement that derives from the work of the philosopher John Rawls, and where the actions of mental health bodies and local councils are concerned amounts to little more than box-ticking designed to establish “progressive” credentials.

And what is ethnicity? What boxes do you have to tick in order to constitute yourselves an ethnic minority?

My children are half French? Does that count? Do the substantial number of well-qualified, professional French people now working in London count? What about the large number of Americans living in England? Does a well-known actress brought up in England by an English mother but sired by a Nigerian father count? Are the Japanese ethnic? The Poles? Was I part of an ethnic minority when I was living in Greece or in Libya?

In my view a lot of nonsense is talked about ethnic and cultural diversity, in the main by people who speak no other language than English and therefore can have little understanding of cultural difference or else have vested interests in exploiting their status as minorities for their own purposes. Vide VS Naipaul and Wole Soyinka on these matters.

I think my cultural viewpoint allows me to see rather further than many! As a classicist I had to study the literature, history and philosophy of the ancient world. I have been involved since my teens in France and Greece. I speak both languages; I have lived and worked in and written about both countries. I have been married to both French and Greek wives. I have been a school teacher in London comprehensives as well as in Greece and Libya. For many years I have had to eke out my earnings as a writer with painting and decorating and other manual work. I speak pretty reasonable Italian and manage in Turkish, Russian and Romanian. I have hung out in the sheepfolds and harbours of the Balkans and eastern Mediterranean for much of my life… I have known schizophrenics from France, Greece, America and Israel. I have French psychiatrist cousins with a schizophrenic son…

FP: In response

One of the difficulties when talking about groups of psychiatric patients and their outcomes is defining about who you wish to draw conclusions.  Another is that what counts as a ‘recovery’ can be different to different people.  However attempts have been made, and when you sum up the work done so far – according to the textbook on my knee – then: ‘The prognosis of schizophrenia is very variable. A review of treatment studies suggests that 15-20% of people with schizophrenia recover completely, about 70% will have relapses and may develop mild to moderate negative symptoms and about 10% will remain seriously disabled’ (Kumar and Clarke 2009).

The question is then how to have a mental health system that can cater for such diversity of outcomes.  As you identify, a mode of operation based on recovery is of little use to someone who is struggling to maintain an independent life, but at what stage should healthcare professionals decide that a paternal approach should be taken?  Doctors and other health care professionals have become very reluctant of late to make any judgments on people at all.  In my view this must be seen as a reflection of historical criticisms of psychiatric treatment. Mental health practitioners and psychiatrists in particular have been heavily criticised for allowing patients had little involvement in their care.  And, more generally,  it is hard to think of many professions that have had an ‘anti-‘ movement against them. In addition we live in an age of empowerment and entitlement so one could argue that the prevailing treatment approaches inevitably reflects this.  There is also the issue of fostering dependency on the mental health system, something else the mental health system has been accused of in the past.  For instance from something I read recently:

‘The mental health system perpetuates the needs of those who enter it, so that it is difficult to exit from the system: patients are transferred from one compartment to the next, with little effort being directed toward developing a functional independency.’ (More is more and less is less the myth of massive psychiatric need British Journal of Psychiatry (1985), 146, 164-168).

Your viewpoint on charities is very interesting.  With year on year growth and influence, many charities have internalised the logic of the marketplace and have begun to see themselves as competing for market share.  Working for a charity has become a career path, and charities have increased responsibilities to their staff and so on.  I feel that this has a lot to do with the broadening of remit that you identify with particular reference to the National Schizophrenia Fellowship.  A wish for a broad appeal may also explain why campaign targets – stigma, fear and prejudice – have superficial appeal, but lack nuance.  I share your view of the fallacy of ‘1 in 4’ of us having mental health disorders, which is part of the same ‘inclusionist’ approach.  Overall I would agree that there is a place for an organisation to campaign for the interests of schizophrenia patients solely and it is a shame that this no longer exists. 

It is generally accepted in psychiatric circles (with an epidemiological basis) that some ethnic minorities and immigrants have higher rates of schizophrenia and higher rates of admission to psychiatric hospital.  Even if this wasn’t the case, low income groups – of which ethnic minorities form a substantial part – are major users of NHS services across the board so it is not surprising that mental health services deal with a lot of people from ethnic minority groups.  At any time, a psychiatric ward in London will house citizens of multiple different nations. 

As you know from your travels people from different communities may have very different viewpoints and requirements.  With regards to these needs opinion formers and regulation enactors have fallen in with the ethos of multiculturalism where the prevailing wisdom is that we should recognise and accommodate difference so far as is possible.  So, whilst it’s true that that what qualifies as an ‘ethnic minority’ is arbitrary, from a pragmatic point of view people whose English language skills are poor or whose cultural norms are significantly different to those of the majority population are allocated the most resources.  It is these people who I refer to as ‘vulnerable’ by which I am ultimately referring to their risk of not getting adequate treatment by virtue of their inability to negotiate NHS care structures.  You may be right that we overdo our accommodation for people from cultures outside the UK majority and if so this is likely to be a reaction to past neglect.  There has been a lot of criticism of the multicultural approach, but the other extreme is to treat everyone the same.  I’d be interested to know where you would draw the line: for instance it was reported in 2006 that the NHS spends £100m on translation services yearly. If we one were entirely ‘mono-cultural’ then this presumably would not be required.

TS:

In response to ‘how do you cater for a diversity of outcomes?’

I don’t know, but I have always felt that a firm, warm, persistent, mildly assertive taking-in-hand of the patient – like a good PE teacher – from the earliest onset of the illness would be more likely to promote a successful outcome than the current holding-back, can’t-do-anything-without-the-patient’s consent approach – the approach revealed in the use of the term client rather than patient. How many cancer “clients” do you know?

If “toxic environmental factors” play a role in schizophrenia, then surely it matters where and how people live. They need decent accommodation. I would not want to live in most of the sheltered accommodation that I have seen. And if they need help in keeping clean, eating properly, keeping physically healthy, having some kind of social life, they should get it. How can leaving someone suffering from an illness like schizophrenia to live in squalor and isolation possibly be good for them? And yet that is what happens – all too often. Years ago a social worker – one of the few in my experience who took her job seriously – made a needs assessment for my son. She recommended sending a cleaner in, signing him up for meals on wheels and a number of other things. Did he get any of it? Of course not. Yet that is the kind of help many patients need.

My local Foundation Trust, justifying a huge budget cut a couple of years ago and aware that recalcitrant “clients” might lose out, made much of its new assertive outreach team. After my son stood them up on a couple of occasions, they said they would not keep him on their books. How assertive was that? Don’t we know that people suffering from schizophrenia are not the most enthusiastic recipients of treatment? I was reminded of Denis Healey’s remark about comparing being attacked by Geoffrey Howe to “being savaged by a dead sheep.”

In response to ‘accommodating other cultures’:

There is a lot of talk in the caring professions about accommodating a diversity of cultures, but I am not sure what is actually provided in practical terms apart, perhaps, from the provision of a prayer room in hospitals and the translation of documents into various languages. And, going by my local experience, there does not seem to be any logic to that: one day French is on, the next it is off; the same with Greek, the same with Albanian, the same with Turkish… Who is taking these decisions and according to what criteria? As to the question of whether it is necessary or worth the expense… Does it really amount to anything more than  Jack-Hornerish ticking of the progressive boxes: “Oh what a good boy am I!”

And if diversity of culture is to be such a cherished part of our way of doing things, might it not make more sense to suggest to the Bangladeshi community, let’s say, that they establish a body of English-speaking volunteers to whom their non-English-speaking…are we allowed to call them “compatriots,”  may turn when need arises? No one, I have to say, when I lived in Greece, France or Libya, ever pushed a leaflet through my door telling me I could apply to have official documents sent to me in my native language.

The little I know of it suggests that the problem in accessing mental health services for people from other cultural backgrounds is not language so much as culture, that is, attitudes to mental illness. Admitting to the existence of “madness” in the family is to bring shame on it; it is something to be hidden. This has certainly been my experience with Greece, with fathers of sons, in particular. Sathnam Sangheera’s moving book about growing up in what was essentially a Punjabi Sikh village community in Wolverhampton, The Boy with the Topknot, throws interesting light on this; both his father and a sister suffered from schizophrenia, something he himself did not realize until well into his twenties. Somewhat paradoxically, one might think, it also suggests that coping with illnesses like schizophrenia in the bosom of the clan, a large extended family, may well be far more effective than our more clinical and professional approach.

FP: In the book you’re critical of the standard of many of the staff who are employed by the NHS, in particular you write:

‘When they can, the bureaucrats always claim a long history of involvement in mental health.  But I am not much impressed by the quality – intellectual, in particular – of the people who work ‘in the field of mental health’.  I am not referring to the medical staff: they have had to undergo a rigorous education.  It is the other services that I have my doubts about.  First of all, mental health is a pretty unglamorous, unrewarding and difficult area to work in.  There is a very high proportion of black immigrants with poor language skills – that is to say they cannot speak English intelligibly – employed among the lower echelons.  This is not because blacks are especially gifted or particularly attracted to the caring professions; it is because these are jobs that better qualified people do not want and, being in the public sector, have at the same time a certain cachet or respectability especially for people who come from cultures where being a public employee and wearing,  as it were, the  uniform of the state gives a certain status and power.  There are certainly some saintly people among them, people with real compassion, but when they move, generally for career reasons, into management and administration their shortcomings are quickly shown up.’

Whilst I don’t think that everyone who works for the NHS is a genius, nor that people are never promoted beyond their ability, are you not being a bit harsh here?  The fault here is that, as a society, jobs in the NHS, and especially some in mental health care, are not valued and do not always attract the highest quality staff.  And not only are they not valued, but the UK does not train people for these jobs in sufficient numbers, necessitating recruitment from abroad.  Shouldn’t we be grateful for the people who are prepared to do the jobs rather than admonish them?

TS: I can see that what I have said might be considered harsh by some. There is, however, truth in it and I do not see that skirting around the truth for fear of offending people, as is currently the fashion, helps anyone. I believe that, if in the long run services are to be improved, we have to be allowed to describe things as they are. We have to know where we are starting from.

On a slightly different point: we hear a lot about ethnic and cultural sensitivity. It does not, however, seem to have occurred to anyone that it might be rather a shock to the cultural system and therapeutically not very helpful for a well-educated young English man, arriving in a psychiatric ward for the first time – a pretty frightening experience in itself – to find himself in the care of people who are not English or European even and come from a very different cultural background, with all that means in terms of attitudes to politeness, privacy, the status of the sick and mad and so forth. I remember a ward manager from Mauritius telling me once that he wished he had some white nurses on his staff.

FP: Can you tell us the reactions you have received to your book?

TS: I have had several dozen written responses to the book, in the main from parents and relatives of people with schizophrenia, but also from sufferers, psychiatrists, GPs and people both teaching and studying on nursing degree courses. The vast majority have written to tell me that my story is their story. Often the emphasis is on the sadness and horror of their experience, but many have also found the care system woefully inadequate and many are infuriated by the “politically correct” attitudes that prevail. Some students wrote to tell me that a lecturer had told them off for thinking of their work as “nursing” and “caring,” on the grounds that such terms implied a patronizing attitude to…well, their “clients,” I imagine, hardly their patients. The people who did not like it, somewhat ironically, I could not help thinking, were the mental health charity Rethink!

Incidentally, one GP – married to a psychiatrist – suggested that I was perhaps too generous about the abilities of psychiatrists, pointing out that because psychiatry has been seen as a poor cousin in the medical prestige stakes it has tended to attract less talented practitioners: easier to become a consultant than in cardiology, say!

FP: I’ve heard it said that psychiatry attracts both the best and the worst doctors; alas every speciality has less committed or talented practitioners.  Not so long ago general practice used to be the medical career of last resort, but now they’re running the show!

Do you have any advice for psychiatrists in training?

TS: I think it is vitally important that they acquire – I don’t know how – some understanding of what it is actually like to live with schizophrenia day by day: how it affects your ability to organise a proper diet for yourself, keep yourself clean, fill the long hours of the day when you have no job or organised activity to go to; how it feels, when like my son you sign up for a writing course and have to face fellow-students who are “normal” and have no inkling of what you go through or why you might look a little strange and unkempt; what it is like to set off to go and buy a packet of cigarettes and half-way there be ambushed by your voices so that you are afraid to go any further… Psychiatrists for the most part see their patients in hospital conditions; it is not the same thing.

And talking of cigarettes: has anyone given any thought, in this caring age when we are so quick to legislate for other people’s own good, to the desperate need that people with schizophrenia have to smoke? For some it is practically their only hold on life. It is cruel in the extreme to make it so difficult and expensive for them to smoke.

One more thing: because of all this, psychiatrists really need to accept the importance of keeping in close touch with parents and other family carers and of listening to them as important sources of information. I talk obviously of those who remain involved with the care of their ill relatives. We are the people who see the daily reality and also know what the person was like before becoming ill; we are the ones who know the real worth of the person and that is never entirely destroyed by the illness. Schizophrenia sufferers themselves are notoriously good at concealing the degree of their need and notoriously obstinate in refusing any kind of help. I see little value in defending their freedom to go round the bend and possibly harm themselves or others.

Review of ‘Crazy like us’

Wednesday, January 5th, 2011

There’s a review by me of Ethan Watters’ book Crazy like us in the British Journal of Psychiatry this month.  Unfortunately you’ll need a log-in to read it.  It’s a book about the spread across the world of the American way of conceptualizing mental distress. 

Edited version of my review: I liked it, although some other psychiatrists won’t.

For a summary of his arguments see Watters’ New York Times article.

Other (but less perceptive and not as well written) reviews of the book can be found at:

Time magazine
Neuroskeptic’s blog
Good reads