Also published on BMJ blogs

Last week’s riots took place across different nights in multiple cities and involved no one ethnic group.  The reasons behind them are complex and a unifying theory is likely to be evasive. 

Many of the explanations for the riots have been made to fit around already established political agendas.  The left has focused on deprivation and an excessively greedy society, while the right has blamed police numbers and a lack of discipline and boundaries.

With such widespread disturbance, it’s more than likely that any explanation will have some merit.  The explanations favoured by our political elite will have very real consequences.  

Criminal?
According to some on the right the riots were largely criminal acts of opportunistic looting and vandalism. This cannot be discounted, not least as there are reports of the looting being highly organised. However it does not have sufficient explanatory power to be the complete story behind the disturbances. 

Political?
The night of the riots involved widespread looting of consumer goods, with institutions of the state left largely untouched. On this basis, they could be described as “apolitical.” However simply because the riots were not purposeful does not immediately disqualify them from being political. 
Alongside their ostensibly consumerist goals, the riots challenged the police for control of the streets, flouting law and social convention. This is arguably a political act. 

Naomi Klein writes of the riots as a “nighttime robbery” following the “daylight robbery” of recent massive banking bailouts and subsequent austerity programme.  “When you rob people of what little they have, in order to protect the interests of those who have more than anyone deserves, you should expect resistance—whether organised protests or spontaneous looting.”

Driven by consumerism?
The looting during the riots was mostly of consumer goods, leading them to be described as “aspirational.”  This explanation for the riots centres on what we value in society and the ability of some people to afford this. 

In a consumerist society, like that in the UK, the idea of social identity through consumerism is promoted. Yet economic hardship has left many people unable to afford consumer goods. 

This article argues that “Far from disregarding the values of society … the young people who were involved in property theft were enacting the very values that are communicated to them every day through advertisements and public culture.”

Failure of the criminal justice system? Poor relations with police?

It was striking how many of the rioters didn’t cover their faces. Why did they think that they wouldn’t go to prison? 

There may be genuine tensions between some communities and the police, and this has been the trigger to previous serious UK rioting.  In October 2010 for instance it was reported that black people are 26 times more likely than whites to face stop and search.

A breakdown in society?
This is an argument favoured by the left. Its proponents feel that a large section our society has no stake in it and that the riots were an understandable response to the brutality of the poverty they experience. 

Put another way, society relies on collaborative behaviour.  The majority of us are pro-social, at least in part, as we are convinced that it is in our best interests. If people feel themselves to be disenfranchised, by a society that offers little educational or employment opportunities, this does not apply. In the absence of mainstream ways of gaining self worth, some look inwards and create their own self esteem through their involvement in gangs, with violent consequences. 

The Prime Minister David Cameron has also talked about societal breakdown, and blamed in part the bad example set by our elites. 

This paper links budget cuts to social unrest.

Parenting/lack of respect?

This is a related argument to that of the “broken society.”

Some of the rioters were minors, suggesting both inadequate supervision and a failure to introduce pro-social values. A judge was critical of a family who did not turn up to the court appearance of their 14 year old daughter. 

Are the riots symptomatic of breakdown elsewhere?  Some people have written that, due to the intervention of the state, parents are no longer able to adequately discipline their children. As a result children are growing up with a dangerous sense of entitlement and lack of responsibility. 
In times of economic downturn some family units can become fragmented. The father of the 14 year old mentioned above said that he was unable to attend court as he has two jobs. 

The power of the crowd?
Other explanations floated for the riots have touched on crowd psychology. This might seem to explain the relative normality of some of participants. 

One psychologist was quoted as likening the riots to those seen in jails where “there is no higher purpose, you just have a high volume of people with a history of impulsive behaviour, having a giant adventure.”

Deindividuation, where social norms are compromised when people are in groups, has also been mooted. “That violence is an epidemic is not a metaphor; it is a scientific fact,” writes Gary Sultkin who likens violence to that of disease spread. Some sociologists write here that crowds are irrational (but then offer to explain them).

Professor Stephen Reitcher, professor of social psychology and expert on crowd psychology is unimpressed. 

Architecture?
Anna Minton writes in her book Ground Control about how current trends in city planning have led to a transformation of public space. Designed with the objectives of profit and safety paramount, physical environments in the city are being created which “reflects the stark division of the city creating homogenous enclaves which undermine trust between people.” 

The gentrification of large parts of previously disadvantaged areas has led to different communities – between whom communication is almost non-existent – living in close proximity as discussed in this London Review of Books blog.

“Historically” writes architectural historian Wouter Vanstiphout, “there is a correlation between large-scale urban projects and upsurges in urban violence.” But, “it is much too soon to say anything,” he says, “about the relationship between the gentrification of Brixton, or the coming of the Olympics to London, and the current explosion of violent alienation”

A unified theory?
The number of people involved in the riots is in the thousands, in cities of several million.  As of 17 August the Met had charged 1005 people and made 1773 arrests.  Therefore we should be wary of making generalisations about communities based on a relatively small number of their members.  All of the above explanations hold some truth, and the discourse is about which we afford the greatest weight. 

At a structural level The UK’s “knowledge economy” benefits some people but excludes many others. Many people are able to accumulate the skills and qualifications necessary to thrive.  However for reasons of upbringing and opportunities, others are unable to benefit. Social mobility remains poor.

Inner cities are particularly disadvantaged. In some communities single parent families are common, and role models are lacking. Family life is difficult if family members are obliged to take multiple low paid jobs. There are few activities available for young people and unemployment is high. 

In addition, the example set by UK elites has been poor and low income groups have disproportionately suffered from austerity cuts.  The money spent on the Olympics has had little effect on surrounding areas.  Expensive consumer goods are available for sale to the affluent middle class for whom city living is now fashionable and more affordable in previously run down areas.

Did something have to give?

BMJ: Riots on the streets.  A public health perspective would help if politicians would listen

It all started with a bomb scare… Outside the conference venue (The Cumberland Hotel, Marble Arch)

I was a lead organiser for this year’s Annual London Psychiatry Trainee Conference.  Dr Penny Brown who was one of the team has written this report.  You can download two of the conference’s sessions from here – Darian Leader’s afternoon keynote speech is well worth a listen

This report initially featured in the London Division December newsletter.  

On an overcast autumnal day in central London, three hundred and fifty psychiatry trainees defied tube strikes and bomb scares to attend the third Annual London Psychiatry Trainee Conference. Joined by a host of names from literature, art, stage and screen, the trainees enjoyed a wide variety of entertaining and thought-provoking sessions on ‘The Art of Psychiatry’.

The conference has become an annual fixture since 2008 and Dr Stephen Ginn, East London ST4 in General Adult Psychiatry, took on the challenge of organising the 2010 meeting. He chose to focus the theme on psychiatry and the arts, explaining his motivation as follows:

‘Many psychiatrists, including trainees, have a strong interest in the creative arts and this informs their practice.  Both psychiatrists and creative artists are concerned with exploring human behaviour and motivation, and come to the subject of the mental disorder from different viewpoints and with different narratives. For instance the language creative artists and psychiatrists use to record or express psychopathology is totally different but equally valid. I have a strong belief that we have much to learn from one another and my motivation for making this year’s London trainee conference about the shared elements between psychiatry and the arts was to explore this space and to give trainees an opportunity to examine their practice from alternative viewpoints.’

Stephen and his organising committee planned a day of lectures and workshops, and in addition to inviting artists and psychiatrists from a number of disciplines, trainees were also encouraged to present their own work. The committee were overwhelmed with proposals of trainee presentations on wide-ranging topics, from studies of ‘Outsider Art’ to psychodynamic interpretations of the baptism scene from ‘There Will be Blood‘.

On the day of the conference, the Cumberland Hotel, with a lobby filled with contemporary art, set the scene for what was to come. On display at the entrance to the conference area was an exhibition of ‘Portraits: Patients and Psychiatrists‘. This award-winning collaboration between artist Gemma Anderson and forensic psychiatrist Dr Tim McInerny is a series of portraits of psychiatrists and their patients, exploring how patients experience mental illness and how this is formulated and treated by the doctor.

“Connor” by Gemma Anderson from ‘Portraits: Patients and Psychiatrists’

After an introduction from Dr Michael Maier, Head of the London Deanery School of Psychiatry, Professor Dinesh Bhugra gave the first keynote lecture on ‘Using films for teaching and cultural competence’. With examples from Hollywood to Bollywood, he demonstrated how film can teach psychiatrists about mental state examination (such as Jack Nicholson’s portrayal of OCD in As Good as it Gets) and psychotherapeutic concepts (counter-transference in Analyze This), as well as cultural sensitivities and prejudice.

Professor Dinesh Bhugra giving the first keynote lecture ‘Using films for teaching and cultural competence’

The enjoyment and good-humour of the delegates was evident even when the following session was delayed due to a combination of bomb scares and stranded pianos, but after an extended coffee break we were treated to a performance of ‘Losing It’, a two-woman show tracing the emotional breakdown of Ruby Wax, through monologue and music, with songs performed by jazz singer Judith Owen whom Wax met while a psychiatric inpatient. Wax’s depictions of her own struggle with bipolar disorder, as well as group therapy in the addictions-riddled world of the Priory, were both amusing and sensitive, and her work in breaking the stigma of mental illness can only be welcomed.

Ruby Wax and Judith Owen perform “Losing It”

The conference was then divided into ten parallel sessions. A team of dramatists and directors discussed theatre and television depictions of psychiatry, and artists explored the role of art in expressing and understanding mental illness. In a workshop on psychiatry and graphic novels, Darryl Cunningham and Philippa Perry gave examples of how graphic novels can provide an accessible but educational medium for discussing mental health issues and battling its associated stigma. Poet Dr Sarah Wardle read from her own work and discussed the benefits to doctors of reading poetry. Author Will Self drew a substantial crowd, despite competing with the delayed lunch, and gave a thought-provoking reading of his latest novel ‘Walking to Hollywood‘, which included surreal stories that raised questions about our daily assumptions. The roles of psychiatry in film and literature were explored, and in discussing psychiatry and music Dr Andrew Johns gave a fascinating talk which included a psychopathy checklist on Wagner’s Siegfried.

Three sessions were led by trainees who discussed their own studies of creative arts and psychiatry as well as experiences working abroad, and opportunities for creativity in teaching psychiatry were demonstrated by the Extreme Psychiatry team.

Will Self discusses Psychiatry and Literature

The afternoon keynote lecture was given by psychoanalyst and author Darian Leader. He spoke about the psychodynamic treatment of psychotic patients using the example of German judge Daniel Schreber, whose memoirs of his own mental illness were later interpreted by Jacques Lacan. Leader went on to join Nell Lyshon, the first female playwright at Shakespeare’s Globe with ‘Bedlam’, Sarah Wardle, Gemma Anderson and Dr Tim McInerny to take part in the final plenary session discussing ‘What can creative artists and psychiatrists teach each other’. Lyshon was accompanied by three poets from Vita Nova, a theatre company providing writing workshops to recovering addicts, who read self-penned poems about their own experiences of mental illness to a captivated audience.

Delegates and members of the plenary panel Dr Tim McInerny, Gemma Anderson, Nell Lyshon and poets from Vita Nova enjoying “Losing It” ealier in the day

The conference ended with a poster prize presentation, won by Dr Paul Wallang (ST6 Forensic Psychiatry, East London) whose poster on “Wittgenstein’s Legacy and Narrative Networks” was perfectly in keeping with the theme. All in all the day was a huge success enjoyed by delegates and speakers alike, as was clearly evident later on in the hotel bar!

Written by Dr Penelope Brown, ACF in Forensic Psychiatry, South London and Maudsley NHS Foundation Trust and the Institute of Psychiatry

With thanks to the London Deanery and the 2010 London Psychiatry Trainee Conference Organising Committee:
Dr Stephen Ginn (ST4 General Adult Psychiatry, East London)- conference lead
Dr Jane Jones (ST4 CAMHS, Tavistock Clinic)
Dr Penelope Brown (ACF Forensic Psychiatry, SLAM)
Dr Myooran Canagartnam (Fellow in Medical Education and ST6 CAMHS, Tavistock Clinic)
Dr Olimpia Pop (ST6 General Adult Psychiatry, South West London and St Georges)
Dr Issy Millard (CT2 SLAM)

Photographs by Dr Wojtek Wojcik (ACF in General Adult Psychiatry, SLAM)

I can’t go but there’s an interesting event coming up which readers of this blog may be interested in attending.

‘Exchanges at the Frontier’ returns to Wellcome Collection this autumn with a second series in partnership with the BBC World Service, hosting some of the biggest names in world science. Join A C Grayling, Professor of Philosophy at Birkbeck, University of London, to test them on the social impact of their discoveries and explore the frontiers of scientific knowledge.

Gwen Adshead is a consultant forensic psychotherapist at Broadmoor Hospital, a high-security psychiatric hospital in Berkshire. Here she oversees some of society’s most problematic personalities, attempting to understand psychotic behaviour and find ways of treating it. She also has a degree in ethics and an interest in the relationship between doctors and their patients. Join her in conversation with A C Grayling to explore what medicine can do for people with personality disorders, and whether hospital is the right place to hold them.

There’s also a tour of Broadmoor Hospital.  Link for details

Gwen Adshead was on Desert Island Discs recently - well worth a listen

If you go please leave a comment to let me know what I missed.

Update 25 November 2010

Here’s the programme

I sent this letter to the Guardian last week, but alas not chosen for publication.  I was trying to advance the idea that prejudice does not flow simply in one direction.  I haven ‘t looked at it for two weeks, and I don’t think I’d make the last sentence so categorical if I was to submit it again.  Comments welcome as always. 

Dear Sir,

Re: : ‘Oxbridge’s class divide raises food for thought’

Given the high prevalence of an Oxbridge education amongst prominent people in our society, few would argue that striving for a situation where access to these institutions is available to students from a broad variety of backgrounds is not desirable.  Your article ‘Oxbridge’s class divide raises food for thought’ examines the difficulties faced by students from lower income families who seek to study in these universities.

Although the start of a university experience is anxiety producing for most, starting out at an Oxbridge college may be more difficult for some than for others.  For example many students from fee paying schools are awarded places alongside a large proportion of their existing social circle, whereas on day one a new student from an average comprehensive might well know no one.

Yet ‘fitting in’ is a skill that is worth mastering at an early opportunity.  It’s a shame then that rather than focus on positive Oxbridge experiences of those from deprived background your article choose to feature students who were as prejudicial towards more privileged students as they expect those students are towards them.  Although their parents do probably listen to Radio 4 (and read the Guardian), I find it difficult to believe that the ‘white posh boys’ described by one student in the article, were really ‘disgusted’ when the television was tuned to MTV.

In reality whilst there will always be people who refuse to see beyond the narrow confines of class the majority of Oxbridge students are friendly and welcoming.  For all but the deliberately anti-social, marginalisation based on background is available only for those that seek it.  

Yours etc.

When I heard one of my acquaintances was heading to Los Angles, I sent him to spy on the Psychiatry – an Industry of Death Museum in Los Angeles.  Here is his report:

Visit to Psychiatry – an industry of death

It’s official; Psychiatrists are all murderers, rapists, extortionists, fraudsters and the scum of the Earth – so say the Citizens Commission on Human Rights.

I am not a Psychiatrist and have no medical training.  My interest in the Museum came about as a result of a very close relative having had the following treatments (not necessarily in this order) for depression about fifty years ago: insulin induced coma, LSD treatment, ECT with and without aesthetic, and a frontal lobotomy procedure (not transorbital).  Fortunately today my relative is alive, well and active and has no depression apart from that caused by England’s performance in the recent World Cup!

The Museum is situated along Sunset Boulevard but not in the best area of this long road.  It’s actually a rather run down white painted single story building which could be mistaken for a shop.  Next door is parking lot and there was a discarded sofa on the sidewalk opposite. 

Inside, the entrance was smart with a large curved reception desk with low level glass.  I was warmly greeted by an English lady who asked me to sign the visitor register and state my profession.  Along side the register book was a sign stating that they had the right to refuse entry – I decided not to ask if this would apply to psychiatrists!

I was invited to enter through the door to the left, which turned out to be a padded cell with bench seats, to watch an introductory video.  My greeter then mentioned, by way of casual conversation, that twenty million children are prescribed mind altering drugs each year and then asked if I knew how ECT came about.  Actually, following a very informative visit to an abattoir, I did know this.  In 1938 Dr. Ugo Cerletti became interested that pigs were prepared for slaughter by being electrically shocked through the temples. This rendered them unconscious but did not kill them, and they could survive the shock if allowed to recover. Since this was the days before ethics committees, he was then able to try this out on his patients. 

This introductory films were called “Psychiatry’s Destructive Agenda” and “Psychiatry’s Path of Destruction”.  Each was hard hitting and very compelling watching with a fast talking commentator who had a voice was just right for the CCHR’s apocalyptic message. 

Following the padded cell, the museum tour consisted of 14 different areas each with an on-demand video.  Here they are together with their CCHR summary:

1 – An Industry of Death
Governments, insurance companies and private individuals pay billions of dollars each year to psychiatrists in pursuit of cures that psychiatrists admit do not exist.  Psychiatry’s “therapies” have caused millions of deaths.

2 – Origins of Psychiatry
From its beginnings in the 1700s, using the practices of confining, restraining and isolating people with mental problems in institutions, psychiatrists have cashed in on human misery.

3 – Man Redefined
Redefining man as an animal without a soul, psychologists and psychiatrists thought man could be manipulated as easily as a dog could be trained to salivate at the sound of a bell.

4 – Psychiatry: The Men Behind the Holocaust
The Nazis killed millions.  Their justification was psychiatry and psychology’s theory of eugenics – that certain people were inferior and should be exterminated and their kind bred out of the race.  These architects of the Holocaust were never brought to justice.

5 – Psychiatry: Creating Racism
From apartheid in South Africa to the Ku Klux Klan and experiments on minorities in the United States, the most brutal racists were inspired by eugenics which justified injustice, inhumanity and denial of human dignity to millions.

6 – Soviet Psychiatry
Men fight and die for the right to speak and act freely.  Psychiatry conspired with those in power in Communist Russia to strip the rights of political dissidents and to define their “search for justice” as a mental disorder to justify their imprisonment.

7 – Brain Damage:  Psychiatry’s Miracle Cure
If an ice pick were accidently shoved behinds someone’s eyeballs, or they were jolted by 120 or 240 volts, leaving them convulsing and barely breathing, they would be rushed to hospital.  To a psychiatrist, these acts are “treatment”.

8 – Drugging for Profit
Psychiatric drugs are not designed to cure, but to suppress symptoms’ and physically damage the person taking them.  Claims of safety and efficacy are made with each new “miracle pill”; its dangers only later exposed.  Psychiatric drugs kill.

9 – Psychiatric Coercion and Restraint
Today, psychiatrists’ use of physical and chemical restraints in mental institutions is a very lucrative procedure.  Admitting that death is often inevitable from such procedures, psychiatrists literally get away with murder.

10 – Psychiatric Criminality
Working in a “profession” made up of people who commit rape, extortion and fraud, many psychiatrists have received prison sentences and civil fines.  Minimally, ten percent of psychiatrists sexually assault their patients, with one out of 20 victims a minor.

11 – Inventing Mental Illness
Psychiatrists charge huge sums of money to insurance companies, governments and anyone else who will pay to “treat” made-up mental disorders.

12 – Kids in Psychiatry’s Cross Hairs
Millions of children are given psychiatric labels for normal childhood behaviour and prescribed psychiatric drugs that drive them to commit violent acts and suicide.

13 – Psychiatry: Hidden Influence
Psychiatry has pushed its agenda of control, power and domination onto an unsuspecting society for over 60 years, infesting the fields of law enforcement, education, medicine, politics and many others.

14 – CCHR: Restoring Human Rights and Dignity to Mental Health
Psychiatrists act above the law – locking people up with no trial, stripping them of their human rights while enforcing unwanted treatments.  The Citizens Commission on Human Rights has exposed, fought and won against psychiatry’s violations for over 36 years.

I need hardly write that these videos were less than complementary about psychiatrists.  They are available from CCHR for about $16 or free from the CCHR site if you register (why would you do this?).  You can also view the complete series online. 

Each area had artefacts and photo images related to the video theme.  There were loads of photographs as well as examples of whips, torture boxes, and ECT equipment.  Drugs samples were displayed next to reports of their gross sales.  I now know that Marilyn Monroe had seen a psychiatrist the day before she died.  But was that relevant to her death? – we will never know.

I spent three hours at the museum and watched all the videos and exhibits.  During my afternoon visit I was aware of one other visitor who didn’t seem to activate any video panels.  I imagine that the visit would be less interesting if several people were activating adjacent videos simultaneously due to the noise generated.

When I left the exhibition area I was asked for my thoughts.  I complimented the quality of the exhibits and video.  I then explained that I was disappointed that CCHR had decided to present the information without any attempt at a balance view.  It might be true that Psychiatrists in the United States have the ability to milk medical insurance via the DSM and disbursements but this must also be true of other areas of their medical system (I recently was charged $400 for a week’s course of antibiotic pills which in the United Kingdom are available for £0.28 each).  Other countries have different reimbursement systems.  Was it not obfuscation to point out that using X-rays it was not possible to see any evidence in the brain of a so called mental condition but a broken bone shows up clearly?  And to describe a person with Bipolar Disorder as having normal ups-and-downs is surely a misrepresentation?

During my three hour stay I was bombarded with negatives statements and images about psychiatrists.  It would seem reasonable to suppose that at least a percentage of the profession provide a valuable service to patients, allowing them to live useful lives but no such information was presented which I found off-putting in the extreme.

I was also concerned about the use of video chips, such as those from the 2006 American Psychiatric Association Convention, where interviewees stated that they had not been able to cure any of their patients.  I have a suspicion that these remarks were taken out of context.

Finally, as the CCHR has a close relationship with the Church of Scientology, I was surprised that there was no obvious mention of this organisation during my visit.