“When I stopped hearing the voices in my head”

In today’s Guardian there is a lovely short article by ‘Anonymous’ about what it is like to hear voices.  Well worth a read for those struggling with the same issues, or those trying to understand the experience of voice hearing.

The author’s story is very familiar to me, the stress of going university seemingly bringing on a severe depression while later, with the added stress of exams, the voices appear.  I’ve been told this story many times, often by people who I interviewed for the Maudsley Bipolar Twin Study, and then more recently by my clients.  My recollection is that the majority of those who’ve related this particular sequence of events were women, but perhaps this was random or recall bias.

The author, via some combination of medication and therapy reports that she no longer hears voices, and that she has found a way to cultivate a supportive inner voice in their place.  No point in me saying more, read what she has to say!

(I assumed the author was a woman from the photo, but it’s just a stock image, so who knows).


“The patient did not respond to the drug”


From http://www.acphospitalist.org/weekly/archives/2011/3/23/

Today, a colleague sent me a press release for an exciting new treatment for psychotic symptoms based on a compound extracted from cannabis (CBD – Cannabidiol).  This work by GWPharm follows up on some work I was vaguely involved in at the IoPPN, King’s College London.  Encouragingly it suggests that CBD might be an effective, and importantly a much more tolerable treatment for psychotic symptoms than those we already have.

But that’s not really the point of this article.  The point is that in the press release we see the following:

… in 88 patients with schizophrenia who had previously failed to respond adequately to first line anti-psychotic medications.

This is one of my big bugbears.  Glossing over the fact I’m not keen on the diagnosis ‘schizophrenia’, what’s the problem?  This is normal, this is how medical professionals really talk about their patients and their drugs.  I’ve heard it hundreds of times in ward rounds, read it hundreds of times in papers.

The problem is that the patient did not:


The drug:


The patient was not inappropriate for the drug, the drug was inappropriate for the patient.  Drugs are supposed to be designed to target specific difficulties faced by a patient, whether than be insulin to replace what is missing in diabetes or aspirin to prevent pain transmission or blood clotting.  In ‘schizophrenia’ we face the problem that we still don’t know the aetiology of the person’s problems, and each person is different, probably because ‘schizophrenia’ simply does not exist in the same way as type I diabetes.  The simple fact is, that if the drug does not work, it’s because it is targeting the wrong mechanism.

campingchair2A random story by way of analogy:  I once went on a camping trip with my brother.  When we put the borrowed tent in the car, I remarked to my brother that the tent, which came in two bags, was remarkably light and small.  For the next six hours, I thought nothing more of it; not until  we turned up at the campsite, and started to set up camp next to our relatives’ warm cosy camper van.  Exited to be out camping, I pulled the first part of the tent from its bag – it looked remarkably like a folding chair.  Somewhat desperate, I hoped the the tent was even smaller and more lightweight than I’d imagined, and tried the second bag.  A second chair popped out.  We were left in Devon cold, with two chairs to shelter us from the elements.

Did I blame the chairs for not being tents?  Of course not!  When we were left cold and demoralised, did I blame my body for not responding to the ‘tents’?   Of course not, I blamed the provider (me, my brother or the friend who lent the ‘tent’, depending on my mood) for not providing the right solution for the problem at hand.

What are we doing when we say the patient did not respond?  We are clearly placing the blame on the patient.  Yet we should be placing the blame on the state of the science, or on our poor understanding of the patient’s condition.

If the drug does not work, it’s not actually the drug’s fault (drugs are not sentient as far as I know), but I’d much rather say that the drug did not work, than the patient did not respond.  This places the onus on us to improve our treatment

Before I finish, therapy does not get a free pass.  We can also find papers that say: “the patient did not respond to therapy”.  Rubbish!  The therapy did not help the patient.  It was the wrong therapy, the therapy was delivered incorrectly, or it was some other of the many factors that can affect the outcome of therapy.

If you are a medical professional who uses such phrases, I implore you to think about the implications of this stultified, automatic way of speaking and writing.  Further I encourage you to suggest your colleagues do the same.  Language is important, it shapes our beliefs and our actions, it shapes the way we see ourselves, and it shapes the way we see our patients.



High Altitude Gardening – SIPping

(Utilice el menú desplegable de la izquierda para seleccionar Español)
The finished product

Just about everything in Quito comes with its own special challenges.  The altitude and climate provide plenty of scope for things to go pear-shaped,  and mean that, from boiling an egg though to baking and gardening, nothing can be taken for granted.

In Quito, there can be downpours for days, followed by weeks with no rain at all.  The sun is  powerful and evaporation is faster due to the lower pressure.  This all makes gardening a challenge, especially for pots and planters, which can dry in a matter of hours.

But all is not lost.  Step up SIPs!  SIPs = Sub Irrigated Planters.

What is a SIP?

Wikipedia’s page is pretty poor, but there are plenty of resources to be found around the web and a community of avid enthusiasts.  And this enthusiasm is not surprising, because SIPs are amazing!  I’ve enjoyed the process and the results so much I’ve become an evangelist (hence this entry).

A SIP is any method of watering plants where the water is introduced from the bottom, allowing the water to soak upwards to the plant through capillary action (Wikipedia).

So, why SIP?  

  • SIP because you don’t want to water everyday.
  • SIP because you don’t want to waste water.
  • SIP because you don’t want to kill your plants through under or over watering.
  • SIP because you’re lazy.
  • SIP because you  just want to.

The basic principles of SIPs:

Essentially a SIP aims to emulate to some extent the way plants work naturally.  Plants generally suck up water from below, taking what they need.  Traditional pots and planters turn this upside down, with the water introduced from the top.  This is rather foolish, maximising evaporation and risking both over and under-watering.  One consequence of this is that we’re sensibly advised to water in the evening to reduce evaporation.  With a SIP, you can water effectively anytime.

There are lots of different designs for SIPS, but the best take into account the following priciples:

  • Water is fed in through a tube which feeds a reservoir in the base of the planter.
  • This tube also allows air to enter into the reservoir, this enters the soil via small holes.
  • An overflow is provided just below the top of the reservoir, this prevents overwatering and maintains an airspace.
  • A wicking material (cloth, newspaper or just soil) allows the water to reach the plant via capillary action.
  • Where appropriate, a mulch or newspaper should cover the soil to further prevent evaporation.

How to buy/make a SIP?

Although you can, there is no need to buy a SIP.  I highly recommend making your own, using the above principles, and drawing on the wealth of designs on the web.  And if possible try to reuse and recycle to do so.

Let’s start simple and move on… Perhaps the most basic SIP is the single soda bottle SIP.  Here’s my schematic:

SIP Bottle

And here’s the real world version
(click on the image for a larger copy).  

This design does, in the name of simplicity, violate my first principal of a good SIP, in that it has no tube to feed the reservoir

Here the SIP is growing oregano.  Generally the occasional rain is enough to water it, the water passes through the soil and fills the reservoir; however sometimes I do need to add extra water – a tube would make this more efficient but would also complicate the simple, easy design.

I’ve also used this design for growing coriander from seed, this worked very well, reducing the chances of the soil drying out and the seedlings dying.

My assistant.

Ok, so what about more sophisticated designs?
SIPs are pretty much only limited by your imagination, and provide a lovely opportunity to get creative.  Following a few other attempts I I settled on this design for long planters.  Here I’ve used a variety of old bottles and some old tubing.  The three white bottles are all joined together and fill directly from the tube.  I drilled small holes (with a Dremel, but they could be punched or cut) in the tops and sides.  The top holes allow air to the soil, the side holes release water into the surrounding soil (added later!).  The transparent bottles are not connected to the white bottles but fill up as water exits the white bottles.


Overflow.  If you look closely, you’ll see that the vinegar bottle sticks though the side of the planter, thus acting as the overflow.  Excess water from the soil enters into the three transparent bottles, and when it reaches the level of the  exit hole (vinegar bottle top) it pours out of the planter, preventing overwatering.  The nice thing about this design is that if for any reason you want to really soak the planter (perhaps you’re going away for a while), all you have to do is put the lid back on the vinegar bottle (remembering to remove it when the soil has soaked).

Fill Pipe
Fill Pipe

Fill Pipe.  The fill pipe is topped by the top section of a plastic bottle. I generally join these to the pipe by cutting a hole in the lid, and then sealing the connection with a glue gun.

For the finished product, see the top of the article!

What else?

For me this is pretty much the beginning, there are plenty of ways of improving these systems, including developing a way to make a truly self watering SIP (again, there are plenty of ideas around on the web).  The bigger project is to make a large self watering planter using rain water.  I’ll update when I’ve made some progress!  In the meantime, try for yourself, and let me know how you get on.


Highs and lows on the (you) tube – and the challenge of empathy.

Over the last few years some of you will have seen a viral video of a man singing along to Rhianna on the tube.  If you’ve not seen it, all the better, have a watch (below) and as you do just have a little think about what’s going on.  What are your first impressions of the singer and his audience?

The video was first recorded surreptitiously and posted on youtube in 2012, becoming a viral hit with over 2 million views.  What was his audience thinking?  For his fellow tube travellers we’ll have to entertain ourselves by interpreting their expressions.  Youtube however, gives us a little more to go on…. some people found the video amusing:

Trying so hard not to bust out in uncontrollable laughter

…others admired his confidence.

Lol. Kudos to him, as funny as it is, I do love how ppl have such cofidence in themselves to do such things. As its nit in the norm to sing aloud on the subway/rail, whether you have a good voice or not.

….some gave their support:

Awesome!  Keep on singing Alika.  Let the stiff upper-lipped boring people jeer all they like.  You are London.

….and sadly many others were just nasty or racist.  Youtube’s comments section can be a dark place.

Yet, few if any of the comments really indicate any attempt to question what was going on in the man’s head (beyond those who accused him of showing off).

So what was going on?  Well we don’t know exactly, but that man on the tube, Alika, has got together with Rethink (in a video) and the Independent (in an article) to tell us a little bit about what he was experiencing (Have a read and a watch, and perhaps compare your reaction to when you saw the first video).  As he tells us in the Independent.

That year [2012] a number of events in my personal life had taken their toll on my mental health. In just twelve months, my auntie died, my five year relationship crumbled, my savings were stolen, and two friends of mine were killed in violent attacks. It all started to overwhelm me, and I began to feel and behave differently.

I was going through depression, anxiety, manic episodes, self-harm, and voices and illusions in my head. But I kept it all to myself, and over time I became more withdrawn and erratic. Singing on the tube was a way to drown out my problems and escape. When you’re in the middle of a manic episode, you don’t think about what you look like or how you come across.

….A story very familiar to clinical psychologists working with bipolar disorder and psychosis.  While some of my clients become ill without any clear stressors, they are in the minority.  Most of the people I’ve seen have worked with have entered a manic phase following difficult life experiences.  Alika’s story may seem extreme, yet it’s not at all uncommon among clients with mania and psychosis.  We all have different breaking points, and these may depend on a mixture of our past experiences and our genetics.  Cities like London do not help, feelings of alienation, racism, insecurity and violence are not uncommon, and are a particular problem for those from less privileged backgrounds (black Londoners are at particular risk of experiencing psychosis, for possible reasons that need another article).

But back to the comments….  the comments for Alika’s Rethink video are in stark contrast to those in the original video.  There are not so many yet, but to give a flavour, here’s just one:

Brother am soo sorry when world star posted it people thought it was funny me being one of them if knew what you were going through i would have not even dare to laugh at that video.respect you for what you have done i too have anxiety when i am in public but its only getting better and better i will let my friends know about this soo they can apologize as well.:)

For me, this is a reminder that empathy is rarely automatic.  We are generally quick to judge by what we see on the surface, but rarely take the time to imagine what lies under the surface, to ask ourselves what might be going on for that person opposite us on the bus or tube, or even over the breakfast table.  We often jump to one conclusion and stick with it, that singing man is what?   Selfish?  Annoying?  Super laid back and open?  Cool?  Attention seeking?

As Alika puts it (kindly).

I don’t want to make people feel bad if they laughed at the video of me singing on the Tube. I can see the funny side too, but I’d like to move on now. Viral videos have a life of their own and capturing someone’s behaviour for a few seconds in a day doesn’t ever show you the full picture.

Jumping to Conclusions (JTC) is something that is supposed to be particularly common in people with psychosis, yet in reality, we all do it, all the time.  And just as it can be helpful for my clients to think of other explanations for their experiences, it can be useful for the rest of us too.  On a bad day, we may tend to jump to negative conclusions, which just make that day worse.  A classic example used in therapy is to imagine someone we know ignoring us when they walk past us on the street.  What’s going on?  On a bad day, well that person is clearly a total ass; on a good day, clearly they were preoccupied and did not see us.

Alika’s second video and article give us context, they give us a way of connecting to Alika.  Suddenly, Alika is no longer a cartoon but a deeper, three-dimensional character.  It’s no longer so easy to apply just one adjective.  Now we are forced to consider Alika as a person with a past, present and future.  It’s harder to be unkind, and easier to be kind.  We have understanding , we have empathy.

Alika was kind and brave enough to give us that connection.  The challenge is to make that connection more often and with less help.

Some thoughts on the use of ayahuasca

Ayahuasca prep” by TerpsichoreOwn work. Licensed under CC BY-SA 3.0 via Wikimedia Commons.

A little while back I was asked by Amy Dron to give my opinion and thoughts on the medicine/drug/spiritual aid, Ayahuasca.  Amy wanted to write an article on the subject due to the experiences of a friend, who demonstrated a significant change in behaviour around the time she was taking Ayahuasca.

I’ve long been interested in the use of psychoactive medications, and have an interest in how medications are used across cultures, especially in light of the rather contradictory approach to different substances in my own country. Travelling in Colombia and Ecuador I had the opportunity to talk to a variety of people about their experiences, and also to take part in ceremonies in both countries. I’ve been meaning to write up some of my thoughts for a while now, but in the meantime, here’s some of them from a conversation I had with Amy Dron shortly after I returned from South America in 2013.

Ascent into Mania…

In researching for a lecture on bipolar disorder, I came across this video.  It’s simply text, set to Samuel Barber’s Adiago For Strings (perhaps the ultimate emotional induction music).



It’s been posted by Brian Miller (Parhamscan, bminternet43), on his youtube channel .  It’s a relatively short film which covers a little of Miller’s early life and then details a manic episode, which led to his sectioning and hospitalisation.  Miller’s is a story that is perhaps familiar to many others with a bipolar diagnosis, although his first major manic episode was probably later than average.

For the mental health professionals, the video would probably make a great resource for bipolar support groups, teaching, ward groups and perhaps in individual therapy.   The comments below, as so many times when people share their experiences, reveal how valuable it has been for other people.

The power of the image: art, science and psychosis.

An interesting short film about Sue Morgan’s artistic way expressing and processing her experiences, as well as some of the science helping us to understand these experiences from a neuroscience perspective (in terms of changes in levels of oxygen in the brain, BOLD, the thing we think we measure with functional MRI).

As someone with a fair bit of experience in brain imaging, two things thing struck me straight away about this film.  The first is the power of imagery,  the second is how, it seems to me, imagery is working in very different ways for Sue Morgan and for the clinical researcher and the film maker.

For Sue Morgan, getting her thoughts out of her brain and down on to paper is a perhaps a means by which she can reduce the power of her experiences and make sense of them.  For the film maker, images of brain scans and MRI machines perhaps help to convey a sense that the research is important, that it is ‘real’ and ‘scientific’.   For psychiatrist and researcher Sukhi Shergill, seeing the activation on a brain scan, helps him to say that he believes that these experiences are real, and do so genuinely.

The film also makes me wonder about the strange tricks that filmmakers like to play.  What we see here is not an image of a real MRI scanner, but a fake scanner.  Putting a laptop into a real scanner would result in nothing less than a very unhappy laptop, and possibly, carnage.  When Sukhi Shergill points at his bank of computer screens, he is presumably supposed to be in the middle of some serious hardcore scientific thought, while he’s probably mostly feeling a bit uncomfortable about having  to make gestures at a touch screen whilst being filmed (conjecture of course).  The visual language here is presumably supposed to make us take the message more seriously, to engage more with the film.  Personally, if there’s no pictures of the scientist walking moodily down a long corridor, I don’t buy it.  Or with less sarcasm, please filmmakers, more content, less nonsense.

There is however, a very important message in this short film, the experiences of people with psychoses are real.  They are not made up, the person is genuinely hearing voices, seeing things, or experiencing the feeling that people are out to get them.  This is why, when these experiences are appraised as negative, they can be genuinely terrifying.  Out clients, have of course, been telling us this forever.  All too often, professionals fail to grasp this, and this leads to a collapse in the relationship.  In a sense, we should not need MRI scans to tell us this, they are simply correlates of our ‘lived experience’, they help us understand at another level, but they are no more valid that what the person is telling us about their experience.  Yet, if brain scans can help professionals develop more empathy and understanding, great.



CBT for Psychosis. Does it only help 5% of people?

Yesterday I went to a very interesting debate at the Institute of Psychiatry, with the motion:

This house believes that CBT for psychosis has been oversold.

CBT-for-Psychosis-Final-Poster399x282 (1)

I’m glad to say that it was a well mannered and reasonable debate, with those on both sides presenting interesting cases.  Although the actual question is perhaps not that interesting, the myriad of underlying issues are. Things like:

  • Does CBT for psychosis actually work?
  • If so, for what does it work best?
  • Which version of CBT for psychosis is most effective?
  • Which outcomes should we be measuring?
  • How do we match clients to therapies?
  • Does CBT for psychosis have to change the topology of positive or negative symptoms of psychosis to be useful?  Or might it be enough to change a person’s relationship with their experience?
  • Are there other interventions that we would be better focussing on instead?

In the end, the motion was defeated resoundingly, with a large shift from the first vote at the beginning of the debate.  Those for the motion, put this down to a triumph of anecdote over statistics.  Of course, as psychologists and philosophers may say, it’s not events that matter, but what we believe about them and how we respond.  An alternative belief is that perhaps the audience actually don’t think CBT for psychosis has been sold very strongly at all, regardless of its effectiveness. Or, perhaps people thought that the issues of CBT for psychosis are too complex to be encapsulated in the particular meta-analyses that were the primary focus of the speakers for the motion.   There are many reasons why the vote could have gone this way, and without doing a survey, I could not tell you!

Response to Keith Laws.
One reason I’m writing this, is that I rashly described (over twitter) one of Keith Laws’s assertions as intellectually dishonest, when perhaps I should have said he was loose with his wording.  He understandably challenged me to defend this claim.   So I will do so here on my blog (as I’m not a very familiar with twitter, and don’t think 140 characters is useful for discussion).  Before I go any further, I should declare a conflict of interest, I’m a clinical psychologist and much of my workload involves CBT for psychosis.

Unfortunately I don’t have a recording of the debate yet, so I don’t have his exact words, thus I’m going to address what I thought his point was!  I remember Laws saying that the evidence says that CBT for psychosis only helps 5% of people treated.  For the moment, you can find a reference to this on Alex Langford’s live take on what was said here at storify, and the tweet of the claim in question here.

Laws, I believe, bases this claim on a meta-analysis on which he is last author.  This paper concludes that based on the meta-analysis:

Cognitive-behavioural therapy has a therapeutic effect on schizophrenic symptoms in the ‘small’ range. This reduces further when sources of bias, particularly masking, are controlled for.

And finds that (for example), the effect size on overall symptoms falls from -0.62 to -0.15 (95% CI –0.27 to –0.03), when studies with insufficient and sufficient masking are compared.   (Always note the confidence interval.  Even here, at this significance level, the true effect size might be as low as -0.03 or as high as -0.27).

My claim is that even if we take no issue with the way in which the meta-analysis has been carried out (and of course we might), and even if we temporarily accept the figure of 5% (I’ll confess I’m not sure exactly where this came from, some NNT calculation?), Law’s conclusion that CBT only helps 5% of people seems flawed.

One key reason for this, is that the meta analysis includes both treatment as usual and control interventions as comparators.  Thus a more valid conclusion would be that CBTp helps only 5% more people than a mixture of treatment as usual (TAU) and control interventions such as befriending.  To me, this is a quite different thing.   For instance, it is possible that the control interventions were also very effective and thus CBT had a hard job getting significantly better results.  As an example, let’s say in a study, befriending had a 40% impact on symptoms and CBT had a 45% impact.  This would not mean that CBT helped only 5%, but 5% more, although the difference between interventions was only 5%.

A second reason not to accept this interpretation is that our clients’ wellbeing can be quite independent of the number and frequency of their positive symptoms.  A person can for instance, continue having auditory hallucinations, but completely change their relationship to them, and thus reduce depression and anxiety, and increase quality of life.  Thus CBT may help clients in the absence of a change in positive symptoms (the meta analysis that Laws was an author on, did not consider other outcomes such as depression and anxiety – key issues for our clients).   Equally, if a client asks us first to help them with their panic attacks, that is generally what we do, yet progress here will not necessarily show in a measure of psychosis symptoms.

I’m  in agreement with Laws in some senses. The literature can certainly be improved upon.  Clinically, we often seem to see remarkable change, yet the literature at large, does not necessarily reflect this.  This may be because CBT is not adding much to treatment as usual, or other interventions, but that we wrongly interpret change as related to CBT.  Or, it may be because there are many different types of CBT, some better than others.  Or it may be because we are measuring the wrong things.  Or it may be that we are looking at the evidence too simplistically.

Incidentally, it was argued in the debate that it would take a huge number of extra significant trials to improve the effect size of CBTp in meta-analyses.  This to me, shows a misunderstanding of CBTp.  CBTp is not quetiapine, which is always the same.  CBT is evolving over time and comes in many forms (from individual to group, from classic CBT to taste the difference Mindfulness Based CBT, from CBT for general psychosis to CBT for command hallucinations).  Lumping all studies together as if it were the same, is thus not necessarily a good idea.

Whatever the explanation, it behoves us to rethink the way we have run our trials to date, in order to capture those outcomes that are most useful to service users.  (I suspect Laws may not appreciate how difficult it is to get funding to run sufficiently powered studies, which may also explain how many studies are at the right side of his forest plot, yet non-significant).  We also clearly need to continue to refine our treatment protocols.  We are beginning to do this, with targeted interventions such as the COMMAND trial (among  others).  It’s a hard slog, but I for one, think the future is bright.

Psychosis Is Nothing Like A Badger

An interesting (but perhaps divisive) animation from Henry Gale.

Psychosis is Nothing Like a Badger from Henry Gale on Vimeo.

The badger of the animation is pretty menacing, with a definite streak of dark humour, and definitely not a badger who’d give up easily.   But Henry is clear:

 psychosis is nothing like a badger… and tends to let go after a while.

Henry  says made this animation……

to raise awareness concerning the signs and symptoms of Psychosis, in the hope that sufferers (and those around them) can seek help without fear, judgment, or hesitation.

Having walked away from two episodes of psychosis myself, I felt that the beginning stages of the illness brought me the most fear and confusion. It was a hazy, in many ways unhelpful diagnosis, that was difficult to talk about – both for its stigma and lack of clarity. I’m hoping that this video might help bridge that gap, giving sufferers, as well as their friends and relatives, a simple insight into how and why Psychosis affects people the way it does.

I know little more about Henry Gale, other than the fact that he’s a clearly talented filmmaker, has a few other videos on Vimeo, and has a tumblr page henrysgale.tumblr.com, which has among other things, info about the making of the film.  Anyway, I’ve little insightful to say tonight… so, if you’re still reading, go watch the film.

An interesting article about asylums and overlooked friendships.

Friern Barnet from wikipedia.
Friern Barnet from wikipedia commons.

In this short article introducing her forthcoming book: The Last Asylum: A Memoir of Madness in our Times, Barbara Taylor describes her experiences of living in Friern Barnet mental asylum.   If the article is any indication, the book should be fascinating.  The piece focusses on the friendships developed in psychiatric wards, something that Taylor feels has been totally neglected by researchers.  As Taylor describes:

Magda suffered terribly from black depression yet nearly always she would pull herself together to be with me. Usually I did the same for her. The obligations of friendship trumped madness – and this in itself could be a form of healing.

it may be that the friendships developed on psychiatric wards can be an essential part of patients’ recoveries.  Yet as mental health professionals we often seem confused as to whether to encourage such relationships, and indeed are sometimes very ambivalent.  We may often fail to capitalise on the potential healing ability of our patients’ relationships.  To my knowledge, we know little about whether these relationships are sustained out of hospital and what they mean to our clients.   Yet we know that having good social support is a key factor that mediates recovery (for instance in bipolar disorder), and we know that serious mental illness commonly wreaks havoc on a person’s social networks (e.g. this study looking at the impact of psychosis on social support), so we really should know…