105. The Firehose Paradox.

The first rule of psychotherapy?  Never quote song lyrics, even if they seem devastatingly apt. Even if someone says ‘it’s like a jungle out there’, do not be tempted to reply ‘you sometimes wonder how you keep from going under’.

Even if someone says, ‘some people call me Maurice’, as actually happened to me once, don’t be tempted to get out the air guitar and play the riff from The Joker. (No, I didn’t do it.)

Quite likely your client will recognise the words, in which case your authenticity is blown. 

Nevertheless, songwriters are great at encapsulating a feeling. If you must quote, include the attribution. Like, ‘as Leonard Cohen would say, Everybody Knows’. 

I’m a late convert to Leonard Cohen’s music and poetry. Clearly, he should have won the Nobel prize instead of Dylan, just for this song. Everybody Knows. In 5 minutes and 37 seconds the song lists all kinds of skulduggery that passes for normality. The dice was loaded. The good guys lost. And in particular, a concern about Fidelity: ‘You’ve been faithful, give or take a time or two’.

There are lots of lines in the song that sound like paranoia but fall just on the right side of understandability. Everybody Knows gets close to conjuring a ‘delusional mood’, an altered state of experience where nothing seems normal. Everybody Knows creates a resonant view of the world’s main problem, which is Falsehood.

But does ‘everybody’ mean ‘everybody’ or just ‘everybody but me’? 

There are hundreds of words for Falsehood and the list is growing. I like ‘knowing’, but you may prefer terms that allow a little more nuance, like ‘greenwashed’, ‘gaslit’, or ‘spun’. Not to mention, for Bill and Ted fans, the evergreen word ‘bogus’.

I am using ‘knowing’ to describe a situation where deceit is implicit but unspoken. Knowingness describes a situation where people quietly share an awareness of falsehood. Like when the checkout assistant asks whether you found ‘everything you were looking for’ today and you say Yes, but you mean No.  The assistant has been told to say that to every customer, perhaps in case Bono ever visits Eurospar. And is still looking for whatever it was he was looking for in 1987. 

What the checkout operator is really saying is ‘I’m being held hostage in this shop, call the cops’.

In Casablanca, (spoiler alert)  everyone knows that Rick shot Major Strasser, including Captain Renault who was there at the time. Instead of arresting Rick, the Captain orders his men to ‘arrest the usual suspects’. Note, Renault does not actually tell a lie.

How often does arresting the usual suspects resonate with our experiences today?

Take this Guardian article by Rafael Behr*

This followed a Sunak speech pretending that he had cancelled a tax on meat, mandatory car sharing, needing 7 recycling bins and other fictitious green policies.

Behr observes that the speech was ‘delivered without the trademark Boris glint that showed at least some awareness that he knew that you knew that he was bullshitting’. Worryingly that means that Sunak is either a better liar than Boris or the opposite, that he has no insight into his own scam and thinks he is telling the truth. 

The glint, the knowing look, is the sure sign of a ‘knowingism’. But if the glint is not discernible there’s a problem. Knowing who knows and who doesn’t has become a major challenge. At one end of the scale, which we can call Glint Positive, is the account of two Russian tourists who visited Salisbury in 2018 and who were suspected of poisoning people. They claimed when interviewed that Salisbury Cathedral was ‘famous, not just in Europe but in the whole world for its 123 metre spire, for its clock, the first one of its kind ever created in the world, which is still working’. 

This is a clear ‘Everyone Knows’ situation. Salisbury cathedral isn’t even famous in Wiltshire.

At the other end of the scale perhaps, I once had a colleague who left stacks of casenotes on every horizontal surface, so that you could hardly see him across his desk. He complained every time you met him that he was grossly overworked. I never knew if he really was stretched to the limit or merely conducting a strategy, possibly one he had learned on a management course, to stop people asking him to do anything. I don’t think he had a glint in his eye though. He probably just had a terrible job.

What happens when a person has learned to disguise that tell tale glint? Or more likely, when a person has talked himself so well into a role that he has forgotten he’s acting?

Misrepresentation, distortion or outright lying is rife in politics, advertising, in corporations and in the public sector. 

Top of the list for doctors in the UK is the monstrous carbuncle called Revalidation. Keen to be seen to respond to the Harold Shipman scandal and strangely determined to force as many retirements as possible, the General Medical Council imposed a time consuming and user unfriendly annual charade on its captive audience of practitioners. As an appraiser and as an appraisee, there are glints in both eyes throughout the process. There is even a glint each time you type the nonsense into adobe acrobat, send it a few times between you and your appraiser and eventually ‘lock it down’.

The GMC removed thousands of licences from doctors for ‘failing to engage in the requirements for their revalidation’. It’s not quite a Post Office Scandal level event. But Revalidation has probably accounted for 10% of medical time and 90% of medical exasperation since it was introduced. And everybody knows that Harold Shipman, if he hadn’t been caught, would have sailed through the Revalidation process and probably led appraisal workshops during which people unaccountably died. (Trevor doesn’t seem to have come back from the coffee break…’)

Doctors would probably settle for a much lower pay rise, or even a pay cut, if they were never again forced to fill in a ‘reflective portfolio’. The GMC say they exist to ‘protect, promote and maintain the health and safety of the public’ much as LAPD  supposedly exists to Protect and Serve. 

The psychology of knowingness was famously invoked by Donald Rumsfeld in 2002:

 ‘as we know, there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns—the ones we don’t know we don’t know’

Rumsfeld was ripping off a piece of psychology called the Johari Window, which has been a stalwart of management workshops since its invention in 1955. 

The four parts of the window are Known / Known; Known / Unknown; Unknown / Known and Unknown / Unknown. Leonard Cohen helpfully simplified the four window system into one – just Known / Known. 

You can probably recall those kinds of workshops and remember the levels of knowingness you felt in the room; the facilitator earnestly drawing the four windows on his flip chart, asking people to think of things that he can write in each window. Meetings where people whispered ‘beam me up Scotty’ from time to time.

Even though the song Everybody Knows, from the album I’m Your Man, came out in 1988, slightly preceding the breakdown of the USSR, the Russians got more and more fascinated with disinformation strategies.

For some reason, the capacity to generate and disseminate false information has become regarded as a work of genius. Russia’s ‘Firehose of Falsehood’ strategy has been hailed as massively effective by some psychologists.

Sometimes attributed to Putin or his advisor Surkov, who presumably read ‘1984’ in the Lower Fourth like we all did, the Firehose involves multiple competing and often conflicting streams of information.

It has been observed that Surkov’s strategy was only really effective because he revealed what he was doing. So that everyone really did know that nothing was what it seemed.

After several decades, the question remains, what has it achieved? 72nd place in the GDP per capita league? And Surkov under house arrest? Yes, but is he?  

Like pirates, a few individuals have made fortunes out of chaotic conditions. Some have been lucky, most have not. The armaments industry has done well, even if there never was a real SDI ‘Star Wars’ program, even if Ronald Reagan pretended there was. As though nobody knew he was an actor.

On the contrary, creating and broadcasting falsehoods is neither difficult nor clever and most often results in a negative outcome for the agent. Take Macbeth for instance. His strategy: kill the king, kill both his bodyguards, blame the bodyguards for the murder, make yourself king, then remember your colleague knows you did it, but have your colleague murdered too. What could possibly go wrong? Only getting PTSD, wife going mad and killing herself offstage and finally getting killed after not noticing a forest creeping up on him.

Macbeth’s plan, like the Rwanda scheme, fell apart under the weight of its own complexity.

The basic problem for propagandists is that disinformation is self-defeating. Especially in the case of propaganda whose objective is to stop people believing anything. Although repetitive and plausible disinformation can seem to be effective in the short term, does it really have a lasting effect? Did it really advance Putin’s agenda if, as a result of the Firehose of anti-vax falsehoods, there is a slightly higher rate of measles in Skegness? Or do beliefs just settle back to where they were before? Every action has an equal and opposite reaction. It’s not rocket science – oh wait, it is!

There’s a contrary view. And an alternative definition of Knowingness. Jonathan Lear, in the book Open Minded,  describes it as a posture of ‘already knowing’ – of purporting to know the answer even before the question arises. Knowingness is a false claim to knowledge that makes it impossible to be surprised by anything new.

According to Malesic,** knowingness can also take the form of ironic or cynical distance, of seeming to have ‘seen it all and gotten over it’. Which is pretty much the world view taken in Everybody Knows and perhaps the true meaning of the song, a jaded acceptance of failing humanity, always attempting to punch above its weight.

It’s become trendy to label such human failings as cognitive distortions, which is a nice way of regarding different ways of lying to oneself. 

As a result perhaps of decades of propaganda, most people’s beliefs nowadays are super shallow – often what the last person they heard told them. Popular beliefs are like topsoil or shifting sand.  

In time perhaps the sands do move and another house in Scarborough falls into the sea. 

In general though, the number of people with views that can be described as ‘fanatical’ stays below 15%, 3% or 1%, depending on where you draw the cut off line and start using terms like ‘far left’ or ‘far right’. For instance, in the UK only about 1.5% of people belong to a political party. This has been falling gradually over the last 70 years.

So, not Everybody Knows. Just 98.5% of people.

Confucious said that real knowledge is to know the extent of ones ignorance.

Socrates said that the only true wisdom is in knowing you know nothing.

Abba, more realistically, just said: knowing me knowing you – its the best I can do.

*https://www.theguardian.com/commentisfree/2023/sep/28/rishi-sunak-success-failure-general-election

**https://psyche.co/ideas/our-big-problem-is-not-misinformation-its-knowingness

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104. The wolves of Wimpole Street.

The Monopoly Board Game is an increasingly valid metaphor for British society. Railway stations, water and electricity utilities can be bought cheaply so that jail is the only service left publicly owned.

Ironically, Monopoly was invented by a Lefty as an educational tool to illustrate the downside of capitalism. Ownership of property slowly but surely polarises the players into haves and have nots, leaving one person super rich and the others destitute. Sure, there is an intermediate stage where a notional middle class can own a few houses, but this is an illusory phase, like Derby County’s sojourns in the premier league. Sooner or later the market will prevail, typically after significant alcohol consumption, leaving family relationships in tatters and one giant corporate entity in control.  

The original idea for Monopoly was stolen by one of the inventor’s dinner party guests, patented and sold to a large games corporation. The inventor did get $500 though, enough nowadays to buy Liverpool Street and Kings Cross stations, given the current exchange rate. The monetary values in Monopoly are pleasingly anachronistic – £200 seems cheap for the whole of Kings Cross. I like anachronisms. Shakespeare in space suits for instance, or the bit in ‘A Knight’s Tale’ where the medieval dance morphs into Golden Years. It was fairly anachronistic when British Home Stores was sold for £1, though it should be remembered the pound was worth a lot more in 2015.

What’s surprising about Monopoly is that there is no hospital on the board nor any other health or social services related property. Players can only build houses or hotels on their streets, not Walk-In or Sure Start Centres. 

Getting out of jail costs £50, maybe even less if you can buy a card off a competitor or throw a double. In real life, the super rich don’t go to jail very often, but may still need to go to hospital. Even the richest individual occasionally crashes a Bentley or has a heart attack during a special massage. 

Which is the moment when, if they have the misfortune to be in the UK – where there is no private A and E – that person realises the paramedics won’t be there for 90 minutes, there are no beds in A and E and their money is suddenly useless to them.

If only there was a card called ‘Get into Hospital Free’, it would trade at many multiples of its face value. Even more valuable would be a ‘Get into Hospital Fast’ card, with a picture of an ambucopter flown by Prince William.

There are two ways into A and E – via reception or ambulance. The reception route collects all those who have been dealt a card called ‘Go directly to hospital, do not pass Go’ and who are well enough to stagger up to reception. 

There are pros and cons both ways. In recent years I have spent a few nights in A and E as an aspiring patient. On the most recent occasion I was walking wounded rather than stretchered, so I went in via reception and I had time – 13 hours or so – for some light blog fieldwork. Staying up all night to get lucky, as Daft Punk (feat. Pharell Williams) would put it. 

During the night the receptionist, who was wearing tight leather trousers and a leopard skin print top, spent a lot of time sticking labels onto case files and filing notes away, carefully ignoring prospective customers. Towards the end of her shift she retreated further and further back from the glass screen into her dark receptionist-cave.

A tall man, probably concussed, with his gashed head bleeding into a towel turban, waited for quite a while before getting booked in. Finally he was asked his details: for occupation he replied ‘international sex symbol’. That was met with a frown. ‘OK, sales executive then’ he tried instead. He reluctantly gave his wife’s name as next of kin. When asked whether he wanted her to be informed, he said, ‘no, that would only make things a hell of a lot worse’.

He took his seat with the rest of us, on the non – covid side of the waiting room. 

Unfortunately the vending machine was on the covid side, necessitating occasional masked guerrilla raids across the imaginary germ frontier. 

Luckily there was a portacabin called The Pod, which was a medium term waiting room, like Purgatory. No-one seemed to use The Pod, probably in case they lost their place in the queue. It was hard to be confident that the staff would come and find you once your turn came up. The pod had a TV, but it was set to a shopping channel and there was no sound and no remote. Don’t tell the Care Quality Commission (they insist on Sky Arts). It was quiet in the Pod. 

Monopoly does pay attention to the random vicissitudes that can affect people, rich or poor, using ‘Chance’ and ‘Community Chest’ cards. The cards do include a £50 doctors fee and a £100 hospital fee, but nothing financially ruinous, like crashing into Gwyneth Paltrow on skis. Chance cards include a range of life events, both positive and negative. According to monopolyland.com the Chance cards are more luck-based and Community Chest cards are more likely to reward the player with money. The worst thing that can happen is the need for property repairs.

Why the game excludes a dimension related to health care is unknown, but my speculation is that the designers were reluctant to admit that accidents and emergencies really happened to property owning people. If they did, they would be treated by insurance based private health providers. The original version of the game, after all, was set in the Atlantic City of the 1930s, a time when Night Nurse was a person rather than a drug of abuse.  In translating the UK version to the streets of London the makers should have gone a bit more Ralph McTell.   

Free Parking? Hard to believe that still exists, any more than Free Lunch. I would call that square ‘Clamping Zone’ and have a picture of a menacing man with a Pitbull. Or instead of Free Parking, on the corner diagonally opposite Go, a square called Stop, a disused BHS shop doorway with a picture of a comatose homeless person under an old duvet. 

Monopoly does not have anything the district council would call ‘high quality public spaces’, so I would suggest they include the Southbank Skate Space, with a picture of Melvyn Bragg, in the background, spraying graffiti. And what about including a square for Tufton Street, where the right wing think tanks are located? Pay a large penalty if you land there, dark money preferred. 

There are versions of Monopoly depicting many different cities around the world. Although there are monopoly situations existing in health care, both government-run and private, the board game itself remains silent on health provision ownership.

I’d like to think this proves that capitalism and medicine just don’t mix well, at least in board games. 

The longest ever Monopoly game lasted 70 straight days, which is about the time it takes to get an urgent eye appointment. It will take a while to find out whether we are getting richer or poorer, but like Derby County, I’m guessing the prognosis for the NHS is Game Over.

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103. The Optimism Crash.

I spent all morning trying to set up Mesh wifi (fail) and all afternoon trying to mirror my phone onto the TV (epic fail). Yesterday I spent an afternoon editing a pdf document to help someone apply for a UK pension (pass, barely). 

And then my HP printer had a seizure of some kind and went into a gobbledygook printing frenzy. HP detected this and immediately sent me an email to say they are really pleased I am having fun with my printer and look forward to more printing in the future, possibly a golden age of print. It’s 1476 all over again.

This is all fine, first world problems, but it’s not quite the future we expected when Tomorrow’s World was on TV. After the moon landings, Velcro and Pot Noodles we looked forward to free energy and a working week of 1 hour when we went in to feed the robots.

Finding that people tend to be optimistic is one of the most important and far reaching discoveries in Psychology. It explains why people keep on buying lottery tickets, electing pathological liars to Downing Street and hitting 3 woods out of fairway bunkers.

People are more optimistic than they really should be.The human spirit is seemingly hard-wired to be indomitable. 

Though it must be said, a lot of optimism research was carried out in the USA, often using samples of college students and arguably during a more optimistic period of history.

During that era, post war, the cultural vibe was an expectation of progress, that each generation would become more prosperous and happy than the one preceding. According to historians* ‘the belief that things are going to get better was already connected to a figurative America even before European settlers set out for the New World’. 

The American Dream preceded D:ream and their song ‘things can only get better’ by 3 centuries at least. 

A word of caution about the American Dream, regarding nomenclature. Call me a pedant, but we need to separate out the differences between Dreams, Daydreaming and Wishful Thinking. People who like to think wishfully fall into the ‘two biscuits later’ category, instead of the ‘one biscuit now’ group who end up in prison. Wishful thinking overlaps to an extent with positive thinking, which can be helpful to the positive thinker, if detrimental to everyone around that person.

The new wishful thinking in politics is to bring back an imaginary world where the map was mainly coloured pink, ambulances arrived within 2 minutes and your GP had a housekeeper called Janet who could mainly solve your problem herself with a shilling’s worth of homespun wisdom. Otherwise a GP would visit before the kettle had even boiled.

Such imagery was perfected by John Major who put it thus: ‘long shadows on county cricket grounds, warm beer, invincible green suburbs, dog lovers and – as George Orwell said (he didn’t) – old maids bicycling to Holy Communion through the morning mist’ (He said ‘hiking’ not ‘bicycling’; call me a pedant again).

Choosing to embrace nostalgia instead of optimism led to Major’s Conservatives being eclipsed by Labour in 1997, who deployed the above mentioned anthem ‘Things can only get better’, by D:ream. Featuring TV scientist and Professor Brian Cox, D:ream were probably the only band ever to use a colon in their name, a device that artfully referenced the computer language underpinning electro-pop.

Dreams, daydreams, nightmares, flashbacks, are all different mental experiences. But they are quite interchangeable in the context of popular music. We are not expecting artists to use psychological terms accurately, (especially as most psychiatrists use them inaccurately too).

Daydream is a Mariah Carey album from 1995, featuring the singles ‘Fantasy’ and ‘One Sweet Dream’. Daydreaming, unlike Mariah Carey herself, is only of limited interest to psychiatrists, since it is a normal mental experience. Daydreaming is a normal mental event, ditto Fantasy and having One Sweet Dream. Or so we thought, until the concept ‘maladaptive daydreaming’ was invented in 2002 by Eli Somer, by which time Mariah Carey had moved on to her ninth album, ‘Charmbracelet’. 

The diagnosis of maladaptive daydreaming was never accepted mainstream. There’s always a backlash against attempts to medicalise aspects of normal life, though anyone could see that daydreaming might be a problem, say, for a fighter pilot or the person who inserts pins on a grenade assembly line. 

Daydreaming is more usually counted as a positive and constructive mental experience, where ideas can flourish. Nevertheless, Somer thought that daydreaming could be problematic if it became excessive or morbid in content. 

Somer was a daydream believer but we are left with the philosophical question first raised by The Monkees: Oh, what can it mean? 

Daydreams are what we do when boring people are giving long speeches. If they are maladaptive they can equally be adaptive. Some of my best thinking, such as planning the list of plumbing parts I will need for a new drain, has taken place as my mind drifted during a long sermon (sorry Father Chris).

The American Dream, which never was really a Dream, somewhere in recent history, seemed to reverse its mood polarity. As Billy Joel put it in the song ‘Allentown’, ‘every child had a pretty good shot / to get at least as far as their old man got’. The lyrics go on to say that, ‘something happened on the way to that place / they threw an American flag in our face’. The song marks roughly the time when the optimism curve started to trend downward.

(That time was emphatically not 1982, which was the year I got married. Allentown was written a few years before that, but yes it was released in 1982. Apologies to Mrs EP).

The life expectancy curve took longer to start declining, but by 2020 most countries, other than New Zealand, Taiwan and Norway, (the smug countries) were predicting reduced average lifetimes. 

Something has gone a bit wrong, but who can we blame? In ‘Allentown’ the problem was the decline of the steel industry, or more accurately its export to Asian countries.

The obvious suspect is the onward march of so-called neo-liberal economics and its fellow apocalyptic horsemen: war, climate change, plague and library closure.

Social division has increased and people are more unhappy in countries with higher levels of wealth inequality. Commentators have linked neoliberal economics to general dissatisfaction and anxiety and to a huge increase in the prescribing and consumption of antidepressants. 

Children in the UK, especially girls, were particularly unhappy compared with other European countries, according to a 2015 study, being made to feel inadequate in one way or another.

Schools continued to overload both students and teachers with assignments and assessment despite the finding that during the plague year, when schools were closed for months on end, the students got better exam results than they ever had when the schools were open.

Social media companies are helping to fuel the fires of envy and self loathing. They are essentially advertising agencies, though more artfully targeted than billboards and posters.  

The targeting still seems erratic, which is why I keep getting adverts from HomeStoreandMore for Patchwork Posie Kitchen Textiles. Or, today, ‘how to make it look like you have abs in every photo’. Instagram is trying to ab-shame me now. And that’s right on top of being cholesterol-shamed at the health centre.

The internet has a lot to answer for and is routinely blamed for every type of disruption. The internet wasn’t a thing in 1982 when Allentown was released, and it wasn’t a thing during most of the 20th century’s wars and genocides. But one has a feeling that the IT revolution exaggerates every social trend, from redefining the ideal female eyebrow to closing small shops and is probably making wars even more deadly than they ever were.

Despite very difficult times ahead, as we collect our thermal pyjamas and hazmat suits from HomeStoreandMore, can we rely on people to stay cheerful? 

Hard-wired optimism is one reason why all of us are not depressed all of the time. Is this resilience being gradually overwhelmed by a tide of damaging online experiences? Yes, clearly, for some, such as adolescents who use Instagram and have been presented with ‘the bleakest of worlds’**.

There is evidence to suggest that Optimism Bias, though basically an incorrect prediction, leads to better outcomes than seeing the future realistically:  

‘that the mind has evolved learning mechanisms to mis-predict future occurrences, as in some cases they lead to better outcomes than do unbiased beliefs’***

This raises a problem for therapists, at least those whose system is based on countering cognitive distortions. This probably explains the recent trend of therapy morphing into Coaching. Check out your therapist’s footwear next time around. If the Clarke’s cornish-pasty loafers have been replaced by Air Max, you may be predicting a ‘better version’ of yourself in the world to come. New Balance might be better. 

According to Wikipedia, Billy Joel is still only 73, so ideally placed for a future presidential run.

*‘Things are going to get better: the American dream in contemporary young adult chicano literature’ Marlene Roider and Stefan Brandt, Graz, 2017.

**Now we know that big tech peddles despair, we must protect ourselves; Zoe Williams, Guardian, 7 Oct 2022

***Sharot, 2011, https://www.sciencedirect.com/science/article/pii/S0960982211011912

102. Fahrenheit 452: the sequel.

What should happen.
What really happens.

For Ian, get well soon!

Gas prices are rising so we need to keep burning carbon on the stove. There is less junk mail to burn nowadays, but there are the weekly leaflets from Spar and Lidl and even better, the journal BJPsych International. This is my system: one small firelighter, a few crumpled pages from BJPi, some bramble twigs and some lumps of Colombian coal / smokeless mix. Apply the match and close the hatch!

Burning the written word always comes with a tinge of guilt. But paper is renewable and psychiatric literature is mainly only of any interest or use to its author’s CV. I just set fire to ‘Stressors and mental health in Bangladesh; current situation and future hopes’. No disrespect at all to Bangladeshi colleagues – I also burned papers from Sri Lanka and Norway. I read them first of course – I’m not a monster. Suffice it to say that mental health services are abysmal the whole world over and not just in Lincolnshire.

Last year though I did struggle with disposing of a lot of books. I went through the proper process – gave some away to charity shops, sold some on ebay, sold more on Music Magpie and stored a lot more in a container park, where for a fixed monthly fee, I can postpone the problem indefinitely, like the Northern Ireland Assembly. 

It comes to a stage where you are dealing with books with 100% certainty of never being opened or read. For example, beautiful, glossy law textbooks just a few years old (they keep changing the law apparently), instruction manuals for Betamax video recorders, anything by Dan Brown, but, most of all, Life in the Fast Lane, the Johnson Guide to Cars (B Johnson 2007) . 

And that’s when the recycling centre comes into play. The sturdy paper-disposal bunkers are militaristic, the only openings are horizontal slits at the top. If there is a shoot-out at the recycling depot, this is where the snipers will hide. 

There is no room for second thoughts. I nearly put in the Haynes manual for the Mazda RX3 but an invisible hand prevented me, even though I’m pretty certain there’s not a single RX3 left in the whole world. That’s the trouble with books. Ever since Fahrenheit 451 was written, in fact ever since some Nazi supporters burned books in the 1930s, disposing of books has been regarded as antisocial to the point of barbarism. That’s despite the invention of word processing, digital storage and ereader devices which can store every book ever written without even warming up. 

Books made of paper, like sound recordings carved on vinyl, have attracted a devoted following of romantic luddites who would regard my Kindle Oasis as the height of vulgarity, even if it contains all the Booker Prize winners (though these were actually downloaded by Mrs EP without my knowledge). 

Even though you can alter the font size. Even though you can turn the page by moving the thumb one millimetre. Even though it has an automatic adjusting backlight. Even though it weighs only 188 grams. (If you’re reading this Jeff, please send the cheque to the usual place).

Part of that is a knee jerk reaction to large tech companies dominating retailing, but part of it is a refusal to face the fact that space is limited in modern houses. 

I searched on Amazon books using the term ‘decluttering’ and this brought up 75 pages worth of books about the subject, ironically nearly all of them available as hardbacks or paperbacks. If you bought all the decluttering books available you’d be a bit of an oxymoron.

A famous study  https://www.sciencedirect.com/science/article/abs/pii/S0049089X18300607

showed that children with a larger home library were more successful. Possibly this is why Wetherspoons started having book collections in some of their pubs, to make their customers more intellectual, though it’s possible that rows of books are now cheaper per square metre than pub wallpaper.

Reading the study more carefully it looks as though you get most of the benefit from a modest increase, up to about 80 books, so one trip to British Heart Foundation in your Volvo should do it. And it’s possible to buy books by the yard:

Have you heard about our Books by the Yard service?

Bookbarn give 5 examples of using yards of books: authentic books for an office space, furniture showrooms, coloured books for google offices, London theatre sets and set design for TV shows. 

Can you imagine? ‘I’m from google, can I have 10 yards of coloured books please. It doesn’t really matter what they are about’. Did that really happen?

But why not try getting a few yards for Johnny’s bedroom to give his brain a boost, in case there’s a causal relationship between a bookish environment and intellectual development? You don’t need to read the books, you just need to have them about the place to create a scholarly atmosphere.

As soon as that thought occurred to me I wished I’d never visited the giant pulping modules at the recycling centre. At least I’ve still got the RX3 manual. 

101. Manchego Nights

I’ve had a lot of dreams recently. Most of them I can’t remember. Analysts used to like interpreting dreams, but now I think dreams are viewed as a kind of mental Pilates, rehearsing possibilities and dangers ahead.

I knew a patient once who thought that we were recording all his dreams and sending them to Disney to be made into cartoons. DIsney never replied to his letters. With medication and therapy he stopped believing his dreams were stolen, but sadly when this happened he also stopped dreaming altogether. I’m sending some of my new dreams to Disney right now before I forget them or get my medication increased.

Driving the bus

This one comes up quite frequently. I’m driving a double decker but from the upper deck, looking down the little periscope window at the right front corner. Sometimes it changes into a Volkswagen Variant station wagon which I drive from the back seat. The bus very nearly topples over round corners. Probably one for the Freudians.

Quantum of Amnesia.

In this one, no-one can remember anything about the Bond movie Quantum of Solace, even though everyone has seen it at least once. Even straight after watching it on TV I cannot remember any of the plot or characters. I find that others have noticed the same thing. Some anaesthetists in China are showing the movie in operating theatres instead of using gas. A news article finds that Quantum of Solace is the favourite movie choice for date rapists. The Alzheimer’s Society calls for the film to be banned.

Wisconsin Shuffle.

I am a professional gambler, working the Mississippi river boats, dealing the Wisconsin Card Sort Test. The other big players are all psychologists, some of whom I recognise, though now they all have moustaches and one of them wears the uniform of a Norwegian navy captain. 

The dream suddenly moves to an appraisal meeting where I am facing the Trust Board. They demand a share of my winnings and suddenly the medical director produces a Derringer from up his sleeve and the chairwoman comes at me with a tiny dagger. I protest that my gambling takes place in my own time and not one of the Trust’s programmed activity sessions. ‘We’ve changed the paradigm,’ laughs the chairwoman. As she lunges forward I see the little NHS Trust logo on her stiletto and then I wake up.

Prince Andrew

Prince Andrew arrives for his CBT session. He’s upset because he’s going down in the line of succession. He was eighth in line to the throne, now he’s ninth, overtaken by baby Lilibet Diana. How badly upset should he feel? Ninth out of sixty million, surely not too bad? 

‘In line to the throne’ is Andrew’s best top trumps suit, even though he’s now overtaken by a tiny girl.

As consolation I remind him he’s still Earl Of Inverness. ‘They can’t take that away from me’ he nods, though in his homework assignment he has found that some residents of that city are trying to sack him. It’s a title that’s been created several times, in 1718, 1801, 1892, 1920 and 1986. I make a note of the sequence to put in a pub quiz one day.

Ward twenty something

In this one I’m admitted to a hospital in Scunthorpe, left in A and E for 12 hours without any water or food, wrongly diagnosed and sent to an inappropriate ward. The other 3 patients in the 4 bedded bay appear to be zombies. Mrs EP visits me and asks if there is any food available. The nurse shakes her head sadly. ‘A long time ago we had vending machines but they have all been taken away’. On her way out, just outside the ward, my visitor sees an enormous bank of vending machines full of chocolate and pepsi. She has enough change for a Twix bar and Ribena, which she brings back for me. I try one finger of Twix, but the effect is like the wafer thin mint in Meaning of Life and I vomit till I explode.

Tower of Babel

This one is like a biblical epic movie, in letterbox format and starring Kirk Douglas. It’s meant to be a comment on the modern world, where there are too many words being uttered or written. But Kirk keeps saying things like  ‘I know there is huge merit in talking about your issues and the only thing about keeping it quiet is that it’s only ever going to make it worse’ and the director just keeps saying ‘cut’.

Be mindful

Its mental health awareness week yet again. I learn that stress affects exactly 74% of people. I take the Perceived Stress test and am surprised to find I score 16, which is described as moderately stressed. Apparently I could reduce it to 10 by taking a Be Mindful course.

After a cup of tea, I take the test again and score 8. Apparently I could reduce it to 5 by taking a Be Mindful course. I open up the Be Mindful course on a web page and a giant shark comes out of the screen and I wake up.

Spacey is exonerated

In this one the actor is totally cleared of any wrongdoing. As a recompense, the movie All the Money in the World, for which he was replaced by Christopher Plummer, has to be re-shot frame by frame with Spacey CGI’ed back in place. I wake up when Spacey seizes the Oscar from Plummer’s cold dead hands.

Learning points

Are any of these dreams food-related? Scrooge, in Christmas Carol, attributed his ghostly night fantasies to tyramine-rich products:

‘You may be an undigested bit of beef, a blot of mustard, a crumb of cheese, a fragment of underdone potato. There’s more of gravy than of grave about you, whatever you are!’, he yells at the ghost of Jacob Marley. 

Dickens was quite advanced in suggesting a molecular basis for psychopathology, even though later Scrooge found plenty of meaning in his dream.

Scrooge changed his whole life around but I came up with two small changes from my dream work. 1. Avoid the combination of Manchego, Chianti and Amitriptyline before bed time. 2. Don’t go to ward twenty something ever again.

    100. Slow train cancelled.

    What does it mean to score zero in the Eurovision song contest? James Newman, the UK contestant, seemed quite cheerful about it; his reaction has been described as ‘iconic’, dancing in the crowd and raising a glass to the cameras. The British have a peculiar reaction to losing and still celebrate major military defeats like Dunkirk and the Charge of the Light Brigade. The word ‘plucky’ usually comes into play.

    But zero, really? If Newman had pretended to set fire to himself with paraffin, or even, like Sophie Ellis Bextor, burned ‘this goddamn house right down’, he wouldn’t have scored any less.  

    Newman’s fire-based song, Embers, was written as a reaction to the pandemic. Newman told the BBC ‘I feel like everyone wants a party and to have some fun so when I was writing, that’s what I had in my head’. 

    Like many songs, from Fire, by Crazy World of Arthur Brown, to Firestarter, by Prodigy, Embers has fire-based lyrics, but is pyrologically under-researched. The fire metaphor suggests that love will grow back from the embers and light up the world (while remaining, strangely, ‘cool under pressure’). 

    Which is the opposite of what happened after the song, which sucked all the oxygen out of the room, but not in a good way. There’s a lesson to be learned from master songwriter, Billy Joel, who famously ‘didn’t start the fire’.

    There’s also a lesson to be learned from the paper, ‘We’re shit and we know we are’: identity, place and ontological security in lower league football in England’.  (Mainwaring and Clark, 2011). People at the bottom of the league, year after year are left with no option but to celebrate, see ‘red wall’, see ‘second highest death rate from covid’ (Poland have gone ahead again in extra time). 

    I know people who regularly attend non-league football, grumble all the way through, eat a terrible pie and leave before the end. Perhaps it’s a reaction to getting judged all the time, from SATs and GCSEs to Masterchef and the Employee of the Week award. 

    In Eurovision the scoring section takes as long as the musical part. Some people just tune in for the scoring, the same people who loved to watch the football results come in on the BBC teleprinter as hors d’oeuvres to the Full Classified. 

    These people, who love making assessments, have been in control for the last century. They are the people who make children compete in local music festivals and adjudicate best artichoke awards in the village show. They are the people who opposed the European super league, because no-one could be relegated and what was left was just ‘a series of exhibitiion matches’. Like, who wants to see an exhibition?

    Flunking a song contest can maybe be seen as a reaction against scoring systems. 

    Perhaps then, James Newman, an Eddie the Eagle for the 2020’s, is ahead of his time in overturning the notion of attaching a number value to a subjective judgement.

    When he wrote ‘Down herе in the ashes, yeah, thеre’s something growing’ was that a sexual innuendo, or something more fundamental – is he imagining a popular revolt amongst the underclass? 

    Sadly, the euro judges didn’t get any of these deeper meanings. Many of the songs are super-ironic, but the performer has to look as though they are totally serious and 200% into the performance. Any glimmer of insight, like Newman showed, a this-is-a-bit-silly look, then all is lost. Newman and the audience seemed to enjoy his losing far more than performing the song.

    Newman has done for songwriting what the Light Brigade did for cavalry tactics; what Dunkirk did for running away; what Count Binface did for democracy and what Gainsborough Trinity have done for football.

    Rather than a simple story about the end of the pandemic, Embers was quite subversive. It might have succeeded if the song had been any good. Unfortunately, The Guardian analysis was ‘began like a Daniel Beddingfield B side and went downhill from there’.

    As such, Embers was a protest song, but it was no Blowin in the Wind. 

    No-one, not even Bob Dylan, ever managed to include the word ‘ontological’ in a song, but I think Supertramp could do it. Next year?  

    ‘Mainwaring E, Clark T (2011) We’re shit and we know we are’: identity, place and ontological security in lower league football in England

    Ed Mainwaring &Tom Clark 

    Pages 107-123 | Published online: 19 Dec 201

    99. Duplo Men in a world of Lego.

    Thanks to Mr Belton, our young, dynamic English teacher, (nicknamed ‘Sexy B’) we studied the novel ‘1984’ when we were 12.  We found out that George Orwell wrote 1984 in 1948, that it had something to do with propaganda and quite a lot to do with Stalin’s USSR.

    Amongst many gems, Orwell coined the term ‘doublethink’, meaning that people could hold two diametrically opposed views at the same time.

    Because Orwell was a writer, the concept of doublethink was largely ignored by psychologists, who were still trying to understand how genocides could happen.

    In 1957 Leon Festinger coined the term ‘cognitive dissonance’ meaning a situation where two opposed beliefs or behaviours could co-exist. 

    In Orwell’s idea of doublethink, there was no tension or anxiety involved in holding opposing views. There was no need to bring in moral-based concepts like hypocrisy, deceit or plain lying. You just had two different views at the same time.

    Whereas with cognitive dissonance there is a tension between the two beliefs, so that a person tries to reduce the tension by pumping up one of the beliefs and diminishing the other. Many (quite unconvincing) experiments took place to show cognitive dissonance happens, at least in samples of carefully selected American college students. 

    Also in 1948, the WHO made a statement defining the concept of ‘health’: 

    ‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. Health became an entirely different thing from not being ill. More recently people are using the term ‘mental health’ in all kinds of contexts, often stretched or inverted, so that people ask me things like ‘was Trump a bit mental health?’

    Trump does not seem unhappy with himself in any way.  Also psychiatrists are not supposed to diagnose people they haven’t met, even if those persons are famous, for instance suggesting certain politicians fit the profile for Narcissistic Personality Disorder. 

    According to the ‘Goldwater rule’ in the American Psychiatric Association’s (APA) Principles of Medical Ethics, ‘it is unethical for psychiatrists to give a professional opinion about public figures whom they have not examined in person’.

    Shouting at the television probably doesn’t constitute giving a professional opinion so it’s probably OK to keep yelling abuse. The TV can’t hear you, or so we thought.

    Despite the rule, in 2019, ‘The Independent’ reported that 350 mental health professionals had written to warn Congress that ‘Trump’s mental state is deteriorating dangerously due to impeachment with potentially catastrophic outcomes’. 

    Conversely, “Trump Derangement Syndrome (TDS) was proposed as ‘a mental condition in which a person has been driven effectively insane due to their dislike of Donald Trump, to the point at which they will abandon all logic and reason’’. 

    TDS is a refreshed version of BDS, Bush Derangement Syndrome, invented by a psychiatrist, Charles Krauthammer, in 2003.

    Notice that TDS affects everyone apart from Trump, including the 350 mental health professionals who wrote to Congress, leaving Trump the only person coming out of the situation looking completely healthy. 

    We should look at Trump and BritainTrump (and the other world leaders that Pink Floyd would have consigned to the Fletcher Memorial Home) and instead of asking why they are deranged, ask instead why they seem so well.

    Along these lines, we need to revisit doublethink and ask, is doublethink a step forward in human development, a special power of some kind?

    BritainTrump for instance wrote two articles within days of each other both opposing Brexit and promoting it. There are websites devoted purely to recording his lies. The Marcus Rashford related lie, June 2020, went as follows:“I talked to Marcus Rashford today and congratulated him on his campaign which to be honest I only became aware of, recent … erm, today.”

    Simon Hattenstone, in the Guardian, wrote at the time that this was a new kind of non-useful lie:

    ‘on Tuesday he appeared to have taken his lying to a new, worrying level – he now seemed to be lying just for the hell of it’

    Yet he seems happy with himself and so far the voting public seem reasonably happy with his behaviour. 

    Let’s assume Britain’s PM has evolved beyond cognitive dissonance into ‘dual mode’ so there are no signs of mental tension. Attempts to see the problem as ‘pathological lying’ or ‘mythomania’ are plainly judgemental. All we know is that there are two versions streaming at once. 

    Double thinking, sometimes called double-bookkeeping, tends to be regarded as pathological, whatever the motivation. Whether it’s unconscious or deliberate, whether it’s delusional or magical thinking, we’re suspecting, in the words of Tokyo Blade, a ‘Head full of Bad Wiring’. That’s in contrast to everyday observations of doublethinkers, suggesting they are very happy indeed, having their cake and eating it.

    Could it make sense to belong to several political parties at the same time? While you’re in town on Sunday morning, could it make sense to attend the catholic church and then the Friend’s meeting house gatherings, if the timings are favourable and you’ve paid for a whole morning’s pay and display? 

    You can’t join the labour party if you’re a member of another party. Churches, on the other hand, don’t employ bouncers. Many are nice places to hang out and some offer low price coffee and biscuits. The methodist church even has a capsule coffee machine. Would you give up Hail Marys in return for Lungo Intenso? Maybe you don’t have to.

    If I’m asked what football team I support and I reply, ‘Man Utd and Liverpool’, am I facing a beating? 

    My argument is that such thinking is commonplace, but also that it is extremely rare.

    98. Monstrous carbuncles revisited.

    This image has an empty alt attribute; its file name is img_20190620_133529.jpg

    People had been working on measures of social deprivation for decades before Donald Trump invented the shithole scale.

    Sadly, the Donald didn’t colour in the broad canvas between Haiti on one end and Norway on  the other. Africa and El Salvador were reported somewhere in between, but where for instance would he place Mexborough? 

    In the UK people love to write satirical articles slagging off their towns, including architecture, town planning, the appearance of the inhabitants and their behaviour. There are a few reasons for this, beyond what Jeremy Corbyn might call ‘english irony’.

    The project ‘Crap Towns’ was an attempt to say something about urban deprivation in the UK. Crap towns featured in a series of publications associated with The Idler.

    Most of the crap towns identified  would also rate as deprived on scales of social deprivation such as Townsend or Jarman, but Crap Towns is more subjective and much more fun. 

    People nominate their towns and surveys are carried out. The process has not been tightened up or ‘operationalised’ as much as social scientists might like. As a result the essential notion of the crap town has been far-fetched to include entities like London, York and Chipping Norton. These places are not face-valid as crap, even though some of their inhabitants know better. There are plenty of aspects to criticise, even in affluent towns. Try walking past the Grafton Centre, Cambridge late on a Friday evening, where the cast of Mad Max has reassembled.

    In another survey  conducted by iLivehere.com, Peterborough came out as the worst town. Runners up to Peterborough include traditional favourites like Halifax, Doncaster, Rochdale and Rotherham. ILiveHere self-identifies as satirical but its findings seem broadly valid. In most of those towns over a quarter of general practice patients are depressed and taking cheap generic fluoxetine.

    Most of the Crap towns voted Leave in the referendum, and in general the Leave vote was closely correlated with the CQ (crap quotient). Crap towns are all about self-flagellation.

    I lived in crap towns, including Peterborough, most of my life and I enjoyed them greatly. I have to say Peterborough is not a proper crap town. It has a John Lewis store which may reopen one day and a fine cathedral, not to mention an excellent road system. It does not have a branch of Boyes (the nearest one is in March) though it does have three B & M stores. There is a large suburb called Eastern Industry, telling it like it is. 

    For me, in a proper crap town the shops will include Boyes, B and M, Superdrug (not a proper Superdrug, but its poor relation, Savers) and at least 5 charity shops. The charity shops will have hundreds of DVDs and Jack Reacher books. There will always be a CD copy of Misplaced Childhood, by Marillion. There may be a branch of Heron Foods, which is a portal to a Waitrose in a parallel universe.

    Greenwood menswear, Weigh and Save and Bargain Booze are now boarded up, having teetered off the top end of the CQ scale. 

    There are often shops that specialise in outdated food items. You don’t have to be a food scientist to know that cream sherry will never deteriorate during your lifetime.

    The post office has usually been transplanted to the corner of a Spar Shop. People tend to travel by electric scooter. These move silently along the pavements catching unwary people lumbering out of Martin McColl’s scratching lottery cards.

    If it’s a particularly cold and windswept day, four TalkTalk reps will be in the market square, trying to make you feel sorry enough for them to engage in light banter. One of them is usually nice looking enough to have attracted the attention of two big girls with prams. There’s a hairdressers that charges £4.99 for a cut and the barber looks like Liberace.

    Crap towns should have poor Air Quality. Crap towns to the West have less pollution, with the exception of Port Talbot, which has the worst air in the UK. Crap towns to the east have less rain, but what rain there is gets more acidic. Scunthorpe is an Industrial Garden Town, or so it says on the signpost, telling it like it isn’t. Scunthorpe has the worst air quality in England. It might be worth spraypainting over the word Garden if you’re passing the town sign. 

    I don’t go there now, although I can thoroughly recommend the colonoscopy department. I don’t imagine there’s a better colon imaging experience anywhere in the world – I still treasure those intimate photos – which goes to show, there is much more to a town’s amenity than its deteriorated retail area. Many facilities that we used to think we needed are now obsolete, following the harsh judgement of the Covid crisis: 

    Pubs – like your living room, but with more infectious particles, and drinks three times the price you pay in Lidl.

    Cinemas – like your living room, only someone is sitting behind you crunching popcorn and someone in front of you is staring at a very bright phone screen, scrolling down ebay items. You can’t skip the trailers by pressing a button.

    Shops – like  your living room (using Amazon) but you have to drive, park, pay and display and not find the thing you want.

    Cafes – like your living room but tea is 200 times as expensive and you need a code for the toilets.

    Libraries – like Amazon but without the book you wanted 

    Schools – like your living room but without proper IT or chocolate biscuits.

    This change toward online living is another reason for shrugging off some of the aesthetic limitations of one’s town centre. Since most retail and many services went online, does it matter any more where you live, providing you have robust lungs, a smartphone and noise cancelling headphones?

    For instance, when you’re asleep – does it matter then where you live ? Or when you’re watching TV, does it matter then? Or staring at a computer screen?

    What about the neighbourhood, what about crime, what about those yobbos on mopeds? What about those hot hatchbacks parked window to window, exchanging little packets of not very legal substances in the leisure centre car park?

    Granted, some areas are a bit too clockwork orange to feel comfortable, but in general, the real risk of violence is far lower than the subjective risk. Even in a crap town, you are far more likely to fall down stairs texting or get hit by a scooter than get knifed in the subway.

    There are many more subjective accounts of terrible environments, such as featured in Failed Architecture and the long running Private Eye column Nooks and Corners. Everyone has their own ideas about which towns truly suck. After a while it becomes obvious that none of the towns are as bad as people make out. Writing about crap towns has become a genre. The writers more often love their towns than hate them. Rather than paint the towns ‘warts and all’ this genre just paints the warts. Finally The Telegraph runs an article called ‘Crap towns and why we love them’. Most people get the joke. We learned to live with concrete and steel. Prince Charles never did. That thing he called a monstrous carbuncle was an art gallery extension, something we’d have celebrated if they’d built it in Stirchley.

    Which is surprising. Charles came from one of the most privileged families in the world and yet was sent to a prison-like boarding school where the dormitory windows were always kept open and he was systematically bullied. He should have written the definitive textbook on family sabotage, a book called ‘how and why we make rods for our own backs’.  Instead he went on to attack modern buildings, usually ones that were made of concrete, forgetting that they were often very useful, warm and nice inside, like the crap towns they formed. 

    97. Snakes and ladders, without the ladders.

     

    Physician heal thyself / the tailor is the worst dressed man.

    This is for my friends who keep asking what’s happened to EP.  I can’t promise it will be a good read, unless you’re one of those rare people who like to hear about other people’s medical problems without getting paid to do so. But, as ABC put it, excuses had their uses, but now they’re all used up.

    From February last year my life changed from being a health care provider to a health care recipient. A service user perhaps, or a patient, or to what non-PC doctors used to call a ‘punter’. Seeking health care is very much taking a gamble.

    Think of it as a long overdue field trip through the health services. Every doctor should be made ill and admitted to hospital for a few days. I’d bring it in as a short module in year five of medical school, between ethics and breaking bad news.

    Early last year I started to get pain in the neck. It began as what felt like a sprained muscle just to the right of C7. It got worse, I went to the GP, he referred me to physio and ordered a lot of blood tests. He forgot to tell me there was a 3 month waiting list for physio, which had been privatised. He also forgot to tell me it was impossible to make an appointment to see him again, ever. 

    The pain got worse again, I went back to another GP who prescribed Cocodamol and Naproxen and ordered an X ray. I spent a lot of time lying on the floor staring at the ceiling. 

    The X Ray showed some degenerative changes and possibly a facet joint problem. The word ‘mild’ cropped up a lot, which was reassuring. 

    But at the same time, a friend of a friend with neck pain turned out to have a spinal cyst which was not discovered soon enough. He developed multi-system failure following surgery and died tragically. An extremely rare occurrence, I was sure, but my subconscious mind didn’t see it that way.

    So, seeking further guidance / reassurance, I got referred to the musculoskeletal service, or ‘MSK’ as it calls itself. MSK, whoever they are, have organised their services based on old kidnap movies. The ransom payer is forced to run between telephone boxes and directed towards a remote venue. MSK make a series of anonymous phone calls and lead you a long way down a symbolically pot-holed road, to an industrial area a long way from where you live, leaving you scanning the skyline for snipers. 

    A letter arrived announcing that I will be phoned to discuss an appointment. The phone call happened on time and I was sent to a contracted out service in a contracted out building. The receptionist denied all knowledge of my appointment, but luckily I saw a man who looked like an orthopaedic consultant – by this I mean he was wearing a suit – and this time for once my stereotyping proved accurate. The orthopaedic consultant, who was also contracted out, did a test where he pressed my head downwards into my neck. The pain got worse when he did that and I think I am still an inch shorter than I used to be. 

    He requested an MRI scan.  

    Same process for the scan – a letter announcing a phone call. The scan is in a portable unit on the same site, sadly there are no toilets. I am phobic of closed spaces but by this time Mrs EP has taught me a lot of Yoga and I yoga breathe my way through the scan trying not to open my eyes or sphincters.

    The MRI showed some mild degenerative changes consistent with age, just like the XRay but commenting on different bits of anatomy.  I saw a few different physiotherapists, two NHS, subcontracted, and two private. And I got referred to the outsourced pain services, also subcontracted to some agency you never heard of. I waited for the ransom demand phone call.

     

    A short holiday in Scunthorpe 

    Then came a huge diversion. At the end of May 2019 I took the prescribed dose of Cocodamol for 2 days which caused a massive abdominal problem, a closed loop bowel obstruction (as it turned out, months later, when my CT scan was reviewed). Cue a very interesting day in a urology ward, which will fuel another article once the PTSD has subsided.

    Then a month of abdominal pain and a diet of fish fingers and white bread and very little fibre, surgical and gastroenterology appointments leading up to a colonoscopy and another referral back to the surgeons, thankfully postponed due to Covid.

    The abdo pain seemed to dislodge the neck pain. I’m not sure how that works, perhaps there is limited bandwidth in the brain. Maybe pains have a rank order, like suits in Bridge. 

    As the abdomen settled down, after about a month, the neck pain came back. 

    Cocodamol was firmly off the menu, not to mention Tramadol, which another GP had prescribed over the phone, which Mrs EP observed made me mildly delirious. Luckily Mrs EP hid the tramodol, so I never encountered the biggest snake pit in the pain game, rapid addiction to opiates. So I was left with Ibuprofen and Paracetamol, neither of which made any difference to the pain. By this time I was beginning to realise that Pain doesn’t play by any rules and should be given a capital P.

     

    The clinic at the end of the world

    The Pain clinic was located at the end of a long cul de sac  along the river, in a former pumping station. Therapeutic nihilism had set in at the pain clinic. There was no sign saying ‘abandon hope all ye who enter’ but that was the vibe.

    The Pain clinic does not believe there is much relationship between tissue damage and the experience of pain. They suggested I check out the work of Lorimer Moseley on Youtube, which I did. 

    So Pain is mostly an illusion. A distorted and amplified rendering of a routine background noise. A warning of some kind, possibly false news, like the antilock brake light on your Ford Focus. 

    Knowing  that Pain is mysterious doesn’t give you much direction. Thinking of Pain as a false warning signal suggests two opposite approaches, which are referred to as ‘recalibration’ or – in technical language – ‘building shit up’ and ‘calming shit down’. The former leads to challenging physical activity and the latter leads to lying down and meditating. It’s vague how you actually go about building and calming shit, but the whole thing is DIY by this time.

    Mrs EP, who is the only person who comes out of this well, as a heroine in fact, taught me Pilates as well as Yoga. We went for long runs barefoot on the beach. We did meditation and relaxation exercises. We made rich fruit cake and pizza dough.

    I kept a Pain diary for months. I gave the different pains silly names to try and diminish them. The ache to the right of C7 I called Boris. The Pain higher up on both sides I called Colin Blenkinsop. The worst Pain, a crushing sensation that sends you looking for the Tramadol capsules that Mrs EP has hidden, I called Agent X47. If that’s not CBT I don’t know what is!

    I apologise if there’s a real person out there called Colin Blenkinsop. Or indeed, Agent X47.

     

    The magic bullet fantasy

    If I was into CBT, which I’m not, I’d mention an automatic thought that goes as follows: 

    ‘It’ll probably turn out that there’s a simple problem – mechanical or chemical –  that’s been overlooked.’

    I was nearly convinced that the experience of Pain is brain based rather than due to tissue or nerve damage. And I began to feel very sorry for people with problems like fibromyalgia and somatoform Pain disorders.  I began to understand how angry chronic fatigue patients got after being consigned to light exercise and extra-light CBT.

    In January this year though, the negative ‘magic bullet’ thought cut in again.  I started to believe the facet joints might be causing the problem. I looked at lots of youtube videos of facet joint injection and radiofrequency denervation. After going through another ‘something must be done’ day I made an appointment at a different Pain clinic. 

    Luckily the clinic did not recommend facet joint injections or anything else involving needles or machines that go beep. The worlds of Pain perception and tissue damage are parallel universes. They never really meet, not even through portals in spacetime. 

    Pain experience is made of Lego and the body is made of Meccano, the specialist told me. Perhaps not a brilliant metaphor, but one I distinctly remember.

    He did however refer me to a colleague to work on my posture, core and neck muscles. No guarantee it would help, but I’d have better posture and muscle strength and my shirts would fit better.  His colleague gave me some very specific exercises. She was positive and reassuring, a welcome change from the doom merchants. Things picked up from there. Co-therapist Mrs EP took over the regime as the lockdown hit and added deep relaxation. We built it up and we calmed it down, without even using the word shit.

     

    Pain is an illusion, just like almost everything else.

    The world is not what it seems. A lot of the news we receive is distorted or made up. A lot of pain we perceive is distorted or made up. The brain employs a cranky, alarmist and unreliable editor, just like the Mail on Sunday. 

    Painkillers don’t really kill Pain. The NHS is not the NHS, it’s been outsourced, sliced and diced and provided by people you cannot ever meet or contact. Symbolically, Pain services are located in the dark places on the edge of town. But – don’t tell anybody – you can also find them in posh looking sports medicine clinics.

     MSK sounds like a terrorist group, and in many ways they do strike terror. Millions of people get addicted to opiates and millions more fall victim to bogus therapies and illicit drugs. Pain patients soon become outsiders to science and society.

    Because pain is so common, and evidence based treatments are so few, Pain patients are filtered through a series of rationing devices, including waiting lists. These are really just holding areas for legions of desperate people. Sadly, the delay in assessment allows Pain experience and behaviour to set in, like Japanese Knotweed. 

    Earlier this month, NICE issued some controversial draft guidelines for managing chronic primary Pain. 

    On Planet Nice, problems are solved with kindness and clear communication. Possibly a little acupuncture, group exercise and a dollop of homespun wisdom aka CBT. None of those nasty tablets. On Planet Nice GPs are like Doctor Finlay or Doc Martin. You don’t have to wait a month before seeing them, you can see the same doctor more than once ever and they may have read your notes. If you see a specialist he won’t be an agency locum. No-one will give you a poor, skewed photocopy of some youtube weblinks and call that bibliotherapy. 

    Sadly Planet Nice is an illusion too.

     

    96. Watching their Rome burn.

    IMG_20190209_124738

    Sorry, I’ve not written anything for a while. The daily news has become so outlandish that the art of wry observation has been killed off. It’s like a weather report has been interrupted by an extinction event meteor strike.

    People keep asking me to explain why the UK is shooting itself in the foot and I suppose the easy answer is that Britain hates itself deep down. Britain is one of the first industrial countries and is the first one to become sick of industrial endeavour. The jadedness is pervasive. No-one’s really facing it. Employment is historically at a high level, but most of what people do at work they freely accept is pointless.

    If Britain turned up in outpatients we’d send it to the crisis café, where it would do breathing exercises and group drumming therapy. Britain is paranoid, but not in a psychotic way. Britain is using the primitive defence mechanism of projection to blame its problems on others, much as Gotham City eventually turned against Batman. Britain will not be given drugs and universal benefit; it will not be allocated to a care coordinator. Britain will be given a self help leaflet and ‘signposted’ to the Tuesday allotment project. Sadly there is no therapist designed to treat whole countries. Although we have Prince Harry ‘starting conversations’ and the government’s behavioural insights unit.

    But will that be enough to rescue us from our angry self loathing? Or do we need a proper superhero? Or even a more universally hated enemy, now that ISIS is receding and Northern Rail have settled their strike?

    Beneath paranoia lies a longing for there to be someone out there who is interested in us– preferably in a good way, like a guardian angel, or Nick Knowles from DIY SOS. If they care in a negative way, such as a stalker or the taxman, that is still better than the complete indifference of a dark, empty universe. If Brexit is a cry for help, rather than a death throe, it relies on someone taking notice.

    We cannot rely on International Rescue since David Milliband took over. I seriously doubt whether David has got the time to monitor every radio network in the whole world 24/7 like the Tracey brothers used to do. The closest we can come to Thunderbirds is the Air Ambulance, which is why we love it so much and keep putting coins in the collecting tin.

    Maybe the giant corporations will look after us. I know that Google Rewards checks up on me regularly, knowing which shops I have been into or near. Unlike my guardian angel or Nick Knowles, Google Rewards reveals itself to me regularly with short survey messages. At the moment it wants to know whether I have spent any money in the shops and in particular what means of payment I used. Quite often it asks me how I feel about Argos. I don’t think Google would come to my rescue in an emergency, but importantly it does pay a small fee for each bit of information I send in. It might only be 6p each time, but it means at last I can say I am a paid writer.

    Up there somewhere, my imagination tells me, there’s a person at a monitoring station looking at a screen, looking at what I am doing, ready to beam me up out of any trouble spot – this is what I call the rescue fantasy.

    If I break down in my car I will call the AA. If I’m in a road accident the ambucopter will arrive, circle overhead for a while and land in nearby school playing fields. If my tooth breaks off the dentist will fit me in the same day and fix it during the Ken Bruce Show on Radio 2, both of us muttering answers to the popmaster quiz.

    The local GP surgery reached out to me recently, inviting me for my 5 yearly check up. It’s called Health Check with the Nurse, though it is a health check with a health care assistant nowadays. In some more prosperous parts of the world it’s maybe a Health Check with a Regional Dean of Internal Medicine, or an underemployed WHO ambassador like Robert Mugabe. Next time here I suspect it will be health check with youtube and a mirror.

    Anyway, the point is there is someone out there who cares about you, even if they have ulterior motives, like targeted advertising or stopping you getting diabetes.

    And we’ve looked upon our parliament and political leaders to take an overview and guard us from our own foolishness. In return for their efforts we scream ‘nanny state’. But now we find our elected leaders fighting among themselves. Our ambucopter has landed, only to reveal the pilot and paramedic beating each other unconscious in a fist fight.

    Some good things are happening, like the minimum alcohol pricing in Scotland, limits on fixed-odds betting terminals and quiet carriages on LNER. The police are asking us to report motorcyclists without helmets, accepting they will be anywhere within a ninety mile radius by the time details have been taken on the non-urgent line.

    If The Rescue Fantasy was a movie here’s how it could all still work out:

    Prince Philip has a dream of a devastated Britain that looks ever more like the set of a Mad Max movie. No More Heroes by The Stranglers plays loudly in the background.

    He sends for Harry and symbolically hands over the key to the Royal Land Rover and Harry’s old army pistol. ‘You’ve got exactly 40 days to save this country from its own danged-bone-headed foolishness. You’ve been talking a lot about starting conversations, Harry. (eyes narrow) Now I’m telling you to finish the conversation.’

    Training montage of Harry ploughing through piles of books: Freud, Durkheim, Nelson Mandela; exchanging ideas with world leaders; mindfulness exercises with the Beckhams; in the lab with Brian Cox; and finally, on the firing range with Prince Philip.

    Cut to Parliament. Just like in Crimson Tide, at gunpoint, Harry relieves the prime minister of command, ‘You’re unfit for duty madam. And that’s the end of the conversation’.

    Epilogue scene, the truth and reconciliation committee, chaired by Ant and Dec, symbolically reunited, takes evidence from the perpetrators. Harry, in the background allows himself a half smile.

    Brief shot of angry Putin, smashing his vinyl copy of No More Heroes.

    The End.

    Post credits shot of the new Nissan X Trail, made in Sunderland after all.