Is Pain a Path to Wisdom? The Writings of Ivor Browne

Ivor Browne: The Writings of Ivor Browne.

By Ivor Browne
Atrium Press

Reviewed July 2013 – Sunday Business Post.

In 2008, Professor Ivor Browne published Music and Madness, a hugely popular book that was both a character-filled memoir and a critique, at the closing of a long career, of the current practice of psychiatry. Now follows The Writings of Ivor Browne, an eclectic collection of Browne’s articles and lectures dating from 1959 to the current decade. It is an intriguing, if sometimes infuriating, read.

The first thing this book does is to reaffirm that Ivor Browne is a crucial figure in the history of Irish psychiatry.

As Clinical Director of St Brendan’s Hospital in the 1960s, Browne, along with Dr Dermot Walsh, began the work of closing the asylums that dotted Ireland. It’s hard to overstate what a transformative change this was in the lives of people with mental illness. In his foreword to this book, Fintan O’Toole describes Browne as a “literal liberator… a key figure in the freeing of thousands of people from institutional incarceration”. Few would quibble with that assessment.

For this reader, the most enjoyable chapters in The Writings of Ivor Browne are those, like ‘Guided Evolution of a Community Mental Health Service: A Personal Odyssey’ that deal with the closure of the asylums, starting with Grangegorman.

Browne wrote ‘A Personal Odyssey’ in 1985, a decade from retirement. He wrote of his optimism in the 1960s as the great liberation began, and of his later dawning realisation that Ireland, particularly Dublin, in the 1970s and 1980s was a tough place to make your way if you had a serious mental illness.

Many who left the asylums thrived, but some struggled to survive in a fracturing society that was not ready to welcome them. What Browne is acknowledging here, I think, is that a liberation can have unintended consequences.

Browne continues to be an influential figure, whose views on mental health are much sought after by national newspapers. He has over many years moved to the margins of his chosen profession, but in publicly opposing much of mainstream psychiatry – which Fintan O’Toole’s foreword mischaracterises as “a model of psychiatry which relies only on the administration of drugs” – he has acquired the status, in the words of the Irish Independent, of a “fearless maverick with ideals”.

In this book, Browne offers a number of sharply worded assaults on physical treatments in psychiatry, such as electro-convulsive therapy (ECT). ECT has come under the spotlight in Ireland again in recent weeks, due to the decision by the government to amend the legislation governing ECT without consent.

Browne’s most pointed comments on ECT come in the article ‘Mental Illness – The Great Illusion’ and in a 2008 letter to the Irish Times. In each piece, Browne lists ECT, emotively but inaccurately, alongside historical “punitive procedures”, including purgings, bleedings, beatings, and frontal lobotomies. He also refers, in the midst of all this, to the mass murder of people with mental illness by the Nazis.

Are we to infer that 21st century psychiatrists use ECT as punishment, or as an instrument of totalitarian oppression? If that’s an accepted view of mainstream psychiatry, we’re really in trouble.

Ivor Browne’s opposition to ECT is consistent with a central theme of his writings here, which is most clearly elucidated in ‘Suffering and the Growth of Love’, a lecture from 1997 that is reproduced here.

Browne argues that mental distress, such as depression, anxiety, or psychosis, is a sign that a person must change. Change can come only from within, through “work and suffering”, via psychotherapy, and any treatment that is externally imposed is either anathema (ECT) or inadequate (medication without psychotherapy).

There is a lot in this, and Browne’s point that mental suffering should not unthinkingly be medicated away is well made. But there are two problematic assumptions here.

The first is that orthodox psychiatry is purely biological, and ignores the social and psychological. In fact, community psychiatry today is defined by a holistic approach. I would be lost without the nurses, social workers, occupational therapists, and psychologists on my team. I would be worse than useless.

The second assumption is that mental suffering always means something. That’s an enticing idea, but it’s wrong.

We are social, psychological, and spiritual beings, but we are also clusters of cells, and sometimes those cells stop working as they should. Thyroid disease, a lesion in the temporal lobe, an autoimmune attack on a glutamate receptor, a dysfunction of the dopamine system: these can all result in distress that is real, and powerful, and even mystical — but it may not mean anything. It may be just chemistry.

Orthodox psychiatry can learn from Ivor Browne: we should push ourselves and our patients in a search for meaning when we can; when those are there to be found.

But Ivor Browne could learn from orthodox psychiatry too. Sometimes suffering is not a path to wisdom. Sometimes pain is pointless. Sometimes pain is just pain, and the job of the psychiatrist is no more complex or simple than this: to make it go away.

‘Lost’: Ordinary Life Is Pretty Complex Stuff

Last Tuesday morning shortly before eight, Cathal Funge played ‘Lost’, Sorcha Richardson’s single released in September, on his morning show on TXFM.

Only a few days earlier he played Big Star’s ‘I’m In Love With a Girl’ in the same peak breakfast time slot. I’ve never before heard ‘I’m In Love With A Girl‘ on the radio, and I would have noticed. I’m going to miss TXFM.

I hadn’t caught Cathal’s introduction and I didn’t know what this song was but ‘Lost’ caught my ear with its opening three bass drum thuds – long, short short; boom… boom boom; and the little rattle of snare. That Phil Spector beat that leads into “The night we met I knew I needed you so“.

A ‘Be My Baby’ beat is to be used with caution. It promises a sweet and deep pop thrill; it gets your heartbeat ready to skip. This sound has a long lineage.

Listening to ‘Lost’, I thought of Camera Obscura alongside the Ronettes, and I thought of Johnny Boy‘s ‘You Are The Generation That Bought More Shoes And You Get What You Deserve’. I thought of the Ramones and of the Beach Boys. Brian Wilson has been saying for fifty years that ‘Be My Baby’ is the best song ever written. You can hear him worshipping that song in ‘Don’t Worry Baby‘, which has its own claim on that title.

So no pressure, then, ‘Lost’.

But ‘Lost’ honours its lineage. ‘Lost’ is a wonder.

I went back to ‘Lost’ on the Luas and played it back to back all the way to work. There’s a point a few listens in on public transport when you are hoping your headphones can’t be heard by the person standing beside you. You don’t want your neighbour knowing as you’re rolling past Bluebell that you’re having a moment; choked up and happy.

But on you listen. You’re hardly going to stop listening.

On Tuesday I tweeted that I found something very moving about the song and didn’t know what it was, yet. This, I suppose, is what I’m trying to figure out here.

‘Lost’ is a song of love and encouragement to a friend whose heart has been broken. (I’m taking it literally because, in her liner notes, Sorcha does.)

She makes the best of it with bravado “(“She is leaving? You just let her / Cause you’re better off”). She understands: she sings “It’s okay to be this way but you don’t have to be forever” with a tender ache in the grain of her voice that makes me wince a little.

She makes plans to divert him with drink: “I know it’s dark inside your head / Replaying everything she said / So come out with me instead… Penny’s working at the bar / We can go dressed just how we are / Forget that girl who broke your heart”.  She feels his pain: “I know it’s bad baby / Come on we can dance it off / Everybody’s feeling lost”.

The chorus is “I don’t wanna see you waste another day / On your heartbreak“. Which is both moving and amusing. I know guys who’ve put YEARS into a good heartbreak.

I should note that the song is brilliantly structured, tightly drafted, colloquial and not overexplaining (who’s Penny?), and, at 2:59 with half a dozen emotional peaks, a tiny bit too short. Another writer would have padded with a minute of an outro, and that would have been OK. But this is better; a tiny bit too short is how long a song should be.

Some of what is moving in ‘Lost’ is the central sentiment – its tender, warm love.

It’s a platonic love, and so the lyric has a selflessness that another song would not have. So many songs purportedly about a lover are about the narrator’s own internal wrangles. Why is this happening to me? I don’t deserve this!

And that’s fine. But this is different; this is generous.

It’s not just that she sings “I don’t wanna see you waste another day“; it is of course how she sings it, with full lungs and fulsome compassion. Which is also how my daughter, who’s six, sang it when we played the song together. She belted it out. She understood it. (Not the bit about getting hammered down the boozer.)

A little of what moves me is my memory of that time in my own life, early to mid twenties, when falling in love and occasionally getting together with someone but mostly worshipping from afar and listening to endless AMC songs and pondering the meaning of love with my fellow doomed romantics was what we did.

They didn’t always feel like it but they were gentle and innocent times. We were trying so hard to figure it out. We were so daft and earnest, and those conversations were the most important, high-stakes event in our weeks.

And I thought of old, old friends I haven’t seen in so many months, who I nearly don’t have time to miss, and I thought – Christ, these people are part of me. Like this, music reminds you to be better at being you. (Then you just have to go and do it.)

What moved me about ‘Lost’ on Tuesday wasn’t the moments I would later have in the kitchen with my kids bonding over the song; but then we did, and so that’s part of it now.

There’s a video for ‘Lost’, and when Sorcha posted this I showed the song to my daughter Olivia. She wants to be a teacher and a singer and I just wanted her to see that you can make a song about something as simple as being a good friend. (There’s a particularly hallowed place in our house for songs that everyone in the family loves. You can’t push your taste on little kids but you can’t deny yourself a little squee when you hear your kids singing Sufjan Stevens, or ‘At My Most Beautiful’, or ‘Confetti’, or humming the harmonies of ‘I Need Direction’.)

The video is a sequence of drawings in a lined A4 pad. Olivia’s a draw-er, and she admired the glitterball that pops up for “I know it’s sad, baby, come on we can dance it off“; my son Michael liked the compass assigned to “Everybody’s feeling lost“, because he just got a pair of binoculars and is beginning to fancy himself as an outdoorsman.

We played the video and they asked to watch it again. The next morning Olivia said she’d had the song in her head all night and “Can you put it on again”? And again, and again.

She is like me in her tendency to get compulsively riveted by a song. We’ve had this with ‘Opportunity’ from Annie, ‘Let It Go’, ‘Halo’, ‘You and I‘, ‘A Real Hero’ by College, and ‘Lost’. She is unlike me in that she doesn’t care who knows she’s having a moment.

As much as I may wax nostalgic for those 1990s nights in the pub failing to understand women, I know that these moments now, singing in the kitchen with my kids, are as meaningful and beautiful as any moment I’m ever going to have, and I’m grateful in a way I can’t describe for these songs and to the musicians who make them.

Songs have been everything to me; God forgive me they have taught me how to live to a great extent. And I’m so glad that songs like ‘Lost’ are embedded in my family life. I hope that my kids learn from songs like this like I still try to do. I hope that they will be the friend that Sorcha Richardson is in this song, and I hope they will only allow themselves to be friends with people who will treat them the way Sorcha treats her ‘Lost’ friend, who may be having a bad week but who knows, I’m sure, how lucky he is.

How Did I Become a Virus? Anohni’s brave, stark, unsettling Hopelessness

This piece was published on State on May 4th. I’ve edited slightly and added links.

In 2005, Anohni, then known as Antony, released the revered I Am A Bird Now. Antony and the Johnsons’ second album was, we thought then, a hard look at a difficult subject. The songs dealt with existential uncertainty and gender disquiet: “My lady story is one of annihilation / My lady story is one of breast amputation”, went a widely quoted couplet.

It felt raw and unflinching.

With the release of Hopelessness, though, the I Am A Bird Now era seems like innocent times. Anohni’s world view has darkened and it’s hard to see a way back.

Hopelessness is a haunted commentary on Anohni’s adoptive homeland, the USA, which she sees as corrupt and failed.

As an American she laments: We elected a president who was our last hope and who has let us down (‘Obama’); we stand by while children are murdered cavalierly from the sky (‘Drone Bomb Me’); we let state invade our privacy and we jail those who speak out (“Watch Me’); we condone torture because we fail to act to stop it (‘Crisis’).

That’s not to say non-Americans are off the hook.

On ‘4 Degrees’, over an urgent Hudson Mohawke arrangement, Anohni takes on climate change with an inchoate anger. She sings of a planet that is literally in terminal decline, at least as a home for animal life; the song is her taking her share of the responsibility for this. The title refers to the global temperature expected this century, which will bring about mass extinction. Up to 75% of animal species may ultimately die out and credible voices such as Elizabeth Kolbert have seriously mooted the possibility that the extinguished species, over the longer term, will include humans.

‘4 Degrees’ is an impressive display of ethical self-scrutiny. Anohni argues that if she acts in a way that causes extinction, then extinction must be what she wants: “I wanna hear the dogs crying for water / I wanna see the fish go belly up in the sea / And all those lemurs and all those tiny creatures / I wanna see them burn”. It’s moral rigour of a kind that is harsh, unforgiving, and head-turning; there’s no get-out on the grounds that she meant well or lacked power. She doesn’t deserve forgiveness. One has to infer the same for the rest of us. “I have grown tired of grieving for humanity,” Anohni has said.

The hopelessness of this album’s title is not figurative. In ‘Hopelessness’, ‘Drone Bomb Me’ ‘Obama’, ‘Execution’, and ‘Crisis’, as far as I can tell, Anohni has no time for hope at all. The prominent emotions are rage, revulsion, horror, and guilt. ‘Obama’ castigates Barack for failing to live up to his promises but arguably sets him an impossible standard – saving the world – while acknowledging the fatuousness of expecting a president to fix things: “Like children we believed”. ‘Hopelessness’, in an unusual move, contrasts the rapacious lives of people such as herself to the apparently ecologically sound, wise lives of pre-civilisation humans: “I, who curled in cave and moss / I, who gathered wood for fire / and tenderly embraced / How did I become a virus?

Hopelessness is unsettling. We still expect artists to comfort us. Even in apocalyptic art we expect some hope, some possibility for redemption, which we then expect will be ours. Anohni refuses this. She says it’s over: as she told Pitchfork “We’ve only got a few years left. The jig is almost up.”

I’m impressed that Anohni’s art raises these key questions with such stark clarity. But I’m not entirely persuaded of her premise.

Humans have been expecting the end for as long as there have been humans, and awful things have always gone on. In The Better Angels Of Our Nature, Steven Pinker wrote about the pre-civilisation peoples romanticised in ‘Hopelessness’: they were slavers and mass killers. The greatest decline in death by murder has come about since the birth of the all-powerful nation state that ‘Watch Me’ decries.

As time has gone on, says Pinker, humans have become more and more humane and, hard to believe though it might be, now is as good a time to live as there has ever been. This does not negate ‘4 Degrees’ and it is not an argument for state surveillance or Guantanamo, but I’ve had Pinker in my head as a counterbalance all the while that I’ve been listening to Anohni.

I’m reminded here of the dialogue in the late 1970s between Richard Hell and Lester Bangs. Hell was a pioneer of punk and a vocal nihilist. It’s hard to argue with a nihilist but Lester Bangs, a fan, confronted him in a passage of writing that comes to mind now, that I’ve intermittently had occasion to cling to:

Just for the record, I would like it known by anybody who cares that I don’t think life is a perpetual dive. And even though it’s genuinely frightening, I don’t think Richard Hell’s fascination with death is anything else but stupid. I suspect almost every day that I’m living for nothing, I get depressed and I feel self-destructive and a lot of the time I don’t like myself. What’s more, the proximity of other humans often fills me with overwhelming anxiety, but I also feel that this precarious sentience is all we’ve got and, simplistic as it may seem, it’s a person’s duty to the potential of his own soul to make the best of it.

We’re all stuck on this often miserable earth where life is essentially tragic, but there are glints of beauty and bedrock joy that come shining through from time to precious time to remind anybody who cares to see that there is something higher and larger than ourselves. And I am not talking about your putrefying gods, I am talking about a sense of wonder about life itself and the feeling that there is some redemptive factor you must at least search for until you drop dead of natural causes. And all the Richard Hells are chickenshits who trash the precious gift too blithely, and they deserve to be given no credence, but shocked awake in some violent manner.

Hopelessness is an exercise in despair that is brave, bare, and often brilliant, and it asks questions of us in a way that art rarely does. It seems to have made up its mind that there’s no redemption, no way back – well, who knows? Wait long enough and every Cassandra gets proved right. I hear Anohni, but for now, I’m holding on to beauty and bedrock joy.

Slow Moving Clouds: ‘All Tomorrow’s Parties’ could easily be an Irish traditional tune

This is a slightly edited-after-the-fact version of an interview I published in State on May 4th, the day before Slow Moving Clouds played a gorgeous set in Bello Bar in Dublin.

Danny Diamond, Kevin Murphy and Aki comprise Slow Moving Clouds, and they were the authors, in Os, of one of the most accomplished and moving albums of 2015.

Danny Diamond, who plays the fiddle and strohviol, is Irish, as is Kevin Murphy, cellist and singer. Diamond also plays with traditional band Mórga and many will know Murphy from Seti The First. Aki, who sings lead vocals and plays the nyckelharpa, is Finnish. (Until now, I had wanted a Rickenbacker for my 50th in a few years. Right now, I’m torn between strohviol and nyckelharpa. Extraordinary instruments.)

The band draws on each country’s native folk traditions and many of the songs on Os are re-workings of traditional tunes or ballads, predominantly from Finland (‘Hiljainen Suru, Devil’s Polska, Rinda-Nikola); you can also hear traces of artists that Murphy and Diamond cited in emails to me, like Steve Reich, Arvo Part, and Philip Glass; Aki cited as his current listening the solo fiddlers Benedicte MaursethArto Järvelä, Erlend Apneseth, none of whom I’ve heard, but all of whom I plan to.

Describing Os in terms of its cultural sources can make sound like an academic project, a dry synthesis of musical forms, but it’s not; probably, it’s better listened to than read about. However Slow Moving Clouds managed to pull their influences together, internalise them, and rebreathe them, the results are transcendent. Danny Diamond’s fiddle, high and flying then soft and graceful, along with Murphy’s taut, rumbling, heart-quaking cello, surrounds the rich ache of Aki’s voice, and it’s not necessary to know where these tunes come from or what the words might mean; it’s just necessary to stop for a while, and take it in, and let the tunes move you, and let them still you.

Slow Moving Clouds are currently touring and in advance of their Dublin show on May 5th, Danny, Aki and Kevin took some questions. I asked all questions of each person by email – Danny Diamond did much of the talking.

You have three distinct backgrounds, each involved in a variety of projects over the years, together and apart. Could you say a little bit about how you came together?

Danny: Aki was the link between Kevin and I. Both of us knew and worked with him: before SMC he played nyckelharpa in the live line-up of Seti the First, while also working with me in a duo ‘Danny and Aki’, playing instrumental music from the Irish, Nordic and American folk traditions.

Slow Moving Clouds draws on Finnish and Irish traditional music. On the Fractured Air site last year I read you saying there are more differences between Finnish and Irish traditional music than there are similarities.

Danny: The differences are pretty fundamental: different musical structures (keys & time signatures) make it difficult to mesh Irish and Finnish traditional material together in their raw form. On top of that, the cultural differences between the two countries come through in the way the music is taught and played. Finnish music, for example, is taught in a very classically-influenced education system, compared to the more informal approach over here. And Finnish music almost totally died out before being revived by music scholars, whereas we’re lucky to still have an unbroken ‘living tradition’ here.

But at the same time the similarities are pretty fundamental too. They’re both Western European folk traditions, based on music built for dancing, played on acoustic instruments; 150 years ago the two traditions would have been providing the same social and entertainment functions in both countries.

What attracted each of you to the other musical tradition?

Danny: What attracted me to Finnish music was that I find the melodies to be particularly beautiful, typically gentle and melancholy in character; also the musical patterns are similar-but-different to Irish music and it is intriguing to try to figure them out. All that said, in our music we only really draw on the traditions for melodies to use as raw material, and they’re re-written, re-arranged to fit SMC’s sound.

Aki: I discovered Irish traditional music as a teenager. The main attraction for me at the time was probably the energy and soulfulness of the music.


Aki’s singing, given its unshowy virtuosity and its subtle shading and complexity of tone, has often had me thinking of sean-nós. Are the Irish and Finnish singing traditions comparable?

Danny: Aki’s vocals draw more on popular music than on either tradition. As we had to create our own sound to bridge the Nordic and Irish traditions, Aki’s taken a similar approach to the vocals to make them sit well with the overall SMC sound, rather than going for a traditional Finnish style.

Aki: There really isn’t any Finnish equivalent to sean-nós singing, although there are solo singing traditions both in the West and East Finland.

It was not obvious to me initially that the album was in any way a blend of different types of music. The songs seemed on first hearing and still seem to have a unity of tone and texture with a unique distinct voice at play throughout. So it didn’t occur to me that there was “fusion” of any kind going on. How do you manage to bring together these elements to produce a coherent sound throughout the record?

Danny: We’ve been working at it since the Danny & Aki duo days, for five or six years, learning by trial and error basically. The key thought for us is to create new music, which draws on these older influences but can stand on its own. Rather than fusing existing traditions, we’re trying to draw on them to create something unique and contemporary. The traditions inform the overall sound, but so do other influences like minimalist & electronic music. That seems to be the trick, for us at least; the way to satisfactorily bring the two together is to find a third sound and reshape them to fit it.

Kevin: I would say that the sense of coherence you mention is I guess our contribution or the third element, which draws the two traditions together. I suppose it is a filter or a lens through which Irish and Finnish elements are drawn. For my part, this lens is constructed from many aspects, though probably the strongest influences are My Bloody Valentine and the Velvet Underground. I always felt that these two bands had something in common with the types of backing that was introduced to Irish trad in the 1970s, specifically the use of open tunings. I always felt that ‘All Tomorrow’s Parties’ could easily be an Irish traditional tune. I also draw on contemporary classical composers such as Steve Reich, Arvo Pärt, John Tavener, Tim Hecker, and so on.

I’ve seen you mentioned alongside The Gloaming, who many would see as signifying a revival in popularity for Irish traditional music. Is traditional music in a good place?

Danny: Traditional music in Ireland is in a strange place in my opinion. There’s a shortage of informed listeners who are tuned in to the nuances of the tradition, while at the same time there’s the oft-touted statistic that there are more kids playing than ever before. Also for years it’s been suffering from a lack of public critical discourse, and mainstream media attention, and it’s seen by so many Irish people as background music for a few pints. All this brings us to a point where perspectives around the tradition can be very inward-looking and insular, those who know and play it can be possessive, and the scene has become ghettoised to the point where the audience and market for traditional music in Ireland relays heavily on other musicians and music students. I find this disquieting but it seems to be changing at the moment, especially in Dublin where the traditional/folk scene is really healthy, drawing new audiences, lots of daring creative music being made.

I think The Gloaming are important because they appeal to a wide audience and give the traditional/folk genre a boost in profile. But the music that excites me the most is the stuff being played & sung around Dublin at the moment. I was at a session on Sunday night listening to members of Skipper’s Alley and Moxie along with a bunch of their mates: some of them ten years younger than me, playing in bands, writing and playing interesting music, but really grounded in the tradition as well. I’m excited for what’s coming down the line in the next few years.

Slow Moving Clouds play the Bello Bar, Dublin, on May 5th and the Crane Bar, Galway, on 20th May. Os is available here.

ECT and “unwilling” in Ireland: the principle and practice

On 8th December, the word “unwilling” was deleted from section 59 of Ireland’s Mental Health Act.

Section 59 of the Act deals with administration of electro-convulsive therapy ECT without informed consent to involuntary patients in approved centres (psychiatric units). The amendments mandating this change and an analogous change to section 60, which governs the administration of medication without consent to involuntary patients, are here.

The Mental Health Act up to 8th December allowed for administration of ECT to people who were “unable” or “unwilling” to consent, or both. The decision as to who whether a patient was “unable” or “unwilling” was formally the decision of the treating consultant psychiatrist along with one other independent consultant psychiatrist. (“Unwilling” is now gone, but the decision around inability to consent remains with two consultants.)

The removal of “unwilling” from the Act was long-flagged. The College of Psychiatrists of Ireland have been advocating for the change since 2010. (The College has only existed since 2009).

The change to section 59 is an important change, in principle. In practice, I would argue, it will make very little difference.

To be “unwilling” to consent, under the Act, implied that the person had capacity to give informed consent – which means that he or she was able to refuse informed consent. A person who received ECT or medication without consent but was documented to be “unwilling” to consent rather than “unable” was therefore considered capable of giving or refusing consent. It never made sense that this provision would be in the Act and I find it hard to imagine a set of circumstances in which I would give a treatment to a patient who refused it, if they were able to weigh up the pros and cons of that treatment.

To be “unable” to consent to a treatment – ECT, medication, or any other – means to lack capacity, which is “the ability to use and understand information to make a decision, and communicate any decision made.”

Capacity is judged on a decision by decision basis so that one might have capacity to consent to one treatment and not another. Ireland’s capacity legislation dates from 1871, but is almost updated – a Capacity Bill from 2013 is nearing the end of its legislative journey.

A person who is “unable” to consent to ECT – “unable” has stayed in the Act, by necessity – is, generally, too sick to make treatment decisions. I’ve written about illness depriving people of capacity here.

The only way that the loss of the word “unwilling” in Section 59 would make a substantial difference in practice is if, in recent years, the number of apparently capacitous people being treated with ECT without consent was large. It was small. (It was not zero.)

The most recent figures on ECT from the Mental Health Commission, which has oversight of all activity in approved centres, are from 2013. They were published on November 12th 2015 and widely reported.

The MHC report records each course of ECT without consent and the assessment of each psychiatrist, documented in a tick box on the MHC’s Form 16, as to whether the patient was unable or unwilling to consent. (The forms are yet to be updated.)

In 2013, 46 people received ECT without consent. In 39 cases, both psychiatrists ticked “unwilling”. In six cases, one psychiatrist ticked “unable” and another ticked “unwilling”. In one case in 2013, both psychiatrists ticked “unwilling”. The analogous numbers for 2012 were 26, 3, and 1; for 2011 20, 4, and 3; for 2010 29, 6, and 5; and for 2009 38, 5, and 11. (I hadn’t gone back as far as the 2009 figure before now and it’s higher than I would have thought it would be.)

What these figures show is that the number of people receiving ECT without consent went down, then back up, in the five cited years, and the number of people receiving ECT under “unwilling” – i.e. those who the Form 16s would indicated had preserved capacity, but had ECT without consent anyway – dramatically reduced, from 11 in a year to one in a year; we don’t have figures for 2014 or 2015 so we don’t yet have a baseline to judge any potential change in the figures to ensue from the legislative change last night.

There is a question here: why did anyone receive this treatment without consent when they were deemed, one would infer, to have capacity to decline the treatment? I just don’t know. It’s a basic principle not just of psychiatry but of all medicine that if you have capacity, and you say no, your no is respected. It’s how we work day in day out. There’s no reason to insist on a treatment that a capacitous person is refusing – not just in principle, but in practice. Psychiatrists are used to thinking that a treatment might help, and to being told no.

I have my suspicion, which is that psychiatrists ticked “unwilling” to mean both unable and unwilling – as in, we wouldn’t even be looking at this form if the patient were “able” to consent. I doubt anyone who received ECT without consent in Ireland in the last several years had capacity to consent. But I don’t know for sure, and I’m not sure we’ll ever know. From now on, we’ll know.

People are going to need treatment with ECT without consent as long as severe depression exists. Those people will receive that treatment without consent because they are unable to consent – they may think all hope is lost when it’s not; they may think we are trying to kill them; they may think they are already dead. Small numbers of people will need this treatment. It is a very good thing that “unwilling” is gone. The number of people receiving treatment with ECT under “unwilling” is now, as it should be, zero. The number of people we have to treat who are too sick to consent will never be.

 

To Be A Psychiatrist Is To Be Uncertain: Cognitive Error and Kindness

“Hello babies. Welcome to Earth. It’s hot in the summer and cold in the winter. It’s round and wet and crowded. On the outside, babies, you’ve got a hundred years here. There’s only one rule that I know of, babies: God damn it, you’ve got to be kind.” ― Kurt Vonnegut

Jerome Groopman wrote a piece in 2007 in The New Yorker called “What’s The Trouble“, which is one of the more influential texts in my life, and which I’m often sorry I ever read. If you want to remain free of anxiety about your potential failings as a doctor, or about the potential failings of your doctor, maybe don’t read ‘What’s The Trouble’. Read this! Or this.

Groopman, who is a haematologist, Harvard professor, and author of more than two hundred scientific papers as well as a New Yorker staffer, because he has more hours in his day than I have, introduced me in “What’s The Trouble?” to the field of cognitive error in medicine.

This is the study of medical mistakes we make by the very act of thinking.

As Daniel Kahneman, cognitive psychology pioneer, put it, people think fast and slow.

Slow thinking in medical decision-making involves accumulation of all necessary evidence, painstaking appraisal of that evidence, and demonstrably disinterested decision-making. This is what college trains us to do. Adherence to this model demands essentially unlimited time and resources and a degree of objectivity that no-one possesses.

Fast thinking is making decisions based on pattern recognition and gut instinct; this is what, as we mature clinically, we mostly do. Fast thinking is good. Efficiency is important; speed is not laziness.

Whenever we have limited time (which is always) and insufficient or ambiguous information (close to always) we rely, said Kahneman, on cognitive shortcuts, rules of thumb, called heuristics.

We are right to rely on heuristics, said Groopman. “Heuristics are indispensable in medicine; physicians, particularly in emergency rooms, must often make quick judgments about how to treat a patient, on the basis of a few, potentially serious symptoms.” And they are fine, until they’re not.

When cognitive shortcuts let us down cognitive error happens, and we risk mistakes. The list of cognitive errors, outlined by Dr Pat Croskerry in The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them, is long. Most cognitive errors are intuitive, if, by their very nature, irrational.

Anchoring is the tendency to rely too much on information obtained early in the decision-making process, even when it’s not the most pertinent piece of information, or when it’s later shown to be irrelevant. If in a phone call about a paranoid patient a colleague mentions a history of cocaine use, it’s going to be hard not to rank cocaine-induced psychosis high up the list of likely diagnoses, even if the patient insists he hasn’t had any cocaine in a year.

(There’s a great example of anchoring involving Mahatma Gandhi, not involving cocaine, here.)

Confirmation bias is the tendency to seek out information that confirms your initial provisional diagnosis and to dismiss information that challenges that diagnosis. You should seek out information that challenges your initial diagnosis; if you’re right, you won’t be able to prove yourself wrong. In the previous example, one might if biased doubt the history of abstinence more than the diagnosis of drug-induced psychosis; a negative drug test would be read to mean the patient used cocaine long enough ago that it’s out of his system, not, as he insists, that he’s clean.

Commission bias is the decision to act (e.g. to treat with an antipsychotic) because you are a doctor and you are supposed to help, even if your actions are not all that helpful (e.g. you might not know exactly what you are treating, and antipsychotics are serious drugs). “Don’t just stand there – Do something!” applies here.

The sunk cost fallacy is the failure to back out of an initial diagnosis because of the feeling that you have that you have committed to this diagnosis – regardless of whether it is right. This must be bipolar II disorder because I said it was in a letter to a GP a few weeks ago.

I have honest to God caught myself thinking this way.

It looks so stupid when you write it down like that.

And there are cognitive errors that doctors make because we are influenced by our emotions much more than we like to admit – influenced, often, by the way we feel about our patients. We make bad decisions because we care about our patients too much (the affective error) and because, less comfortably, we care too little.

Making the affective error, we may act as if a clinical situation was how we wish it to be rather than how it is. If a patient looks like he has a psychosis, but we’re not 100% sure, and if receiving that diagnosis may have adverse consequences for the patient, we may hold off on making the diagnosis for longer than we should, because we don’t want to upset our patient. (Magical thinking is common in cognitive error.)

Conversely, if a patient is difficult or self-destructive, or engaging in behaviour that is not helping us to help him, we are prone to the fundamental attribution error: “the tendency to be judgmental and blame patients for their illnesses rather than examine the circumstances that might have been responsible”. Then, we need to be careful that we don’t let ourselves off the hook of helping that patient – he’s not helping himself, why should I?

In ‘What’s the Trouble’ and The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them, Jerome Groopman and Pat Croskerry gave some great advice.

They said, primarily, to use the patient. Don’t just trust yourself. Ask for hard questions from your patients and their families. Insist, politely, that they test you. Ask that they ask you why you’re doing what you’re doing – how do you know you’re making the right decision?

Put yourself through the effort of considering three or four diagnoses even when you are sure you know what the diagnosis is – you can be sure and still be wrong. Routinely ask the question: What else might this be?

On commission bias: Don’t just do something – stand there!

Croskerry also advised clinicians to develop insight into their own thinking style and be aware of the potential for error. I did this – I internalised Croskerry and wrote about cognitive error in psychiatry, and worried myself, and taught it to freaked-out trainees.

I figured the likelihood in psychiatry of error related to complexity and ambiguity was high; to be a psychiatrist is to be uncertain. Psychiatric diagnostic systems depend on subjective assessments of ambiguous information about inner experience. How much anhedonia is enough anhedonia to count towards a diagnosis of depression? How bad should concentration be to be “poor concentration”? How firmly held must a belief be to count as a delusion, and so to justify consideration of an antipsychotic? The potential for bias is huge, as is, accordingly, the potential to be wrong.

So I’ve always found cognitive error compelling and deeply unnerving.

I’m a busy clinician. I have the guts of 300 patients on my books at any one time. I make a lot of decisions; some without much time to make them; some with potentially serious consequences. All you have in your clinical practice is your ability to think through a decision. If you can’t trust your thinking, where are you? Knowing how wrong you can be is unmooring. You can easily run into crises of confidence when you are hyper-aware of your fallibility.

So how do we know we are making the right decisions?

We have to trust ourselves, up to a point, and trust those around us. We have to ask our teams how we are doing, and I do this to a degree that I worry might annoy my team. (“Oh Jesus get on with it.”) The occupational therapists, social worker, psychologist, and nurses on my team are well able to tell me when they think I’m wrong. I rely hugely on that.

I ask my trainees to tell me what they think of the plan I just put together. Some look perplexed – why are you asking me? – and some get it. Consultants have the final call – we are the people on the team who need to be OK with every decision anyone makes – but we need help. In avoiding overconfidence you have to have the confidence to ask for honest feedback, and hope that it is forthcoming.

And you rely on your patients as much as you rely on your colleagues. You have to trust your patients and their families to tell you what they really think and to co-design their care with you. My favourite words to write in a chart (after “Mood subjectively ‘grand'”) are “We agreed the following”. There’s something so reassuring about that.

The more I go on the more I’ve realised that external assurances aren’t enough. You need a solid underlying principle if you want to be confident that you are doing the right thing by your patients. You need bedrock. This probably seems obvious. But I don’t remember being trained to have such a principle in college, or in basic or senior training.

And it’s back to Kurt Vonnegut, and I think it’s kindness.

Kindness is not talked about too much in medicine or psychiatry right now. It’s a little paternalistic and probably embarrassing. But kindness, I think, anchors you. How far wrong can you really go? If you are a clinician focused on being kind you are not focused on your own ego. You won’t make the mistakes we make for not allowing ourselves to be wrong. You were wrong. So what? Get over yourself. As Neal Maskrey wrote in the BMJ in 2013 in a beautiful blog postThe Importance of Kindness, “it isn’t about you… it’s about them”.

Aspring to kindness also sounds self-righteous. But you can aspire to be kind and know that you won’t, obviously, manage it. Maskrey quoted the late American novelist David Foster Wallace: “It’s hard, it takes will and mental effort, and if you’re like me some days you won’t be able to do it, or you just flat-out won’t want to.”

A practical approach could work as follows. If you’re practising medicine, or psychiatry, and you feel like being kind or compassionate, go for it. It’s easy when you’re feeling it. And if you’re practising medicine, or psychiatry, and you don’t feel compassionate – do it anyway. Behave as if you were feeling compassionate. Make the effort. You know what you’d do if you were feeling compassionate – so do it.

David Foster Wallace knew that kindness doesn’t always come easy, but, still, he said, “Most days, if you give yourself a choice, you can choose to look differently”. Maskrey replied: “I’m trying David, every day I’m trying”.

Pockets of Light

Responses to my piece on The Stone Roses last week got me thinking about ageing and about the ever-evolving role of music in our lives.

Why do any of us love the music we love? How does our relationship with music change as we age? Is it possible, ever, to fall for a song the way you did when you were fourteen and everything was up for grabs?

I am not the first person to wonder about this.

I think, for the record, that the answer to the last of those is Yes – though I’d be surprised if a song ever transformed things again like ‘Tame’ did in April 1989. When you’re 41, the days of songs inducing seismic upheavals in your sense of self are over, you’d hope.

So, I had great intentions on Saturday night of posting on this subject.

What ended up happening, though, in a pattern that I’ve been repeating for 25 years and more, is that rather than complete the task I’d set myself, I listened to loads of music.

Not too constructive, but it felt constructive on Saturday, as it did throughout college, when I would sit up to 3AM with textbooks sprawled, ostensibly cramming but, in fact, devoting all my attention to AMC’s Engine.

(Quick aside: how great a track one side one is ‘Big Night’? The day I don’t get a shiver from its steadfast forlorn devotion – “When time peels off your statue skin, I’ll still be fooled by what remains / Yeah, whatever’s left of you will be my dream” – is a day I will have a stern word with myself.)

In an attempt at salvaging something from Saturday, I made a playlist, which I called Pockets of Light, after Lubomyr Melnyk and Peter Broderick’s beautiful 2015 piece on the wonderful Erased Tapes label.

spotify:user:ncrumlish1:playlist:504O20wuzCmXVhT1Uei2Zs

I started on this playlist because it occurred to me that if the pieces I love right now have anything in common, it is a transcendent quality.

I don’t mean sacred as such – though the oft-religious output of the Louth Contemporary Music Society has heavily influenced my taste in the last half-decade, and there is Russian choral music on the playlist, which would have nonplussed the 1989 version of me.

What I mean is something in the music operating at a level I don’t understand, that’s visceral, usually involving sheer beauty, and makes me happy and sad and yearning and centred at the same time.

It’s something about the quality of emotional focus the piece induces and it has an addictive feel. How I know this is happening is that when the song ends, I miss the feeling, and I have to put it on again, like Dave Fanning used to compulsively replay MBV’s ‘Sometimes‘.

There’s a neurobiology of musical emotion here, possibly involving delta waves, that a more biological psychiatrist than I could explain. There are certainly enough fMRI studies.

I’m not sure how much these transcendent songs have in common.

I think the description applies to Nick Drake’s ‘Place to Be‘. I think it applies  to Jon Hopkins’ and Natasha Khan’s ‘Garden’s Heart‘ and Ergodos Musicians’ ‘Ladrang mugirahayu‘; to Squarepusher’s ‘Tommib‘, John Cage’s ‘In A Landscape‘ and Sufjan’s ‘The Owl And The Tanager‘; to Ghost Culture’s ‘Glaciers‘, Guided By Voices’ ‘Chicken Blows‘ and Arvo Part’s ‘Da Pacem Domine‘. The compulsive thing alluded to earlier means that as I type those names in rapid succession I want to hear them all, like now, and all together if necessary. At times like this paragraph I feel a rush of gratitude to these people.

If one way you recognise transcendence in music is the profundity and inexplicability of the effects it induces – in your stomach, in your suddenly dry throat, in a fluttering of your heart that you weren’t expecting – then ‘Os’ by Slow Moving Clouds is transcendent.

This band is completely new to me. I came across them just on Saturday night, through Fractured Air, though I know Seti The First, the wonderful band belonging to Slow Moving Clouds’ Kevin Murphy.

Slow Moving Clouds are Finnish and Irish and I have to assume that ‘Os‘ is sung in Finnish. It’s one of those songs that you don’t understand and you completely understand. The confluence of Aki’s strong, brittle baritone, the restraint replete with emotion, Danny Diamond’s keening fiddle and Kevin Murphy’s sweeping cello, and what I read and hope may be a nyckelharpa – it’s quite something.

I’ve listened to ‘Os’ twenty-five times in a weekend. I’ve played it five times writing this piece. I need to stop, and I will, but not now.

NC 30/11/15