Champion

Let me give you a privileged, early glimpse of "Sue's View", a rolling response to WAG's consultation on the draft Regulations for the Mental Health Measure which our service user champion Sue Barnes is leading. As I said last week we've only just seen the Regs but Sue has already identified the key weaknesses in an otherwise well-judged draft. Sue says:-

"Service users know from experience that a Care Plan needs to be holistic. A Care Plan that just covers medication, for example, is not enough. But we are concerned that the Regulations do not ensure that all areas of life will be addressed in the Care Plan.

What does the new Measure say about the Care Plan?

The Measure requires at least one or more of the following eight areas of life to be addressed in the Care Plan:

● accommodation
● education and training
● finance and money
● medical and other forms of treatment, including
psychological interventions
● parenting or caring relationships
● personal care and physical well-being
● social, cultural and spiritual
● work and occupation

But Assembly Government policy (in their Care Programme Approach guidance published in 2010) states that they should all be addressed. To make sure this happens we need a box for each of the life areas in the Care Plan.

Just to be clear, all service users have needs in all the eight life areas – even if they don’t need help from anybody else with some of them it’s still important that outcomes are recorded! (The only exception to this is that some service users may not have caring or parenting responsibilities.)"

Sue goes on to pin-point another problem:-

"We also noticed that the long-term outcomes need to be linked more clearly to the short-term actions in the Care Plan."

If you agree with Sue do please tell her and also tell the Assembly Government! This link will take you to more details of how to contact Sue and to engage in the consultation process.

New Age Crank

The sunny weather this weekend gets me out into the remotest parts of North Pembrokeshire to track down one stage of the curious journey taken by St Teilo from his birth in the 6th Century to the present day. This spooky tale puts Dan Brown's clumsy fiction about the Holy Grail into the shade and has the bonus of being true.

Teilo, born in Pembrokeshire and a first cousin of St David, is well-known as the founder of Llandaff Cathedral and the patron of churches around Wales (notably Llandeilo, Carmarthenshire) and Brittany. On his death his body miraculously cloned itself into three in order to satisfy the clamour from various churches for a reliquary souvenir (well, that bit might not be true I suppose) and for many years his skull was venerated in Llandaff itself until 1450 when piratical raids from Bristol necessitated its removal by the Mathew/Melchior family, its hereditary guardians, to the Preseli mountains which is where I take up the chase.

Sadly the church of St Teilo up the road from Maenclochog is now a total ruin having been abandoned in the mid 19th century - we find brambles with a few grave-stones peeping out - but the farm where the skull was kept by the Melchior family is still there as is the holy spring (picture) whose waters, if drunk from the holy man's cranium, would cure chest complaints.

So what happened to the skull? It was still being used by pilgrims to the spring up to at least 1947, rather discreetly as this sort of thing wasn't approved of by the low Anglican Church and even lower Nonconformists who predominate round here (had this been RC Brittany there would have been a Rococo shrine, plastic bottles of water in the shape of Teilo, etc). But then it vanished and the handful of interested parties - local historians and superstitious people with bad chests - lost touch for several years.

However, I can report that the saint's already well-travelled coconut turned up again in the 1990s, having emigrated with the Melchior family to Australia for a while and then returned, and is now back in Llandaff Cathedral after over 500 years.

Needless to say some New Age cranks have asserted that a pre-Christian, hereditary priesthood of skull-worshippers are at work (a laughable scenario considering the Melchior family themselves - presumably the candidates for the mysterious priesthood - became Nonconformists many years ago) but actually I think that the true story is quite sufficiently intriguing. Google time yesterday evening shows that the leading expert on the skull story was amateur antiquarian the late Colonel Kemmis Buckley (of the brewery family), a colourful personality whom I met a few times in the early eighties to discuss the Dyfed Best Kept Village Competition, an annual bureaucratic nightmare for which I then had responsibility (running Hafal is a stroll in the park by comparison).

Meanwhile I track down two early 6th Century inscriptions from the ruins of St Teilo's. They were removed in 1959 to Maenclochog Church (key from the shop - it's locked because elf'n'safety have condemned the main door/bell-tower so everybody has to go through the vestry). These are grave stones inscribed in Latin and Ogham for two brothers who lived at the same time as Teilo and, just to give a sense of how long ago this is, King Arthur - whose historicity, if not the details of his deeds, is quite well evidenced contrary to anglocentric historians' lazy assertion (but that's for another time).

After all this excitement I resort to the nearby corrugated Tafarn Sinc, a congenial left-over from the time when the now desolate uplands of Preseli were dotted with slate quarries. This linguistic fortress offers a hearty welcome to all visitors but it is somehow more seemly to speak anything other than Welsh sotto voce. Over a diet coke and giant packet of Walkers I muse that the two brothers, clearly people of importance, could even have been with Arthur as he pushed back the Saxon raiders decisively to the east for a generation (against the tide of history) as the archaeology does indeed suggest happened. We might call that time the "Dark Ages" but to these people it was real enough and probably a time of hope because they didn't know the tide of history.

Spot On

All credit to the Assembly Government for listening to patients and recognising what needs to be done right now about mental health. In their Annual Quality Framework for 2011/12 (see it here) they have not made a long list of priorities for mental health but rather placed a simple focus on just two, delivery of dementia and depression care packages and full compliance with the agreed CPA process.

This is a recognition both of the priority for people in highest need (CPA is of course for people receiving secondary mental health services) and the centrality of CPA for those patients as (i) the agreement of what care and treatment they need and (ii) the pathway to their recovery.

It is also important because the substantive core of the Mental Health Measure, which will have teeth from late this year if the timetable holds good, is the right to a (CPA) Care and Treatment Plan. The NHS and local authorities will want to clean up their act on CPA so that the Measure doesn't find them out in a few months time.

We all hope that the LHBs will get on with this target not waiting around for a steer from the Mental Health Programme Board which I fear has too big an agenda and needs to focus down on what really matters if it is to make any difference: they could do a lot worse than follow the lead of patients - and now the Government - who want a concentration on secondary services, CPA, the Measure, and recovery - that's really a single focus when you think about it...

Yeagh But No But...

A bit of a first for Hafal as we appear twice on the Welsh telly news (ITV) last night on separate topics.

Hafal Deputy Chief Exec Alun Thomas chides Aussie euthanasia enthusiast Dr Philip Nitschke for bringing fear and anxiety to mental health patients on his visit to Wales while I offer a neutral account of the interminable process necessary to bring the Mental Health Measure into law under the Government of Wales Act provisions presently in force.

For the record Jonathan Morgan AM won the ballot to bring forward an LCO on mental health back in 2007 but the new law won't actually help any patient until the end of this year 2011 at the earliest. For some this is a very good argument to vote "Yes" in the Referendum on Welsh powers but of course that is because this Measure is a good thing which couldn't come quickly enough. However, if you believe the National Assembly might bring forward ill-conceived legislation in the future you might wish to sustain the "veto" of the UK Parliament even at the price of very long delays in all Welsh legislation good or bad. It's your call.

My only message is to get out and vote one way or the other. It would be dispiriting for democracy if there was a low turn-out.

Postscript:
Unwisely I bet Alun a pint that my piece would come higher up the news than his. He won of course because the death doctor was bigger news than the major constitutional change which the Referendum could herald. Ho hum: I will have a modest revenge by giving him a pint of that straw-coloured, flavourless and light-weight beverage laughably known as "Amber Nectar" in honour of his ghoulish antagonist's country of origin.

Them Regs

The draft regulations for the Mental Health Measure have been published (see this link), including the all-important format for Care and Treatment Plans. These Plans are the most important, substantive right which the new Measure accords to all patients receiving secondary mental health services so it is vital to get this right.

At a glance and following discussion with a few activists there is agreement that there is much to commend the draft but it is not by any means water-tight. In particular it is still possible to "complete" the form without ensuring that all important areas are covered; there is also a bit of a "disconnect" between the recording of outcomes (mainly long-term goals or ojectives) and the actions which will be taken to achieve them (short-term steps). We need to relate actions very specifically to the outcomes in order to ensure that all the longer-term outcomes are being targeted by specific actions this month, next month etc. Our service user champion Sue Barnes is doing a briefing so watch this space...

Pickled Egg

A game of two halves this weekend. On Saturday after an intense session at the gym your intrepid reporter heads for the location of the second highest crime rate in the UK, that is Wind Street, Swansea, which achieved this dubious accolade when the "citizen-friendly" on-line crime map was published (take a look at your own neighbourhood here).

If this is the worst that the criminal fraternity can throw at us then we should feel reasonably secure. I have an early lunch at the north end of this infamous thoroughfare (Yates' wine bar - bacon sandwich and cup of tea, £1.49) and my fellow customers seem sedate, middle-aged, and rather timid. It dawns on me that I am the scariest person around and that's not saying much, I hope. Of course I am aware that the trouble can start in the evening but Stacey, 22, who works in Wind Street most weekends, is "surprised" that it ranked so high - "It's like any other street really," she says. "You do get fights, but when a lot of intoxicated people are around that kind of thing will happen." Wise beyond her years.

But I have not so long ago enjoyed the atmosphere in the giant mega-pubs of the street on weekend nights and, though it is not surprising that there are occasional affrays and even broken heads (not funny of course) I would recommend the happy party atmosphere which offers a contrast to the daily grind of this struggling community. The two main features of interest in the city centre this afternoon were a caravan buying jewellery from sad-looking local citizens trying to make ends meet and the ever-optimistic sellers of Socialist Worker (headline "Jobs for All" - amen to that). Little wonder people look for a bit of fun at the weekend and the vast majority do so without annoying anybody else.

On Sunday down to Pembrokeshire (almost the lowest crime rate in the UK) for a blow on the beach at Newport Sands and Sunday lunch as guest of an old friend of my mum's. Sadly the afternoon takes a turn for the worse when this kind lady gets her finger jammed in my car door necessitating a 5 hour marathon at A&E in Withybush Hospital (all well at the end).

I take time out from the waiting game to walk all around Haverfordwest noting that the guest house I lived in thirty years ago has gone along with the Rifleman public house which served as my local in those days. I recollect that in this frankly squalid establishment the pub meal of choice (actually the only thing available) was a packet of crisps - potato flavour - with a pickled egg crumbled into it, washed down with Whitbread Trophy bitter (advertised optimistically as "The Pint That Thinks It's a Quart!"). It was also more dangerous in my estimation than Wind Street today.

Imbécile!

I know from long acquaintance and discussion with people with a serious mental illness that many still doubt the possibility that they will ever be listened to concerning the management of their illness and of their wider needs. Such is their low expectation that the best they dare hope for is some benign intervention on their behalf by, for example, organisations like Hafal. It is difficult to engage those with such low self-esteem in fighting for their rights though there is a rapidly-growing group of Hafal Members who believe they can change things, drawing inspiration from the significant successes of our campaigning, all of them made possible by the involvement and indeed leadership of people with personal experience.

Anybody still doubting that people who have long been oppressed by authorities who "know better" can win through might draw inspiration from the people across the Arab world who are finding their voice to such revolutionary effect. They have discovered that their oppressors rely on the cooperation of the oppressed and so it is always possible to change things if people have the will. I sincerely believe that people with a mental illness can make change happen if they choose and the challenge for them is therefore to identify that choice and find the confidence to make it.

A technical-sounding but actually most important opportunity for people with a mental illness to effect change is upon us now. Very shortly we should see the draft regulations for the Mental Health Measure including the proposed format for the Care and Treatment Plans which all secondary mental health patients will have a right to when the Measure comes into force. Hafal will also be providing a briefing including suggestions to improve the Regs if they aren't sufficiently robust.

WAG is organising a series of events to consult on the Regulations as follows:-

events particularly for service users and carers...

7 March - Wales Millennium Centre, Cardiff
11 March - Dylan Thomas Centre, Swansea
17 March - Management Centre, Bangor
23 March - Town Library, Haverfordwest
1 April - AVOW, Wrexham

events that are open to all...

10 March - WAG offices, Merthyr Tydfil
16 March - The Assembly Rooms, Llandudno
18 March - WAG offices, Aberystwyth
24 March - Hill House, Carmarthen
28 March - ECM2, Port Talbot
30 March - Glyndwr University, Wrexham

You can book your place at one of the consultation events by completing and submitting a form which is available from: mentalhealthandvulnerablegroups@wales.gsi.gov.uk. or ask at any Hafal project for help - they have the forms and other details and can submit your request for a place if you want.

If you are attending and would like to see Hafal's briefing in advance just email us or you will find it in due course here - it will come out shortly after we get the draft Regs from WAG.

Hafal will also be consulting through all its project meetings and carer groups so that we can convey a clear and comprehensive message back to WAG.

Postscript

A reminder that those in authority are no better than the rest of us may be found in the President of Tunisia's wife Leila Ben Ali's words to her husband as they fled the country ignominiously:

"Monte, imbécile, toute ma vie il aura fallu que je supporte tes conneries!"

("Get on the plane, imbecile, all my life I've had to put up with your screw-ups!").

It is heartening to know that during all those years of oppressing his people he was getting some of this from his eloquent better half (picture below) each evening as he got home from the office.

Pig Takes On Shane

Having extolled the merits of universal suffrage this is a good moment to point out all the upcoming opportunities for people in Wales to exercise their right to vote.

Hafal has always taken a keen interest in elections, both aiming to persuade people with a mental illness and their families to use their vote (and to put candidates on the spot about their promises on mental health matters) and also persuading politicians that there are "votes in mental health" even if traditionally many people affected haven't been comfortable raising their concerns in public hustings. In both these respects we have had good results, seeing much more about mental health in manifestos and plenty of active interest in elections from Hafal Members.

So what treats are in store for the Welsh voter eager to wield power through the ballot box?

Coming up very rapidly is the referendum on 3 March on extending the National Assembly's powers. This is only days away and my impression is that many people haven't yet cottoned on to the debate. However, the rival camps have now marched out to battle and you will see more on this over the final few days. Looking for somebody persuasive to press the case for more powers the "Yes" campaign has wheeled out that well-known authority on constitutional affairs Shane Williams. The "No" people have also taken an intellectual approach by launching an inflatable pig with "No" painted on its bum. But of course this matter is important so do check out the issues and get to the polls. The basic facts about the Welsh referendum can be seen here.

More in due course about the Assembly elections on 5 May - Hafal will be publishing a manifesto and a guide for voters just before the campaign begins. Meanwhile note that on the same day the UK referendum on the "Alternative Vote" system will now take place. The basics about the AV referendum can be seen here.

Sick to the Stomach

The time was bound to come when this Blog would employ the saloon bar adage "There's one law for the government and one for everybody else". So here goes...

What would you think if the Government announced that it was going to exclude the right to vote from certain people on the grounds they were not morally fit? And what if they proposed to do this in defiance of the law?

That is virtually what the British Government is doing in tacitly supporting M.P.s in undermining the European Court of Human Rights requirement that some prisoners at least should be allowed to vote. See the shameful story of yesterday’s Commons vote here.

This is also a matter for people with a serious mental illness as the current rules prevent many people detained under the Mental Health Act from voting (but not all: there is a useful explanation of the voting rights of detained patients here).

The Prime Minister says it makes him “sick to the stomach” to allow some prisoners to vote as if the proposal was to give them champagne breakfasts. In fact having the right to vote is scarcely an attractive benefit but rather a civic duty and there would surely be advantage in encouraging prisoners to maintain their engagement in democratic processes. It is not credible that we will see a new “Member for Dartmoor Central” becoming Minister of Justice and going soft on crime as the tabloids would have us believe. And David Davis M.P., in unholy alliance with Jack Straw (who wouldn’t let people receiving treatment for mental health problems serve as jurors – see this post), is scarcely polishing his libertarian credentials by defying the European Court and asserting that MPs should arbitrate who is fit to vote for them.

Prisoners in Australia, Canada, the Czech Republic, Denmark, France, Japan, Netherlands, Norway, Poland, and Sweden can vote and there is no sign of these countries suffering as a consequence.

By contrast several States in the U.S. have a disgraceful history of using laws disenfranchising felons to exclude a significant percentage of poorer people and those from ethnic minorities. This can actually affect the outcome of elections meaning that the people who make the law excluding people from voting personally gain in terms of the vote they get. Nobody is suggesting that Mr Cameron has this in mind but it illustrates the danger of compromising the principle of universal suffrage.

What will be unfortunate will be seeing prisoners winning large sums in compensation if the government won't act because it wants to save its hard-line face. They should send the bill for compensation to the Prime Minister to pay personally if he doesn't obey the (European) law. But then there's one law for the government and...etc.

Wonderland

Having explored military matters in recent posts it may provide a little balance to report my attendance at a performance of Aristophanes' Lysistrata at the Grand Theatre, Swansea, last night. This is a play about pacifism comically imagined through a sex strike by women of various warring Greek factions, notably Athens and Sparta, organised by the eponymous Athenian heroine and aimed at forcing their men to end the Peloponnesian War (431 to 404 BC).

The play dates from 411 BC when Athens was in desperate straits following the annihilation of its massive and ill-judged amphibious expedition to Sicily. So the play will have got a sympathetic reception. The following year the Athenians were briefly back in the ascendancy but the Spartans went on to win the war, so it's a pity the strike didn't really take place.

Though one of Aristophanes' best plays it wasn't much studied officially in my time at school because of its unrestrained lewdness (don't ask me to explain) though all of us young classicists read it - and in the original Greek not because we were studious scholars but because the rude bits were bowdlerised in translation. This was hard work as vulgar words could be found in Liddell and Scott's Greek Lexicon but they only gave the Latin translation, necessitating recourse to Lewis and Short's Latin Dictionary - and even there the translations were periphrastic (or "circumlocutory"?) at best as these two, like the Greek geeks, were morally upright Victorian gentlemen (Dean Liddell was the father of Alice in Wonderland, one of ten children in a household where one imagines there was no talk of sex strikes). I own a beautiful and weighty 19th Century edition of Liddell and Scott given to me by Mrs Blog on my 25th birthday.

But the reward for our effort was great - there is no superior triumph for the schoolboy than to find that an adult has written something smutty even if it was 2,400 years previously. I am not sure why this should be so but I guess it was because it proved that adults were low and bestial forms of life just as they hypocritically accused us of being.

This performance by the Fluellen Company is performed energetically and the translation is true to the original only updating some of the political jokes and softening some of the smut. It also bears comparison, which you wouldn't see just from reading the play, with those war-time British comedy films which combine a light-hearted childishness with an underlying, deadly-serious urgency. It makes you realise that war must seem much the same to people in every era.


Postscript:
By the oddest coincidence I get home from the theatre to read in my paper that Belgian senator Marleen Temmerman is trying to organise a sex strike to persuade her male colleagues to settle their differences and form a united government (they haven't had one for 241 days owing to the distrust between the two linguistic communities). I suppose she knows what she is doing but I wonder if her fellow legislators might hold out for a long time, finding solace in moules frites and hand-made chocolates washed down with those powerful fruit-flavoured beers which they enjoy so much. Besides, the Belgians have never really had their heart in their own country, an invention of the Duke of Wellington I seem to remember rather than the rallying point of a united people.

A Civilised Society?

I'm up at 5.00 this morning eating my favourite breakfast of fish-fingers, egg and tomato sauce and reading the National Assembly report on Post-Traumatic Stress Disorder among armed forces veterans (see this link) in anticipation of an early morning interview on Radio Wales. The story leads the news and my piece goes well though it is easily capped an hour later by arguably the most well-known former Welsh Guardsman Simon Weston who tells it how it is - he's particularly good at explaining how bog-standard counselling isn't going to fix these "mental wounds" but targeted, bespoke talking therapies can work quickly and cost-effectively.

I'm pleased to see that the BBC has picked up on a little-known point I made that Wales is exceptional in providing more than twice the number of recruits to the armed forces compared with England or Scotland - a badge of honour perhaps but also a challenge in terms of taking care of those of them who struggle on their return to civilian life. Shame on the Ministry of Defence for grudging no more than a pittance towards helping struggling veterans.

Hafal has always said that a key measure of a civilised society is how it treats people with a serious mental illness; others have said the same thing about the treatment of veterans. What sort of society is it that has so many veterans with a mental illness suffering homelessness, addiction, imprisonment and early death?

The picture shows Sgt Robert Bye, the first Welsh Guardsman to be awarded the Victoria Cross in 1917: he went on to serve in the 1939-45 war as well.

Wales Needs To Catch Up

There's a lot happening across the border on mental health. The (English) Department of Health has launched its No Health Without Mental Health strategy outlining how a new emphasis on early intervention and prevention will help tackle the underlying causes of mental ill-health. Follow the links from the Mental Health Wales story here.

Central to these plans is an additional investment of around £400 million (though some say it's not all new money) to improve access to psychological therapies over the next four years, extending the current programme available to offer personalised support to 3.2 million people across England, making available a choice of psychological therapies such as Cognitive Behavioural Therapy (CBT), Counselling for Depression, and Interpersonal Psychotherapy and (they claim) ensuring access for anyone who needs it.

The new strategy commits the government to expand provision of psychological therapies to children and young people, older people, people with long-term physical health problems, those with medically unexplained symptoms and (fanfare here) those with a serious mental illness. Patients will be able to request a referral via their GP or contact the provider directly for a self-referral consultation.

The government asserts that extending psychological therapies to all those with mental health problems will result in one million people recovering from their condition by 2014 and 75,000 people getting their lives back on track by returning to work, education, training or volunteering. They say it will also create over £700 million of savings to the public sector in healthcare, tax and welfare gains.

Wales needs to get its act together but should start by providing psychological (or "talking") therapies to those in greatest need (and incidentally those who cost most to support) - people with a serious mental illness. Here as in England there is a tendency even among supporters of psychological therapies to see them as appropriate for low-level problems but not to recognise their importance to people with schizophrenia, bipolar disorder, etc, contrary to NICE guidelines which, though conservative and cagey about more in-depth talking therapies, do recognise that they can be both effective for patients and also cost-effective for commissioners (see for example their guidance on schizophrenia here).

Of course if patients with a serious mental illness actually had a choice of therapies they (as NICE admits) would go for "middle-ground" talking therapies - not as superficial as quick-fix CBT but not as deep as traditional, long-term psychoanalysis. I am quite certain they are right.

Guns for Llandysul

Two snippets of mental health interest from beyond these shores ...

Hafal Chair Elin Jones has just returned from a conference on education in Venice. She reports that the conference centre was located on the island of San Servolo (picture below) which was used as a mental hospital from 1725 until 1978 and still has a sinister museum looking back at that era. Perhaps appropriately for a city built on water the hospital had a particular focus on hydrotherapy – a fancy term for trying to get patients to snap out of their mental illness by alternating hot and cold showers. This is reminiscent of the Greek mental hospital island of Leros though I recollect that the patients there (typically left to wander around naked) were routinely hosed down outside in the interest of hygiene rather than therapy.



Meanwhile I see that Janet Napolitano, Homeland Security Secretary to President Obama, was challenged on the very liberal gun laws in Arizona (where she was previously Governor) following the shooting of Congresswoman Gabrielle Giffords by Jared Loughner, a mental health patient. She argues that the case should prompt rethinking about mental health services in the state and elsewhere rather than a look at the right of citizens to bear arms. On Sunday I held a lunch party for a brother, nephew, niece and cousin (plus Skype link to the family diaspora in England and Spain) where we argue about this. I make a habit of trying to see things the American way but find it hard to defend their approach to firearms though we should not sneeringly underestimate the principle of keeping the government in its place which is generally a good aspect of the political culture of the U.S.

Anyway, we all agree that Arizona’s gun laws are not always used for bad purposes. My great uncle Dick left Wales to make his fortune and did so by building the city of Coolidge, Arizona, (named after the then President) where he is still celebrated as the founder. In 1939 he was keen to support his motherland and took the very practical step of buying a dozen Winchester carbines - the Model 10 0.401 blowback-operated repeater (see the picture above: this is a formidable weapon and the successor to the “gun which won the West” but with the advantage of being fully self-loading rather than requiring the lever action so familiar in cowboy films) - and shipping them to his family in Llandysul for use against the Axis hordes in the event of them invading Ceredigion. Needless to say the UK’s more severe gun laws prevented them reaching my family’s eager hands though my cousin David says some of them were released in due course and used for hunting. Meanwhile it is beyond question that the best-armed unit of the British army during the last war was the Llandysul Home Guard.

Feisty Cougars

I am still excited after seeing King Lear transmitted live from the Donmar Warehouse to the Maltings Theatre in Farnham last night (along with dozens of other venues in the UK and around the world). Not for nothing has Derek Jacobi’s Lear been called the best in living memory.

It is often said that it is a play about madness but that is really a misunderstanding. Shakespeare – and his audience – were probably not so much concerned with mental illness as with the emotions, politics, and social upheaval which theatrical madness might illustrate. Nevertheless, let’s take up the challenge of looking at some diagnoses of key characters ...

Lear himself progresses from a position in Act 1 where he is already in the thrall of a massive and dangerous psychodynamic game with his daughters and courtiers through to psychosis and, following some remission, a final, fatal seizure.

This game can be readily identified. He adopts the position of an infant (5 years old maybe?) seeking approval and love from mother-figures (ironically, and disturbingly, actually his daughters). As his Fool says "thou madest thy daughters thy mothers: for when thou gavest them the rod, and put'st down thine own breeches".

Goneril and Regan are happy to play his game but the slightly priggish Cordelia won’t play and takes the consequences. In spite of a grounded intervention by Kent (who I think remains the only person to keep his mental balance rock solid throughout the play) Lear carries through his childish game into the macropolitics of the British realm and so the tragedy unfolds. His later psychotic phase is possibly unrealistic in the sense that the causal link from his initial game is suspect, although arguably the terrible events afflicting him are on such a scale that psychosis arising from both his initial imbalance and the environmental pressures is just about plausible.

The Earl of Gloucester's attempted suicide is not the result of a mental illness so much as betrayal by his bastard son Edmund and his violent blinding by the Duke of Cornwall. His dutiful son Edgar, disguised as "Mad Tom", employs an “ethically challenging" therapeutic technique to get his father straight, that is allowing him to believe that he has thrown himself off the cliff at Dover ("Why I do trifle thus with his despair / Is done to cure it") then remonstrating with him when he finds himself still alive. It works: says Gloucester

"...henceforth I'll bear
Affliction till it do cry out itself
'Enough, enough,' and die"

Edmund is the biggest villain displaying a spectacular personality disorder and a level of psychopathy only mitigated by his last minute qualm about ordering the hanging of Cordelia (or does he know it’s too late anyway, as my more cynical Mum suggests as we leave the theatre?).

Goneril and Regan are played as feisty cougars in this production driven by greed for power and lust for young Edmund which he merrily exploits. They have no recourse to mental imbalance as a defence.

In summary the good guys are the ones with the mental illness and the bad guys are disordered maybe or just plain wicked, a neat contrast to the modern tabloid and celluloid vision of mental illness.

Saga Lout

Yesterday I was at the CBI in central London for the first meeting of the Mental Health Foundation's new working group on mental health and aging. I am pleased to join the great and the good to work on this project as I have faith in the Foundation to get it right - as they have recently in their excellent work on loneliness (see this page on their site and my previous post here) and very recently sleep (see this page for a great interactive resource). Unlike some prominent mental health organisations the Foundation is careful not to infect other areas of life with the baleful and disempowering language and methodology of the "progressive" (i.e. intrusive and untherapeutic) mental health establishment.

I should first own up to a longstanding reluctance to get involved with the issue of old age. This may be down to several things: (1) having acted as secretary to an Age Concern group in West Wales as part of my professional duties in the then Dyfed Rural Council about 25 years ago. This was an unrewarding experience both for me and I suspect for them although I do remember having some mischievous fun getting avant-garde Royal Academician Arthur Giardelli to judge their art competition to general consternation as he chose as winners some rather (let's say) primitive pieces over the more traditional watercolourists who expected to succeed. Everybody went home early in a sulk and I had to sheepishly take back three out of the four sale-or-return bottles of sherry to Victoria Wine; (2) without any defence I admit that I had until a few years ago shared the prejudicial view that organisations like Hafal were for "people of working age"; (3) I am irritated by the widely-held assumption that old people in general are the salt of the earth and somehow better than everybody else; and (4) no doubt I am afraid of death and don't care to contemplate my own decline towards it: however, as I now qualify as a "Saga lout" being over 50 I suppose it's time get my head around the matter.

But after yesterday's discussion I am quite eager to to get stuck into this subject. I can't fairly give a commentary on what was said by others - you will have to wait for the report - but I can tell you some of my own initial thoughts. From my own observation there are two very specific predictors, or possibly even determinants, of whether somebody is heading for, or already experiencing, a good old age...

The first is their politics. I don't mean whether they are right or left or whatever but rather whether they line up politically (in its widest sense) with other old people (and implicitly or explicitly against everybody else) or with the community of all ages with whom they choose to identify (whether that's their local community, their nation, or something else). To me it is self-evident that the latter group are almost invariably happier and better-equipped to live a fulfilling old age.

The second cross-roads is the attitude of older people to new technology and media. There is a startling divide between those older people who embrace IT and modern communications in order to overcome isolation and engage strongly in the life of their families and wider community and those who do not who I believe substantially lose out not just in practical ways but in terms of their general happiness.

If these are only predictors rather than determinants, in other words already vulnerable people form the unhealthier viewpoints and make the less successful choices, then nevertheless I would argue that useful advice could be formulated to assist people who may not have the best instincts for managing their old age, along the lines of: don't believe everything you read in the Daily Express about young people and the state of our society; bribe your grandchildren to set up and support a PC in your parlour; etc. We will see what the project comes up with.

Also a member of the working group is Bharat Mehta, formerly my boss at NSF whom I haven't seen for many years; he runs Trust for London, the huge fund based on historic bequests which aims to tackle poverty in the capital. It is a great pleasure to see him again and I will be carrying his best wishes back to the many Hafal veterans who have happy memories of his kindness and wit.

For myself I will aim to follow Montaigne's counsel of embracing frailty with equanimity and resignation. As Mark Twain said Age is an issue of mind over matter. If you don't mind, it doesn't matter.