Be More American

The City of Coolidge, Arizona, founded by my great uncle Dick - I don't know why

Sound advice for patients from Professor David Haslam, the boss of NICE (the UK Government's gatekeeper approving drugs and other treatments for NHS use - not the safety check but the benefit-versus-cost check if that makes sense) - see the story here and coverage on Hafal's Facebook platform here.

The Prof says we all need to behave more like Americans when we talk to our doctors. This means that instead of sitting quietly and being grateful for whatever the doctor decides to do for us, we should engage in a proper discussion and negotiate the best treatment available having regard to our own preferences.

The Professor says: "The fundamental point is it’s your body - and the more you understand about the drugs you are taking, or what you might be able to have, the better you are able to work with your doctor."

The Professor previously worked as a doctor near an American air force base and contrasts how his American patients engaged with him compared with the British:

"Americans tended to want to know more about their treatment than the British who tend to be much more ‘thank you doctor, I will take that’."

This is really important stuff. We hear a lot of debate about drugs and other treatments which NICE may or may not approve but this testimony proves that if you don't ask for the ones they have already approved you likely won't get them. I can understand the Professor's frustration.

We all know that this problem is much worse in mental health where several obstacles prevent patients getting the best treatment:

(1) Many patients struggle to articulate their needs because of their mental illness

(2) Doctors, like the rest of society, often have a problem with the idea of listening to mental health patients

(3) The complexity of so much of the medication, especially the antipsychotics - that difficult mix of variable effectiveness, unpleasant side effects, and difficulties in managing dosage etc

(4) Cost - even where NICE has approved we know that NHS Boards are keen to avoid using the more expensive drugs

(5) Access to psychological therapies - where do you start? Often not even considered by doctors and frequently unavailable if they are considered

This year Hafal is committed to working with our partners the Mental Health Foundation and Bipolar UK to help patients get the best possible treatments (this is in addition to our joint summer campaign on physical health).

Watch this space and other Hafal media - especially our next Mental Health Wales magazine which will have a special focus on treatments. You heard it here first.



Postscript:

Welsh people make good Americans as George Washington remarked - eighteen out of the fifty-six signatories of the Declaration of Independence were of Welsh descent.

Another fascinating view of Coolidge - there are more of these but I don't want to spoil you...

Wheedling And Pathetic

Longbow arrows - the Kalashnikov of mediaeval Europe

I've just finished reading Dan Jones' The Plantagenets in an effort to consolidate my knowledge of mediaeval history.

Much is familiar but it is enjoyable to trip through this series of kings (oh, and the Empress Matilda of course) most of them a bit thick frankly but alternately brutishly effective or wheedling and pathetic.

It is however painful to re-rehearse the Welsh campaigns of the all too brutishly effective Edward I. By chance I was in N Wales as I read about the English army's push west down the A55 and Llywelyn ap Gruffydd's escape down the A470 - only to be spotted and killed at Builth (perhaps he was fatally held up by farmers crawling along the road as I always seem to be? Though I only lose the will to live rather than life itself).

Familiar stuff but still moving considering they had held out against Saxon and then Norman invasion for nearly a thousand years since the Romans left believing the cause of protecting Romano-British (ie Welsh) civilisation was lost!

For the record the main other "hold-outs" against the barbarian hordes were the Hen Ogledd (in the north of what is now England) until about 730 AD and Dumnonia (now S West England) until about 930 AD though the Cornish tip survived after a fashion until the Norman Conquest.

The surprising survival of Welsh sovereignty almost to the 14th century has always been put down to geography but the history of the Plantagenet kings of England, both before and after 1282, suggests to me something else possibly more significant...

It is clear that throughout this long period the survival and success of England - I mean the English state - relied on two things.

First (and this is well known) wool: the huge economic benefit of trade in wool (everything else was just subsistence) bankrolled everything the English did - fighting the French to hold onto their territories down the west of France, fighting the Scots, fighting the Welsh, fighting Muslims while on Crusade, and fighting each other in routine civil war (when the kings fell into the wheedling and pathetic category and the barons got fed up).

The other thing the English relied on was... Welsh mercenaries.

On almost every page of this book you see the evidence that whenever the English contemplated fighting anybody their first instinct was to use the wool money to hire Welsh mercenaries (at very high cost - the Welsh bowmen at Agincourt earned the equivalent of £1,000 a day). Evidently it was understood that you weren't going to get far without these specialist, crack troops.

So the Welsh mercenaries crop up over and over again fighting for the English against the French, Scots, and on behalf of the English king against the barons (and vice versa and at the same time). Incidentally "English" armies marching against the Scots had to proceed carefully as they found that the Welsh would start fighting their English allies and employers at the drop of a hat.

Like many self-employed, highly-skilled specialists the Welsh could not always be relied on for punctuality - both Edward II and Richard II (both of them in the wheedling and pathetic category) lost their crowns and their lives because their Welsh "contractors" failed to turn up on time.

So no wonder the Welsh held out so long, and no wonder the last Princes of Gwynedd did not come to terms (or pretended to and then broke their word contemptuously) - they knew that no English army could hope to conquer them.

But, I hear you say, that is exactly what happened? But in fact there were more Welshmen fighting on the English side than on Llywelyn's. As I say, if you wanted an effective army, you had to hire the Welsh - Edward had learnt the hard way but he did learn).

The modern equivalent would be Chechnya, a tiny country which thought nothing of fighting the entire Russian military machine in 1996 - and won. But the Russians swallowed their pride, recruited Chechen mercenaries, and came back and overwhelmed them.

Lightly-armed Chechen rebels who destroyed 2,000 Russian tanks while successfully freeing their country in 1996. They have been deserted by the West since 9/11 after which these heroic freedom-fighters were unjustly "reclassified" as terrorists

The Piece Of Cod That Passeth All Understanding

I'm in North Wales for our quarterly meeting which brings managers and trustees together informally to compare notes, share ideas, and plan ahead to address specific challenges here and to ensure that the voice of Hafal's Members and staff in North Wales is heard loud and clear on national issues.

This week we have news of further repercussions from the difficulties encountered by the Local Health Board up here with their in-patient facilities - see the story here. Hafal Chair Elin Jones spoke up for Hafal's North Wales Members and clients last night on Radio Cymru (here).

We must be worried that patients are paying a further price in disruption and diminished service and we trust the Board is doing its best to minimise the affect on patients and return rapidly to a point where services are fully in place, settled, and operating to a satisfactory standard. The big clue when these difficulties occur is to be transparent and involve patients in working out solutions.

Meanwhile earlier in the week we observed Deputy Prime Minister Nick Clegg's major speech on mental health which certainly made the right noises. The most interesting bit - actually a reannouncement - was about the extension of choice in the English NHS to mental health patients (it's already in place for other patients). This is a continuation of the previous UK Government's move towards empowering patients to choose who provides their care and treatment.

It will be interesting to see how this plays out. It should begin to change the top-down, take-it-or-leave-it approach which makes services not only unresponsive to individual need but, more importantly, less respectful of patients.

Juxtaposition of these two stories is entirely uncoincidental.



Postscript:

Excellent cod, chips, mushy peas, bread (white naturally) and butter, and a big pot of tea - £5.49 at Gillies Plaice on Abergele Road, Colwyn Bay, served with old world charm, a friendly smile, and great care to check that everything was to my liking. I don't suppose it would be like that if they were a monopoly and so the only place you could get dinner...

Quelle Horreur!

Madame de Pompadour (1721 – 1764) - but is it okay under French law to publish a picture of Louis XV's mistress?

Out walking this morning I listen to New Yorker journalist Adam Gopnik on my device discussing President Hollande's alleged infidelity. He repeats the line that the French are much more tolerant than the British.

This of course is so much hocus. There is no more popular politician in the UK than Boris Johnson (like him or not) and there is no other politician to rival Bojo's colourful and complicated sex life.

Of course there are people in the UK who disapprove of personal behaviour outside traditional norms but so there are in France - there are plenty of practising Catholics who would find their leader's antics unacceptable.

The difference is that the French have draconian privacy laws restricting people from telling the truth about matters which the politicians have decided are none of the public's business. Further, the French press is much too close to the political establishment - witness the embarrassingly deferential, pre-prepared question put to the President at his news conference.

It isn't up to politicians to decide what aspects of their behaviour are relevant to the public's decision about whether they trust those same politicians. Personally I don't judge politicians' personal infidelities as especially important but, if others do, who are the politicians to tell them off?

All politicians point to their personal trustworthiness as a reason to vote for them. I should have thought it was up to individual voters to decide whether evidence of untrustworthiness by a politician towards their own family might cast light on their wider trustworthiness.

Privacy law from Europe has already been used in the UK to suppress truthful reporting of public figures using prostitutes. I find that extraordinary and it raises questions about how other vulnerable groups, including people with a mental illness, could be exploited under the shadow of restrictions on press freedom.

We don't need lessons from the French about the public's tolerance - we are much the same on that one - but they badly need a lesson from the UK about supporting an independent and unafraid press, warts and all. And incidentally we in turn need a lesson on this from the US who find our acceptance of creeping press restriction alarming.

Wacky And Fun

"The Lad": Tony Hancock is today more famous for his troubled life than his comedy - a shame, he was very funny

I have previously on this Blog drawn attention to studies which establish the bloomin' obvious and today's news that Oxford University health research wonks have found higher than average signs of mental illness among comedians might fall into this category. Certainly the comedienne wheeled out on Radio 4 this morning as I drove to work was quick to ridicule the researcher - who took it rather well and with good humour.

But actually I thought the detail behind the research was at least quite interesting. The research specifically found a high incidence of both extreme introversion and extreme extroversion which are associated with psychosis. This leads you to wonder whether these traits are a cause of illness or a response to or consequence of illness?

Probably the story will disappear quickly but I think the risk with these things is that they somehow glamorise mental illness, giving the public the impression that mental illness can be wacky or even fun. I know many people with a serious mental illness who are indeed wacky (in the sense of zany or eccentric) and fun but these are not necessarily characteristics of illness but of their personalities, surely? But of course "wacky" has a secondary, slightly rude meaning of "mentally ill", rather illustrating the problem.

Breaking News - Pope Is Catholic

Interesting item in The Scotsman here suggesting that men's mental health can be enhanced by going to the pub. The theory (carefully circumscribed by warnings about alcohol abuse of course) is that men can open up in the pub to their friends especially if their inhibitions are diminished by a pint or two.

And the Pope's a Catholic. You wonder if the research was commissioned by somebody who had never been to a pub? But perhaps that is unfair as there may be nuggets of more subtle wisdom to be learnt from the study.

I confess I am a bit wary of research and project work which treats men as an ill-adjusted and endangered species not able to work out how to socialise or get their emotional needs met. I think that you can trust most men to work these things out for themselves even if they haven't embraced their metrosexuality just yet (and they wouldn't thank you if you tried to help anyway) but we should concentrate rather on helping people of either gender who are struggling - and, yes, there may be some gender-specific types of support which can be offered.

Postscript:

I was appalled by the story this week that a zoo is stopping giving bananas to monkeys! Read the shocking story here. Not fair to stop them conforming to normal monkey behaviour - next they will ban those delightful tea parties which they enjoy so much.

Seedy Golf Club

There is some consternation about Channel 4's new documentary Benefits Street - see our story including onward links here.

Colleagues in the Who Benefits? campaign which Hafal supports are calling on Channel 4 to clean up its act and avoid misrepresenting people who receive benefits. Follow the link and you can express your view on-line.

I watched last night's programme with a heavy heart - expecting it to be unambiguously unhelpful - but actually I think the effect is mixed.

Our colleagues are right that the examples are unrepresentative. It is particularly unfortunate that the programme links the "benefits culture" which it purports to portray so directly with criminality. That's not fair because it's not typical for people receiving benefits to be involved in any crime, let alone some of the more unpleasant dishonesty and drug use which the programme seems to delight in reporting.

The reason I say the effect is mixed is because the programme does at least convey that there are real people behind the statistics and every person on benefits has a unique and different experience and a particular set of challenges. The trouble is they have chosen the people with more colourful stories which will provoke those who are inclined already to be unsympathetic.

Personally I thought the programme ran even greater risks in creating hostility towards people who have come from elsewhere. It was mysterious that in a programme supposedly about benefits they included stories about immigrant workers who were not actually claiming benefits, a conflation of alleged "social problems" that belongs in a prejudiced and mean-spirited discussion in some seedy golf club, not on mainstream television.

Triangulation

View south from Dinefwr Castle at 9 a.m. yesterday

A welcome break yesterday in the miserable weather - sunshine and quite warm, rare indeed in January - allows for a long walk up and around the Towy Valley, though it is necessary to stick to high ground as the valley floor is treacherously boggy having spent much of the last few weeks under water.

I reach the top of Dinefwr Castle when the sun comes up but hasn't yet chased away the mist in the flat valley bottom, giving a primeval impression to the south (see picture above) with scarcely a visible sign of human influence on the landscape. You could imagine a dinosaur roaming into view.

Looking west (see picture below) you can see signs of human cultivation but there is nothing which would have surprised Rev John Dyer (1699 - 1757) whose poem Grongar Hill arguably kicked off the Romantic Movement - certainly Wordsworth gave the Welshman much credit.

In his poem Dyer describes his view looking straight back at me (except 300 years earlier) from Grongar Hill - the bluff to the right in my photo - including how

Old castles on the cliffs arise
Proudly towering in the skies!

Castles presumably is plural because he also glances west to see the ruins of Dryslwyn.



Cue a third viewer to complete a sort of triangulation, the engraver who captured Grongar from Dryslwyn Castle about 50 years after Dyer. I have an original print (worth about £5 - these are fun to collect and very cheap) hanging in my sitting room. You can see Dinefwr in the distance dead centre, while Grongar is largely hidden behind the ruin in the left foreground...



Incidentally I published a picture in summer 2011 of me clambering over precisely that bit of ruin (the outer gatehouse) here.

Dyer might have liked this combined literary and pictorial exposition as he was a painter as well as a poet. However, churlish though it may be to say so, he actually wasn't much good at either. Judge for yourself here and here.

One of his paintings is of his brother's wife, a member of the ancient Croft family, one of whose ancestors married Owain Glyndŵr's daughter Janet...but let's stop there, it's nearly time for lunch.

Pulp Fiction

Doubt has been expressed by a new study about the effectiveness of CBT (cognitive behavioural therapy) in helping people with schizophrenia - see the story here.

This is not conclusive and, though I think the benefits of CBT have been exaggerated compared with in-depth therapies, I'm inclined to agree with Paul Jenkins from our English sister charity Rethink that you have got to listen to the patients who report that they have been helped.

But I suspect there is a bigger issue here which is a general prejudice against talking therapies for those who are very ill. This prejudice is shared overtly by some old fashioned clinicians ("What's the point of bothering them with a lot of words when they are out of touch with reality?"), by woolly "progressives" whose antipsychiatric position makes it too uncomfortable to face up to the need to use both medical and psychological treatments so they just steer clear (and campaign for talking treatments in primary care without mentioning those who have a more severe illness), and by doctrinaire practitioners who want patients to conform and match with their precious methodology rather than the other way round ("It's no use using my brilliant technique on these people because they are too ill to benefit from it").

This is immensely frustrating. Isn't it time to develop psychological therapies which help people with schizophrenia and other serious illnesses rather than try out existing trendy therapies and then give up if they don't work? Isn't it time to end the prejudice which says there is no point in engaging closely and methodically, one human to another, with people who are very ill? And who seriously believes that this would not work better than leaving them alone with their distress and hoping the drugs by themselves will sort them out?

Oddly I think the public would be shocked to learn that talking therapies are so scantly used for in-patients. Most of the public have a vision of mental hospitals from literature, films and telly where there may well be medication involved but there is also a busy regime of patients experiencing psychological therapy individually or in group sessions - and that, they imagine, is the main purpose and routine daily activity for a mental hospital. Similarly many members of the public believe that the primary occupation of psychiatrists is to deliver in-depth psychoanalytical therapy (probably with the patient on a couch!).

Of course it's easy for mental health insiders to sneer at the public's illusion which is largely based on pulp fiction - but isn't the public's perception as it relates to the availability of therapy (as opposed to any lurid view of how wicked mental health services might be) actually much closer to what we should want in reality?

Reasonable Bloke Or Grumpy Git?

Readers of this Blog will know that last summer in the midst of the extreme heat I developed a scary heart problem and then experienced severe pain from a slipped disk (or more accurately a "spinal disc herniation"). These are both now more or less resolved without treatment - aside from some awkward exercises which I'm still doing intermittently.

Spooky then to read A M Homes' novel This Book Will Change Your Life, recommended to me by Hafal's health and safety consultant Amanda Trimble (not in her official capacity!) who had read my post about Homes' more recent book May We Be Forgiven.

Spooky because the novel's hero also suffers a cardiac episode followed by severe pain in the height of summer which appear to resolve themselves without treatment. It is never fully explained but his problems seem to have been extreme physical manifestations of a mental breakdown caused by social isolation and a dreary life of unsatisfactory routines. In my case I did consider psychological causes and indeed these can be behind heart arrhythmias and some back pain problems, although my symptoms were so specific as to tip the matter more in the direction of physical causes.

Unlike me the novel's hero lives in Los Angeles and, also unlike me, his response to his health episode is to embark on a relentless, warm and friendly engagement with everybody he runs into, ranging from a doughnut salesman to a Hollywood megastar. I'm afraid by contrast I just returned to my normal persona of reasonable bloke or grumpy git according to mood and provocation.

In spite of its title this isn't a self-improvement book (apparently the publishers had some trouble because people didn't want to be seen reading it) but there again maybe it is obliquely - it's brilliant and uplifting, in some ways quite like May We Be Forgiven because it is about redemption and a sort of reignition of joyous life.

Maybe I should have read it before my rehabilitation commenced at the end of last summer?

Enlightened

Can't think of a picture to illustrate this post so here's a gratuitous one

There is a big news story today about improper use of antibiotics (both by doctors and the public) and the risk this poses as bugs develop immunity. We might even see the return of TB as a major scourge of poor and vulnerable people, as it used to be in the living memory of those over about 70 years old.

Earlier in the week the somewhat similar matter of the improper use of anti-depressants came up. A study indicates that these drugs are being used for problems which are not mental health-related and for minor mental health problems which should not be treated with drugs - something I have been banging on about in this Blog for years. See the story here.

At the heart of this is the debate about what constitutes a mental health problem. The important thing to bear in mind is that this is not something defined by severity. So, for example, there are life problems like bereavement or unemployment which don't necessarily cause mental health problems but may be much more difficult things to experience than a minor mental health problem. Put simply, you can be extremely unhappy but, if that is a proportionate response to the reality of your external experience, then it's not a mental health problem.

It is absolutely wrong for mental health interventions to get in the way of people resolving such life problems and it is an insidious and dangerous trend of our times that mental health busybodies are making work for themselves by redefining life's problems as mental health ones. This leads to improper use of drugs - which can inhibit people from addressing their problems - as well as all that disempowerment which goes along with the typical mental health approach.

Incidentally, it is not just drugs which can be inappropriately deployed. Psychological therapy is a distraction and a waste of resources if provided to somebody whose problems are not mental health ones - they need to get on with fixing their problems through practical steps and the support of friends, family, or appropriate non-mental health agencies.

I recollect some years ago an unusually enlightened therapist explaining to me how much can be achieved by simply changing the language we use away from mental health terminology and towards the words used by ordinary people. For example, if you substitute the over-used and misused mental health word "stressed" with the ordinary words "anxious" or "frightened" they automatically lead you towards the questions "what are you anxious about?" or "what are you frightened of?", and the answers to these questions lead you on towards the challenge of what you are going to do about the problems you identify. You can experiment similarly with the substitution of the over-used and misused word "depressed" with ordinary words like "unhappy".

It is really important I believe to make those substitutions if your problems - however severe - are not in fact mental health ones, in other words to actively steer well clear of the smothering and disempowering language of mental health. But in many cases such substitutions can be helpful even where the problems are mental health ones. It's good therapy! None of this of course is to deny that there are mental illnesses for which the term depression and other mental health diagnoses are appropriate.

Mental health organisations and professionals are much to blame for infecting society with the wrong language and wrong strategies for dealing with the challenges of life. They would do better to concentrate on improving their woeful record of poor practice in helping those whom they should be helping - people with a mental illness.

Black Shorts

Another day another dollar. I am back in work tomorrow, refreshed after an enjoyable and varied break.

Like last year we spent Christmas in Bristol including a marathon walk up to posh Georgian Clifton, across the Suspension Bridge into Somerset, along the rough path in the woods on the west bank of the Avon, and back through the old docks.

I am fond of Bristol and I like its people. To judge by their museums and tourist information the local authority is quite exercised by the fact that the sumptuous municipal, commercial, ecclesiastical and academic infrastructure of the city was built on the proceeds first of slavery and latterly tobacco. But the population seems unworried, not unreasonably as they can hardly be held responsible. Of course Bristol has modern problems to address (see this post) but that's another matter.



On Boxing Day I look around the sales in Broadmead. This quickly begins to feel like a mistake as I join crowds of depressed families roaming endless racks of shoes and frocks, most of it just so much dross.

But then I stumble on a small independent outdoors specialist who has in stock a pair of size 13 Brasher Hillmaster walking boots. My old pair of Brashers - the Rolls Royce of boots - is over 20 years old and has, I calculate, enabled me to walk about 8,000 miles, or from St David's to Constantinople and back twice, but they are now finally falling apart. I didn't want to buy on-line in case they didn't fit so this discovery was heaven-sent (and they were on offer too). It seems disloyal to chuck the old ones away but perhaps I could hang them outside and plant flowers in them?

On to London where we enjoy lunch at Jewish deli Mishkin's just off Covent Garden (embarrassing that I didn't know what a "slider" was - apparently it's a small hamburger but you probably knew that - although I did know that a "sandwich" in American English is the filling between the bread and not the whole thing like here).



Mrs Blog has the strongest Old Fashioned in the history of cocktails (a Mishkin's speciality) which helps her to enjoy the show afterwards.

Jeeves and Wooster with Stephen Mangan and Matthew Macfadyen starts a bit clunkily as they set the scene improbably with Bertie putting on a stage show to describe his recent experience at Totleigh Towers. This awkward Brechtian moment is swiftly forgotten as we get into the familiar plot about the cow-creamer, enlivened by a memorable Roderick Spode, leader of the fascist Black Shorts (they had run out of shirts).

I reckon I can easily spot the amendments and links added to the inimitable P G Wodehouse material even though I last read the books years ago but, for all that, it is a lot of fun with good visual gags enhancing the writing. Rather like Downton Abbey except well-written, well-acted, and funny (actually I haven't seen Downton so that's just a guess).

Finally to West Wittering on New Year's Day where the tradition of barbecuing on the beach with my friend Nick Jarman is tested to the very limit by torrential rain, hurricane force wind and surf spraying half a mile inland.


Selfie on the beach

But we succeed in front of an incredulous audience of passing walkers...


The Director of Social Services for Neath Port Talbot cooks sausages on a Sussex beach