Development of an Online EWS Symptom Card Sort

The Early Warning Signs (EWS) card sort is a task commonly used by mental health professionals to help develop Staying Well Plans with patients*.

These Staying Well Plans are often developed towards the end of therapy, and include a number of elements, one of which is a plan of action should a person start to notice warning signs that they might be becoming unwell. This might mean being at risk of becoming depressed, becoming manic or developing escalating symptoms of psychosis.

Screenshot from card sort demo video.

The standard card sort is a physical sorting task used to help patients and therapists quickly and effectively select symptoms from a set of common symptoms, and arrange them into early, mid and late signs of becoming unwell. In my experience most patients find the card sort to be an engaging and useful activity.

A video example of a card sort can be seen here.

During the covid-19 pandemic, it became difficult to do the card sort in person. As a result I have developed a digital version. I have shared locally, but perfectionism (and time pressure) prevented me from sharing more widely.

I’ve looked into a wide range of more or less sophisticated options for replicating the face to face task in a way that could be shared for collaborative access over platforms such as Microsoft Teams / Zoom. I have settled for the moment on using presentation software such as Powerpoint (which most NHS professionals have by default).

Instructions for Use

Profesional Use

The tool is designed for use by appropriately qualified and supervised mental health professionals. If that’s you, you should know!

You use the tool in much the same way as the physical version. It’s not just something that’s done by rote, but individual to the person you are working with. It’s really important to map out the characteristics and meaning of each symptom/experience to each person.

As the tool develops it will be more interactive. For the moment I tend to use it while screen sharing. It can also be shared collaboratively with the patient if they have a copy of Powerpoint – or used in a face to face session on a big screen, for some covid safe card shuffling!

Non Professional Use.

Individuals who struggle with symptoms of depression, mania and psychosis are very welcome to try out the tool themselves as a self-help tool. For the moment I have incorporated some basic instructions in the tool. I will update the instructions and this blog article in due course.

Download and Feedback.

The Powerpoint version is available for download and use, click here. I would appreciate feedback and ideas if you find it useful (or not!). You can find a feedback form here.

Google Slides Version is available here. This is probably better for realtime collaboration than the Microsoft Powerpoint option. The patient will need a google account.

I have a few other versions which I intend to make available soon(ish!), check back for updates.

Powerpoint Card Sort: Mania Symptom Select

Development Plans

I hope to continue with the digitisation of the card sort and develop an easy to use tool that will help patients and professionals quickly and easily develop accessible staying well plans. Together with a few others, I already have a number of ideas that, if we can implement them, should make a really useful tool.

Card Sort Literature.

A very brief, not at all systematic, dip into the literature:

The earliest published use of the EWS card sort I’m aware of is in a paper, published in 2000, by Max Birchwood, Elizabeth Spencer and Dermot McGovern, which details how the card sort can be used in identifying a person’s ‘relapse signature’.

Two more recent papers review the literature on the card sort task. Agius et al, 2006, describe the literature and report on a pilot study, but I only have access to the abstract. A 2017 by Tern et al (last author Agius), follows up on the 2006 paper with a review of the card sort for people with bipolar disorder, but again, only an abstract is available to me right now. The message of the abstract is that there is not much of a literature and that the card sort is:

useful in elucidating the relapse signature for each patient, which can then be used in psychoeducation or identification of future relapse episodes. However, more research is needed directly assessing the usefulness of the card sort exercise in helping patients and their families gain insight into the possibility of an imminent relapse.

They also suggest that the card sort may be ‘less use for depressive relapses, where prodromal symptoms are harder to pinpoint’.

*As always, it’s hard to know whether to use patients, clients, people. Evidence is mixed as to patients’ preference.

John Maddox Prize Nomination 2020

In 2018, I nominated Alexandra Elbakyan, the creator of Sci-Hub for the John Maddox Prize for Standing up for Science.   The award

Recognises the work of individuals who promote science and evidence, advancing the public discussion around difficult topics despite challenges or hostility.

As you may know, Sci-Hub provides free access to an extremely large corpus of academic journal articles, circumventing traditional publishing paywalls and copyright.

My nomination was an attempt to help recognise Ms Elbakyan’s immense contribution to the opening up of scientific publishing.  Ms Elbakyan made it to the final shortlist, but did not win.   I am nominating her again this year, as I feel a win would be a much needed further boost to the open science movement.

The shortlist for the Maddox prize has not previously been made public.  I feel the nominations themselves deserve a platform, not to mention the shortlisted nominees.  I make a plea to the panel: in keeping with the open science ethos, please consider creating a platform not just for the winners, but for the shortlisted nominees, together with a summary of the panel’s deliberations

The nomination:

Dear Prize Committee, 

I would like to re-nominate Alexandra Elbakyan for the 2020 John Maddox Prize, for her efforts setting up, maintaining and defending Sci-Hub, a website that provides free access to paywalled research. Alexandra Elbakyan may not be a typical candidate for the John Maddox Prize, however, I hope to make a convincing case that she is a worthy one.

I do not know Ms Elbakyan personally, and have been unable to obtain agreement to nominate her.  However, I have sent a message to inform her.

I have addressed the four stated criteria below:

How clearly the individual communicated good science, despite challenges

Access to and dissemination of scientific research has historically been controlled by journals and journal publishers. Subscriptions to these journals are bought by universities, and are made available to the academics within those universities, but not to those without such privileged positions.  While the prevailing publication model may have had some justification in an era of dissemination by physical methods, with the advent of the internet, and essentially free/zero costs of dissemination, it is harder to justify these archaic models.  Furthermore, many of these journals, which were previously affordable, have risen in price, unaffordable even to rich institutions.

The majority of institutions and academics in the developing world/global south are further impoverished by this lack of access. Despite a vocal open-access movement, a significant proportion of the scientific literature remains behind paywalls. Inertia, power dynamics and conflicts of interest have prevented rapid change, and thus an innovative/disruptive solution was necessary – Alexandra Elbakyan provided this solution with Sci-Hub.

The majority of published research is publicly funded, with much of the work in the reviewing process carried out by volunteers, yet remarkably, the public who have funded it are typically unable to access it without charge. The public are hampered in accessing scientific information, preventing learning, innovation, and citizen science.

The ramifications of these barriers to access are innumerable, but to pick just one example doctors, patients, and researchers are often unable to efficiently (or cheaply) gain access to all the potentially relevant literature – they are therefore disempowered in their decision-making.  Likewise, journalists, who especially in an era of increasing ‘fake news’, play an indispensable role in disseminating accurate information, may not have access to original sources.

In the traditional sense, Alexandra Elbakyan has not ‘communicated good science’.  She has instead worked at a higher level and directly facilitated the communication of science via opening access to everyone on the planet who has access to the internet.  It is hard to think of a greater individual contribution to the communication of scientific knowledge.

The nature of the challenge(s) faced by the individual

Unsurprisingly, given the nature of powerful institutions, and the economic incentives to maintain the status quo, Alexandra Elbakyan, has faced very significant challenges in initiating and maintaining Sci-Hub. So far, she has been the subject of two legal cases, both found against her by default.  The first case was brought by Elsevier, and awarded $15 million in damages.  The second judgement, in favour of the American Chemical Society (ACS), of $4.8m, also awarded an injunction “against all parties in active concert or participation with Sci-Hub”. This essentially provides the ACS, and those who wish to align themselves, with the tools to attempt to censor Sci-Hub.

The effect of these judgements is that Alexandra Elbakyan fears that if she travels to Europe or the USA, she may be arrested or extradited on further hacking charges.  Clearly, she would be unable to live or work in the USA due to the financial penalties she faces there.

How well they placed the evidence in the wider debate and engaged others

Sci-Hub places ALL the evidence into the wider debate; and in doing so, it brings the evidence to the people, and brings previously disenfranchised people to the debate.

As of March 2017, Sci-Hub’s database contains 68.9% of the 81.6 million scholarly articles registered with Crossref and 85.1% of articles published in toll-access journals.

Sci-Hub is now internationally known as the best way for those without privileged access to read scientific papers.  It is even used by those with access, as it often provides the fastest method of downloading papers. Even for members of Western universities, Sci-Hub often provides a better level of access than their institutional subscriptions. According to an article in eLifeSciences, “For toll access articles, we find that Sci-Hub provides greater coverage than the University of Pennsylvania, a major research university in the United States”.

According to an article in Science “Over the 6 months leading up to March [2016], Sci-Hub served up 28 million documents. More than 2.6 million download requests came from Iran, 3.4 million from India, and 4.4 million from China”.  Even this old data demonstrates both the depth and breadth of the reach and influence of Sci-Hub and how it’s providing access for exactly the people it was designed to help.

Their level of influence on the public debate

Beyond providing access to the disenfranchised, Sci-Hub’s success has driven public debate as to the ethics of traditional subscription-model publishers as well as to how to achieve a more equitable system. The concrete and visible action of actually providing a working alternative, has had a significant effect on driving the debate out of ivory towers into a more public forum.  Sci-Hub has acted as an advocacy tool for open access.  Barriers are often invisible to those for whom they are not a problem; by creating a system without barriers, Sci-Hub has helped delineate and highlight these barriers.

I write having spent years working in Ecuador, where my students worked without the benefit of privileged levels of access to public research. I saw directly how a lack of access affected every one of my students.  And having introduced my students to Sci-Hub, I see how it enriched their scientific lives, and unlocked their potential – helping them to find postgraduate positions in prestigious European universities.

Article 27 of the UN Convention on Human Rights, cited by Ms Elbakyan, states that “Everyone has the right freely to participate in the cultural life of the community, to enjoy the arts and to share in scientific advancement and its benefits.”  This statement implicitly acknowledges that science and scientific advancement is not an individual pursuit, it is a societal activity. Yet right now, while some of us are standing on the shoulders of giants, others are scrabbling at their shoelaces.

Ms Elbakyan’s activism has included actions that are considered by some to be illegal. Those with established financial interests in academic publishing have been particularly vocal in their opposition.  I would like to draw a parallel here with the Suffragette movement, who faced imprisonment for acting according to their values.  The cause of the Suffragettes is now almost universally lauded, illustrating how the law shifts as society changes.  Thus I would encourage the panel to put aside the question of legality, and consider the value and wider impact of Ms Elbakyan’s actions.  These actions, along with those of other advocates of open science, have arguably resulted in a paradigm shift in thinking about equality of access to science.  The movement has been so successful that even dominant academic publishers have been forced to change their own models in fear of being left behind, even if they have not changed their underlying philosophy.

Alexandra Elbakyan is an activist, acknowledged by Nature in 2016 (alongside 2018’s co-winner Terry Hughes), who has risked her liberty to confront a system that impoverishes humanity. Recognition is essential to activists, not only to further their work, but also to protect them for persecution and prosecution. I hope that you’ll consider extending this recognition to a true revolutionary.

Yours sincerely,

Dr Fergus Kane


Videos about Psychosis: 2020 Updates

This blog started at the end of 2013, with me making public notes about representations of mental health in online media.  6 years or so later, there has been an explosion in the amount of high quality information available.   Spurred on somewhat by the struggles of some of my clients during the covid-19 pandemic, I’m doing some more research on what’s out there.   I’m updating the blog again with what I come across.  I’ll start with four videos about psychosis, two new to me, and two classics.

Being Jesus

A brilliant punky, sweary, funny short film by John Oewinne about an experience of grandiose psychosis.  Opening warning from the film: comes with flashing imagery, blasphemy, irreverence, humour, music and other misdoings.     The video talks about a common grandiose religious delusion.  The protagonist (it’s not clear if the person in the video is an actor or not) thought that he was Jesus, and also felt that he was able to talk to his recently deceased father.  He talks us through the chronology of his delusion, from beginning to think he was Jesus, to being sure, to getting into conflict with his family about his beliefs, being hospitalised, being released from hospital and then experiencing a depressive fall that came after realising he was not Jesus.

John Oewinne is involved in a number of interesting mental health projects and I’ll be checking out his Coffee and Psychosis podcast ASAP.

Compassion for Voices.

I’ve posted this one before, but it continues to be incredibly well received by the people I and others work with.

Being compassionate towards one’s voices, especially when the experience of voices can be deeply unpleasant, can see counter intuitive and even insulting.  However, from what many of my clients have told me, learning to be compassionate towards one’s auditory hallucinations / voices, can be much easier than fighting against them or studiously ignoring them, both of which can be exhausting.  Compassion for voices can also fit together with being more compassionate with oneself and with other people.

For those that consider their voices to be a part of them, it can make sense to be compassionate to their voices, as in the end, being angry at the voices means being angry at oneself – a stance that rarely takes one to a better place.  At a deeper level, many have come to the conclusion that their voices also carry another message, about their own unprocessed emotions – whether that be able difficult childhood experiences or more recent difficult experiences such as bereavement or workplace bullying.  There is no one explanation-fits-all solution or explanation, but this one certainly resonates with many people.

Compassion is often seen as a sign of weakness (a view that is often propagated by the society around us), but instead we can see it as a sign of strength.  Likewise, for some, the idea of being compassionate can be scary, as they feel it might put them at risk.  However, a true, mindful compassion can help put us in a strong, wise position, where we are able to take control back over our lives.

The Voices in My Head

Compassion for Voices links really nicely with another classic talk, this one by Eleanor Longden talking for TED.

Eleanor talks eloquently and with humour about how stigma, a poor response from health services and fear of her voice hearing experiences led to  a huge worsening of her experiences while making sense of them and developing compassion led to recovery and reclaiming her life.  Now a successful academic and campaigner, she promotes solitary among voice hearers and is a strong proponent of voice hearer groups such as the Hearing Voices Network. and the International Hearing Voices Network, Intervoice.

You might recognise Dr Longden’s own voice as she also narrated the Compassion for Voices video.

People Call Me Crazy – A Film by Juno Jakob

This one’s actually from back in 2014, but I’d not seen it.  It’s Juno Jakob, recounting in his own words his experiences with ongoing psychotic symptoms, sigma and hospitalisation among other things.  It’s open, honest and straightforward.  A great description of what it’s like for some people to struggle with psychosis.  Inline playback is disabled, so click on the link to watch.

There is a more recent shorter companion video produced with Mind, also from Juno, which is worth a watch.

That’s all for today

I’ll be asking around for more resources, and will try to update as I come across them.

Trusted Therapists In Ecuador.

Although I no longer practice in Ecuador, I often get questions about therapists who are trustworthy and competent.

The following is a list of therapists who I have worked with and interacted with personally.  I have had positive feedback on all these therapists from clients.

Liliana Podvin.
Approximate cost.  $50 per session.
Hotel Quito area, Quito
M.A Marriage, Family and Individual Therapy in San Diego University for Integrative Studies (California).

Alejandra Morales.
Approximate cost.  $40 per session
Voz Andes y Juan Diguja / Cumbaya Parque Central .

Daniela Ordonez
Approximate cost: $50 per session.
6 de Diceimbre y Whymper
Master’s in Family Counselling from Universidad Javeriana, Colombia

Andrea Yadun
Approximate cost:  Between $35 and $45 per session
Isabel la Católica N24-848 y Coruña
C.C. Centro Plaza, Av. Pampite
Masters in Systemic Family Therapy from King’s College London

I try to keep this list up to date based on people’s feedback.  Please, if you would like to recommend a therapist in Ecuador, contact me directly.  Also, if you would like to provide any feedback on there therapists I have listed (both positive and negative), that would be very useful.  You can find my contact details on my main webpage:

How to Choose a Psychologist in Ecuador.

Why I’m writing this.

I have worked in Ecuador as a psychologist for about three years now, both as a therapist and, for a time, as a teacher at Universidad San Fransisco, de Quito.  Over that time, I’ve heard numerous tales of bad practice,  running the gamut from fraudulent psychologists, inappropriate relationships with patients, through to serious breaches of confidentiality.  As a result, I felt it was important to write a guide to finding a good enough psychologist.  It’s not a guarantee of finding a perfect therapist, but hopefully, it will help avoid the very worst!

There are many different things to consider when choosing and sticking with a psychologist.  To some extent, this will depend on what you need from them and whether their skill set matches with that.   I’ll deal with that briefly and then move onto some more basic issues – like whether your psychologist has any real training, whether they are running to Ecuador because they lost their license in their own country, whether they use an evidence-based approach and whether they can do the basics like talk about and maintain confidentiality!

Basic Questions.

I’ll start with some commonly recommended questions you might want to consider asking, and then I’ll move onto discussing the issues in more detail.  I’ve adapted these questions from the American Psychological Association (APA) and added some of my own.

  • Do you have, have you ever had, or have you lost a license to practice psychology? (there is no licensing system in Ecuador, see below)
  • How many years have you been practising psychology?
  • What is your approach to confidentiality?
  • Do you currently have your own supervision?  If not, why not?
  • I have been feeling (anxious, tense, depressed, etc.) and I’m having problems (with my job, my marriage, eating, sleeping, etc.). What experience do you have helping people with these types of problems?
  • What are your areas of expertise — for example, working with children and families?
  • What kinds of treatments do you use, and have they been proven effective in dealing with my kind of problem or issue?
  • What are your fees? (Fees are usually based on a 45-minute to 50-minute session.)
  • Do you have a sliding-scale fee policy?
  • Do you work with insurance companies?

Is your psychologist a good match?

Besides the basic ethical and competence issues discussed below, the most important thing in therapy is that you and your psychologist are a good match, both in terms of the difficulties you face and in terms of the ‘therapeutic relationship’. Whenever possible, your psychologist should have experience in working with the kind of difficulties that you are facing; if they don’t you may still be able to work together, but in this case, it is important that the psychologist has regular access to high-quality supervision with someone who does.  It’s also important that the type of therapy matches the issue you face.  For instance, a number of therapies have been shown to have good outcomes when working with trauma (CBT, EMDR and Narrative Exposure Therapy included) and it’s generally best to stick to these proven treatments.

Likewise, it’s generally acknowledged that the quality of the therapeutic relationship is extremely important.  In a good therapeutic relationship, you can expect to experience what Carl Rodger’s described as ‘unconditional positive regard‘, to feel like you are being listened to and understood, and that you can be open with your psychologist without fear of judgement (for many people, this can take some time even with a great therapist).  Therapy should also feel like a collaborative process.   Conversely, it’s essential that you don’t feel bullied, pushed way beyond your limits, told what to do, or like the therapist is imposing their own beliefs on you (to pick just a few issues).

It’s also worth noting that not every psychologist will be able to work effectively with every client.  Some people may have preferences for the gender of their psychologist, while for others there may just be something in the relationship that does not quite work.   Even if a psychologist comes with great reviews, but you just don’t seem to be able to mesh, please don’t assume that therapy won’t work for you.  A great psychologist will be able to listen to you when you say therapy is not working and either suggest a new approach or refer you to another psychologist.

That covered briefly, let’s move onto the issues that I think may be particularly important here in Ecuador.


Now for a bit more detail, let’s start with licensing.  One of the most serious problems with psychology in Ecuador is that there is NO licensing system here.  It is quite simply not possible to lose your license, because it’s not possible to get one in the first place.   To be clear, a license is not a degree, but part of a post-qualification system that is designed to make sure that only qualified, competent and ethical psychologists may practice.  Importantly, a degree cannot normally be rescinded, whereas a license can be rescinded at any time following a complaint and investigation.  In many other countries, such as the UK and USA, you are always able to check whether your clinical psychologist had their license challenged due to malpractice.

It’s not possible to check the status of an Ecuadorian psychologist’s license unless they trained or worked abroad.  It is, however, possible to check the previous status of foreign-trained psychologists.  For instance, a clinical psychologist working in the UK has to be registered with an organisation called the HCPC.  Although I let my registration lapse when I left the UK, as it no longer seemed relevant, you can still look me up here, via my surname.  In addition, you can also google my name and phrases like “UK lost license” “ethics” etc.   I’m aware of people who have found out a lot more about their psychologist using this latter method and I thus recommend it for anyone looking for a psychologist.  For US-based psychologists, in particular, there is a lot of information available from state psychology boards.  For Ecuadorian psychologists, although there is no license system, it might be worth checking what Google knows about them!

Qualifications and Experience

If you can’t check for a license, what can you check for?  Qualifications.

Ecuador has a system for registering your degrees run by SENESCYT.  With a person’s ID, you can check here which degrees they have registered with SENESCYT (this applies to all professionals, so you can also check out your architect etc).  If you do this, you’ll see a list of the degrees that have been registered (click on the image to see an example from my record). It is also possible to check details with a person’s name, but for foreigners this has to be done on a separate page/tab, which has slightly less information.  If you want, give it a go with my name.

Now I do not wish to suggest that just because a psychologist has not yet managed to register their degrees in Ecuador, that they can’t be trusted.  In my case, it took quite some time to register all my degrees, because of some random bureaucratic obstacles when registering doctorates.

Regardless of the status of a psychologist’s registration with SENESCYT, please ask about your potential psychologist’s qualifications and experience.    Even if not registered yet, they should also be able to show you their certificates and consent for you to contact their place of training if you so wish.

How much training and experience should a therapist have?

Experience.  There is no easy answer to this question.  Generally one would assume that the more experience the better; however the evidence is, as usual, more complex than that.  For instance, it has been found that there may even be a negative long-term effect with the most experienced therapists being slightly less effective, perhaps related to a common finding that sticking closely to the protocol (therapeutic integrity)  rather than going ‘off piste’ may be related to better outcomes.    A newly trained psychologist with supervision may be far better than a more experienced, unsupervised, burned out and cynical psychologist!  Whatever the case, it’s likely that the majority of variation in therapist effectiveness is due to other factors than simply years of experience, which brings us to training and evidence-based practice.

Training. In the UK, to call oneself a ‘clinical psychologist’  requires at least a first degree of three years and a three-year doctoral degree (DClinPsych) from an appropriate university.  In practice, many therapists qualify with significantly more experience than that, often at least a Master’s degree and sometimes a PhD.

In Ecuador by contrast, the term ‘clinical psychologist’ does not appear to be protected and so anyone can call themselves a psychologist or clinical psychologist.  In practice, some ‘psychologists’ have only a 3-5 year degree (often with rather little actual psychology) while others simply have no related qualifications.   I highly recommend, where possible, looking for a psychologist who has at least a Master’s qualification from a foreign university (there is no Master’s degree in clinical psychology in Ecuador).  In particular, watch out for ‘internet’ or ‘mail order’ degrees, they are often not worth the paper they are written on.  None of this is to say that a newly qualified ‘psychologist’ in Ecuador with just a first degree can’t be helpful, but please do be aware that it’s a level of training that would be unacceptable in many other countries.

Evidence-Based Practice.

I practice CBT (Cognitive Behavioural Therapy) and ACT (Acceptance and Commitment Therapy), both evidence-based therapies.  What does this mean?  A full discussion would be too much for here, but essentially, at the very least, nowadays it means the therapy has been tested to see if it is more effective than a placebo.  It also means that the basic assumptions of the therapy will have been tested to make sure they are correct.  Evidence-based therapies are also constantly re-evaluated and improved, and the results of studies are published in peer review journals.

In Ecuador, one can find a wide number of therapies, many of which come under the term ‘esoteric’.  These include things like ‘family constellations‘ therapy.   While these therapies may come with great reviews from some of their participants,  they have generally not been scientifically tested and moreover may be actually dangerous. Beyond that, they are often allegedly based on untested or untestable concepts like ‘morphic resonance‘ and rely on guru like figures.    Worryingly, just in Ecuador, I’ve heard multiple reports of people being left feeling traumatised following family constellations work, and being blamed for the failure of the therapy to work.  It is one thing to know how to get a person to revisit a trauma, and another to be able to safely guide them through a therapeutic process.

I do not mean to rule out complementary techniques.  Indeed I fully encourage trying meditation (which I also teach/practice), having a massage, attending support groups, exercising, horse riding, spending time in nature and such like – all these may be important components of recovery and living a good life.  However, I advise being cautious in taking serious issues to poorly trained practitioners selling untested or miracle therapies.  For instance, many practitioners will have little or no training in working with suicidal thoughts, flashbacks, trauma, the disclosure of abuse and so on… all of which are key parts of good training for clinical psychologists.


This is the most basic cornerstone of psychological therapy, yet based on what I’ve been told, it something that seems to be ignored by a lot of ‘psychologists’ working in Ecuador.  My personal belief and training is that confidentiality should be clearly and openly discussed the first time that you meet with your therapist – and it should be the therapist who brings it up, ideally before anything else.  With specific exceptions, a therapist should never discuss identifiable details of your therapy with anyone else without your specific permission.

It is NOT ok (without your consent) for your therapist to tell their family and friends about your therapy, it is not ok for a therapist to let others know you are in therapy, and it is not ok for them to discuss  your therapy with your family or friends.

In other countries, a therapist could lose their license for such lapses.   I have heard far too many examples of broken confidentiality.  Again, it’s not ok.

There are exceptions to the above rule, and these should also be discussed in therapy.  For example, a therapist may have to break confidentiality in the case that they are concerned for your safety or that of others. Equally when conducting therapy with children, confidentially is important, but there are times when a therapist will need to disclose information to the client’s parents – generally this should be done with the child’s knowledge.

Supervision and further training

It is my belief that any good therapist should be consistently questioning and updating their own practice.  Part of this includes continuing to attend conferences and training though-out one’s career.  Another part of this, which I consider essential, means being part of a system of supervision.  Supervision allows a psychologist to talk to another psychologist about their clients and to explore any doubts about the approach they are using.  Good supervision regularly provides useful insights into what a therapist might be missing and helps improve the therapy that our client’s receive.  Please ask your psychologist about their supervision practice.

Defensiveness and your right to ask questions!

It’s natural to get a little defensive when asked questioned about one’s abilities, training and practice – and that’s as true for psychologists as for anyone.  However, a psychologist should be able to recognise this in themselves and deal with it.  They should also recognise that it’s entirely for reasonable and indeed sensible for a client to ask certain questions about their psychologist’s professional training and approach.  If your psychologist is not willing to answer such questions, that could be a warning sign.  It may point to poor training, or it may even indicate that the psychologist is hiding something.

Professional vs Personal Questions.  Having said that, most psychologists do set boundaries between themselves and their clients, for good therapeutic reasons.  That means that they may be cautious in disclosing personal information about themselves.  Each therapist has their own boundaries. My take on this is that while a therapist should be open to professional questions, they have every right to gently refuse to answer personal questions.  I do sometimes share information from my personal life when I think it might be therapeutically useful, but I also maintain certain boundaries.

Signs you’ve already got a dodgy therapist.

I may still write something on this, but Joseph Rauch’s 25 Signs of a Bad Therapist: You Deserve Better is pretty good!

That’s it for the moment.

I hope that this is useful to some of you who might be looking for therapy.  As always I welcome comments and suggestions.

Next up hopefully… making the most of your therapy.

Water Filtration 2. Systems

Here I attempt to summarise some of the options for providing safe water, both for disaster preparation and  for general travel in areas where there is limited access to potable water (or where you’d prefer not to have to buy bottled water).

It’s a delayed follow-up to my first post on water filters, which focussed on the rationale of ensuring that people (especially in disaster prone areas such as Ecuador) have water autonomy.  Both posts were inspired by my work following the Ecuadorian earthquake of April 2016.

The article is still far from comprehensive, but I’ll update it from time to time with new information as I get it (or remember it!)

A quick note on water supplies.

Regardless of which of these filters you use, they will all work better with water that has been pre-filtered to remove gross sediment and turbidity.  This can be done with something as unsophisticated as a t-shirt.

Also, be warned, none of these filters alone will remove heavy metals, pesticides, salt or other chemical contamination.  Additional activated carbon filters will help remove some chemical contamination, but their effectiveness depends on the dwell time (how long the water is in contact with the carbon) and the contact area – and commonly these are nowhere near enough to make a significant difference.  Thus, if your water supply is heavily contaminated with dangerous chemicals, you’ll need another way to get clean water.  For most people, the easiest and best way is to collect clean water for filtering is from the sky using something else most people have, a roof.  Even if this becomes contaminated with bacteria, the filters will deal with that for you.

Membrane Filters

This is a class of filters that includes those made by companies such as Sawyer and LifeStraw.  These filters, much like ceramic filters, work on a simple idea: contaminants such as bacteria and viruses are larger than a molecule of water, therefore to remove the contaminants, one needs a filter medium that has channels that are reliably larger than water but smaller than these contaminants.  There is an essential trade off in these filters: the smaller the channels, the slower the filtration, but the more types of contaminant it will remove.

These systems are mostly ‘gravity filters’ as they rely on the force of gravity to force the water through the filter.  This means that their speed does vary as a function of the relative hight of the water source (or pressure when driven by a tap).

A variety of companies use this technology, but Sawyer and LifeStraw stand out because their filters are rated to filter a huge amount of water – and are cleaned rather than replaced.  To confuse matters however, each company makes a large number of different filters or filter sets.  I’m going to cover the main ones below:


bucket2Sawyer’s filters come in two filtration levels.  The Point ZeroTWO (0.02 micron) filter will essentially filter all protozoa, bacteria and viruses, while the  PointONE (0.1 micron will filter bacteria and protozoa, but NOT viruses).  Each type of filter is sold in a variety of different setups: including systems that filter from one bag or bucket to another and systems that plug directly into your tap (faucet for you North Americans).

Following Ecuador’s devastating earthquake in April 2016, a variety of organisations brought down Sawyer filters to help.  These were invariably the PointONE bucket filter system.  The link I’ve provided is to a full set with tap adapter, but Sawyer generously provided a stripped down bucket system at a charity price of only $10 per filter, way below the normal cost of $50 for the full set.

Now these filters DO NOT filter viruses, so if there is any concern of viral infections, one should use the more expensive Point ZeroTWO systems.  In Ecuador, the risk of viral infection in the water source was considered minimal.  Other than being more expensive, these 0.02 filters are also much slower at filtering; while the 0.1 system can theoretically filter around 2000 litres per day, the 0.02 system can ‘only’ filter around 700l.  However, in both cases these number are theoretical, and rely on a constant source of non-turbid water with sufficient pressure.

CLEANING:  Depending on the level of contamination (sediment, bacteria, algae etc) in the water, the filter will need regular cleaning.  To test and demonstrate the filter to people on the coast, I spent two weeks drinking water filtered from a very green source of water in an abandoned swimming pool (I sadly neglected to take photos, but I did survive).  In this fairly extreme case, the filter became very slow after around 10 litres.  Cleaning of the filter is done by backwashing with clean water using a syringe or a plastic drinking bottle with an adapter.

This process is very simple, but it is perhaps the one major weak point of the filter.  When giving these filters out to poorly educated people, who may speak a different language from the donor, there are a variety of possibilities for problems: the person may not understand the initial instructions, they may not understand what constitutes uncontaminated water or even if they do understand at first, they may forget in time.  And of course, one needs to have a source of uncontaminated water and have all the relevant attachments in order to carry out the backwashing.

Pressure issues: When driven by a tap (or a high cistern), the pressure can easily be higher than that for which the filter is rated.  According to what I’ve read from Sawyer, the filter is designed to leak in such cases to prevent actual damage to the filter.  However, if unnoticed (this can easily happen) the leaking source water can contaminate the output as it drips down.

CONTROVERSY:  Sawyer claim that their filters are good for ‘up to 1,000,000 gallons’ (4 million litres).  However, this has been disputed by researchers from Tufts university (article here and presentation here), who claim that the filters may be seriously degraded within 24 months of use.  The quality of the science behind the claim, has however been disputed by Sawyer (here and here) and by other academics (see here).  While another study appears to support the real world benefits of using the Sawyer filter in Bolivia, it is worth noting that there do not seem to have been any proper long term field studies of the filters.


LifestrawFamily-01LifeStraw’s eponymous filter is a straw for drinking directly out of rivers/ponds, and seems impractical for most real world uses, except travel emergencies.  However, LifeStraw also make a variety of filters designed for families and communities.  For example, the LifeStraw Family is rated for 18,000 litres and filters at 0.02 microns (removing virtually all bacteria and viruses from the water). I’ve seen the family version in action, and it’s looks good.  In particular, it has a clever integrated backflush mechanism that should eliminate the possibility of contamination while cleaning.  The retail price is around $80 on Amazon.

The community version is much larger and more expensive.  It is rated for around 70,000 litres.  I’ve never seen this version in action; it looks like a good product, but it’s relatively expensive and bulky.  On Amazon right now it costs over $500.  Like the family version, it comes with an integrated backflush, and it also comes with a pre-filter for sediment.

In the end, in Ecuador many groups chose to go with the Sawyer filters because they are extremely portable (one can just buy the filter and buy buckets in the destination area), but mostly because Sawyer has made them available so cheaply for charitable use.  One could buy 8 PointONE filters for the price of a LifeStraw Family filter.  I also now use one in my house in Ecuador for drinking water as it’s quicker and easier than the ceramic filter I had before.  The max flow rate of the Sawyer (which does not filter viruses) is 10 times that of the LifeStraw filters.  See here for a spreadsheet comparing the filters (a work in progress).

Ceramic Filters

copyright unknownThe first modern ceramic filter was ‘invented’ by Henry Doulton, who  devised the modern ceramic candle filter in 1827.  However, ceramics were reportedly used to filter water long before that (I’m still searching for a good article on this).  Ceramic filters generally come in two forms, the replaceable ‘candle’ (which includes the traditional Doulton version on the right and the modern plastic you can see below), and the ceramic pot.

Shop Bought.

In Ecuador where I’m based, ceramic filters are quite popular for household drinking water.

This is the standard model and can sometimes be bought in shops, and can always be bought online (see here).  It consists of two compartments and two filters.  The filter you can see in the upper (dirty water) compartment is the ceramic filter.  This will theoretically remove all bacteria and viruses.   The filter in the lower compartment contains a variety of components, including activated carbon to remove contaminants (the black stuff at the top) and others which I guess are supposed to introduce minerals into the water.

I used filters like this for a couple of years and they work fine.  The biggest disadvantage is that they are slow and require work to fill and maintain.  They can achieve around 1-2l/h (depending on age and amount of water in the top container), which is ok if you are organised, but you can’t expect to have water right away of you forget to fill it.  The containers will also develop algae if they are not regularly used and kept away from light.  Furthermore, as with all filters that store water, the clean water can become contaminated, so regular cleaning is recommended.  The cost is around £30 for a complete system and $6 for the filters ($12 for both), which need to replaced every 6 months or so.

Locally Manufactured pots

This is a very interesting option for low income countries – albeit perhaps less so since the introduction of other low cost alternatives.  This system in its ‘modern’ incarnation was developed in Guatemala in 1981 by Dr. Fernando Mazariego.  In 1986, Ron Rivera of  ‘Potters for Peace‘ collaborated with Mazariego to develop the technique and since then has been helping to export the idea around the world (for instance this in Cambodia, and I have contact details for manufacturers in Ecuador if anyone wants them).  These filters can be made by traditional potters using a technique which involves adding a fine inflammable material (such as finely ground rice or coconut husks) to the clay.  When the pots are fired, this material incinerates leaving fine channels in the pot, through which the water will filter, but through which the bacteria and viruses struggle to pass.  This process removes around 95% of the bacteria and viruses, which can be improved closer to 100% via the addition of colloidal silver.

The ceramic pots themselves are designed to sit easily into a standard plastic bucket which can be fitted with a tap (see image).

Locally manufactured pots have the advantage that they support the local community and likely have a reduced carbon footprint compared to imported versions.  They may be particular useful for use in very poor and isolated communities where imported systems are unlikely to be regularly available.  A possible downside is that the pots might not always be correctly manufactured – the rule of thumb is that if they have a flow rate of more than two to three litres per hour they are not working.  A scientific analysis of both this filter system and biosand systems can be downloaded here.   The ceramic pots may be bought for between $20 and $30.  Only the recent development of filters such as the Sawyer membrane filter have made this look like less of a good deal.

Whole house systems

Ceramic filters can also be bought to be plumbed in to service a whole house and can have pretty impressive flow rates with sufficient pressure.  This 0.9 micron system from Doulton (for example) has a flow rate of 1000l/hour at 40 PSI (1.4 Bar/14m head).  Note however the relatively large size of the filter.  This WILL let through some bacteria (and definitely viruses); it seems Doulton are is relying on only the bigger bacteria being pathogenic and say the filter removes 99.99%+ of these..

BioSand Filters

By OHorizons –, CC BY 3.0

Another very interesting option.  BioSand filters are based on the slow sand filters that clean municipal water throughout the world, including that of major cities such as London.  They use both physical and biological methods to clean the water.  The physical is the sand, gravel and sometimes activated carbon.  This upper layer of find sand supports a biological top layer, known as a biofilm,  hypogeal layer or for those who like german words, Schmutzdecke.   The biofilm layer provides the bacterial reduction which can be up to 99% in a well functioning filter.  A new filter has a much lower efficiency, which gradually builds up over time.  Importantly these filters CAN NOT be used with municipal water supplies, as the chlorine will kill the biofilm.  The cost of a system is basically the cost of the container (generally a 50 gallon plastic water butt or a concrete alternative), the sand, some piping and a tap.   In total this might be $50 or so.

An unpublished analysis by Duke, Nordin & Mazumder suggests that biosand filters may be very useful as a first line treatment for water, perhaps for washing, cooking and showering (as they can quickly remove the majority of contamination and turbidity at circa 19l/h), but due to their variable efficiency at removing bacteria, should be complimented with ceramic filters for drinking water.  For further information see wikipedia and this construction manual from CAWST (Centre for Affordable Water and Sanitation Technology).

UV water treatment.

The bacteria and viruses in water can also be killed via UV light.  This is the basis of many pond treatment systems, but is also used for household water treatment and the portable Steripen.
The Steripen is a very popular water treatment system for backpackers.  Basically you put the steripen in a bottle of water, turn it on and stir the water.  The UV light does all the rest.

I’ve not used on, but it’s a pretty good solution assuming that you have a source of  non-turbid water.  Perhaps the best thing is that you will be certain as to whether it’s working or not (if the light comes on, it works and your water will be treated).  Some potential downsides are: 1. It is an active system, which means it can run out of batteries and may go wrong; 2. It can only treat a small amount of water at a time, making it best for individual use; 3. It needs clear water and will not filter or treat turbid water properly.  4.  There a plenty of reports of the Steripen being unreliable (among plenty of other singing it’s praises).  All in all, it’s an interesting alternative to filters for personal water treatment (if you a travelling where there is not a clean water supply, always carry a backup such as bleach drops).  The steripen retails for about £70/$70.

At a household level, it is possible to buy inline UV treatment lamps.  I’ve never used one personally, although I’ve seen one in action at the Brighton demonstration earthship (a UV filter is not very exciting to watch though).  These retail at around £500/$500 (see here for an example capable of 60l/h) . and require a source of electricity and yearly replacement of the lamps. While probably a good option for many, they may not make the best solution for disaster preparation (they would be vulnerable in an earthquake and not function without power).  They will also need pre-filtration in many cases.

That’s it for the moment.  More later.

I’m posting this now to make it available for feedback.  It’s not finished yet, but some people have been waiting for it, so I thought I’d get it posted.

Experiences of Psychosis on YouTube: Part 2:

This is a follow–up from the previous post on psychosis related media.  I’ll be adding any new media and recommendations here.  Starting with this one suggested by Rob and made by the Greater Manchester Mental Health Trust, as collaboration between service users and MH professionals.

It covers similar topics to the media I’ve published recently, but adds a specific regional identity, which may be important in helping to engage people.  As the makers say: “The aim of the film is to raise awareness, reduce stigma and encourage people to seek help early”.

To see the part one of this post, click here.

Experiences of Psychosis on YouTube

I’m back in media research mode now, and I’m teaching undergraduates about psychosis this week, hence the topic.  There are some exceptionally brave people who have posted on YouTube about their experiences of psychosis.  I’ve picked some of the most interesting material I could find and have summarised it below.  I’ve gone a bit further than normal and added quite a lot of my own reflections on the videos (I hope this is a good thing).  The list of videos below is far from exhaustive and as always I welcome any other suggestions and feedback from readers.

Maya Imani-Amani.

Schizophrenia: My Story.  In this video Maya briefly recounts her experience of developing voices and her diagnosis of schizophrenia at 17.  She tells of how her problems started with sexual abuse that began at age 10 and lasted for a decade.  In her early teens, she lost interest in the things she used to like (such as sports), and this led to her father taking her to a doctor.  Having told the doctor that she was thinking of suicide as he was admitted to hospital, at which point she told the doctors about the voices she was hearing.  She says that she now has 7 voices and discusses briefly how the voices evolved over time and how they relate to her experiences of abuse.  This story is one I have heard all too many times from clients over the years (and I only began my clinical training in 2009).  However, the familiarity of this story may mean that it will be particularly useful for all those who have similar stories.

This is just one of quite a few videos by Maya about her experience.  I’ve not watched them all, but those that I have all are excellent.  They are well paced, concise and compelling, which is not always the case on YouTube.

One of the more difficult things about these videos however is that they are done in ‘real-time’.  This is a real person, providing regular updates about their progress.  Thus, when she tells us that she is coming off medicine without her doctor’s knowledge or help, I cannot help but feel concerned for her.  And when we see her a month or so later (just two weeks before this post), struggling more with her voices (but still very coherent), this concern does not abate.

It seems that Maya is using YouTube to process her own experiences, and perhaps as a kind of therapy.  Beyond this, she is reaching out to her audience to form some social connection, as she notes that she has ‘no friends’ in the physical world.  We know that supportive social networks in the physical world are important in staying well, but in the absence of a strong physical network, perhaps online networks can provide some of this support.

Finally I notice that Maya has subscribed to rawsammi’s channel, which I covered some time ago in another blog post.  Rawsammi is another youtube poster, who talks about her diagnosis of bipolar disorder.  There’s definitely a good story to be told about how people are using youtube to connect with and support each other.

Autumn Likes Elephants.

Autumn is another YouTuber with a diagnosis of schizophrenia.  Like Maya above, she has a channel of videos all about her experience of schizophrenia.  In the video above, she tries to make sense of what caused her schizophrenia.  Her struggle in working this out mirrors the struggle of all clients, psychiatric professionals and researchers.  After many decades of research, we know there is no single clear cause of psychosis, but in most cases it is likely that a complex set of genetic and environmental causes are involved. This is not just a case of genes or environment, but gene-environment and environment-environment interactions (which I think I may write about in a future post).

Unlike Maya, she describes herself as having a “great childhood”, but that she remembers being paranoid and that she has been told by her parents that she was delusional as a child.  From a familial perspective, Autumn talks about how her great-aunt (and other relatives in her maternal line) experienced similar difficulties and thus may have carried genes for psychosis.

Interestingly, Autumn talks about how she was a quiet child and suggests that this may have made her symptoms less obvious than they might be in more outgoing people.  She says that this meant that her family did not notice anything being seriously wrong until she became very unwell.    Like many people I’ve met, stress at school and in her first year of college seems to have exacerbated Autumn’s problems (for many of my clients, the first year of University or exams seem to have been a trigger for manic or psychotic episodes).

Autumn says:

“I’m not a professional… but I can say I’m a professional on the schizophrenia illness because I’m a schizophrenic*”.

It’s a standard trope in psychology to say that while the psychologist is (hopefully) an expert in how the mind works, the person is an expert in themselves.  Trope or not, it’s very true, and the person’s own expertise is central to therapy working. Thats also why I’m interested in these videos; it’s my firm opinion that the people who experience these difficulties are the best people to explain the experience, both to other patients and to healthcare professionals.  Indeed I first started looking for such videos around 6 years ago in an attempt to open up conversations in group work on the psychiatric ward I was working on (LEO, which at least at the time, was a relatively enlightened and forward thinking place for helping young adults with psychosis).

(*I’m generally not keen on people calling other people ‘schizophrenics’ because it can be stigmatising and the label might overshadow the person’s essential humanity.  However, a person with a diagnosis has every right to describe themselves however they wish!)

Something else that Autumn mentions is vitamin B12 deficiency as a potential cause of psychosis symptoms, which is not something I’ve come across before.  However a (non-comprehensive) literature search, brings up a number of results, including this case study of a 16 year old boy.  For me, this is an important reminder to thoroughly check a person’s physical health when they present with psychological difficulties.

Finally I thought I’d point you towards Autumn’s art video, which I’ve not watched properly, but which perhaps reflects a common, but not universal, flip side of psychosis, creativity.

Schizophrenic On a Bad Day

In this video, IhaveSchizophrenia is currently experiencing auditory and visual hallucinations and he posted it in order to try and show what it’s like to function while having such symptoms. He has a voice that tells him do do things and not to do things (known as a command hallucination), and is seeing animals and letters on the wall.  His thoughts are somewhat disorganised and he says he is paranoid – as one might expect when having hallucinations.

Like the two vLoggers above, IhaveSchizophrenia, has a variety of different videos about his experiences of schizophrenia – indeed, he’s truly prolific, with dozens of videos. In the video “What Caused My Schizophrenia“, he talks about how his hallucinations started around age 5, and how they were not associated with any stress that he was aware of.  However, he then talks about how he was very severely bullied for many years and how the death of his grandfather had a serious impact and how he felt that this ‘pushed me over the edge’.  Again, well worth a watch.

Catatonic Schizophrenia

This is a bit of an odd video. It’s mostly a collection of older videos about people with catatonia.  Often these old videos can be rather uncomfortable viewing due to their low production values and questions about consent.  Nevertheless, I think the video provides a useful teaching tool on a symptom that is seen much less that it used to be.

What’s really odd about the video is that it comes with the disclaimer, yet..Screen Shot 2017-04-16 at 13.50.04the people who made the video chose to add spooky music with rather undermines the idea of respecting the patients.  In any case I include it as it could be useful as a teaching aid.

Auditory Hallucination Simulations

These two videos (here and here) attempt to simulate the experience of hearing voices and other auditory hallucinations (they are generally designed to be used with headphones to simulate the stereo nature of some hallucinations).  I usually try to check the comments before recommending any video, and in this case both videos were positively recommended by people who hear voices. Again, these videos should be useful as teaching aids.

Four Patients with Schizophrenia

This is more of a classic teaching video.  It features four different people with a schizophrenia diagnosis who are all currently experiencing symptoms such as paranoia, delusions, problems with attention and cognitive function.  These videos always beg the question of informed consent, however as they are already available on YouTube, I guess we might as well make respectful use of them?

The video is actually compiled from the following sources (1,2,4) and one which I can’t find.

Living With Schizophrenia

A short US based documentary on schizophrenia focussing on recovery.  This one is a classic educational doc, with various talking heads, a patient advocate, a psychiatrist, a clinical psychologist, and various patients talking about their experiences.  It covers a variety of issues including how people can be helped by their family, the different types of symptoms a person might have, the behaviours associated with this, the use of medication.

I have a bit of an issue with this documentary however, stemming from an opening statement that:

Schizophrenia is a disorder of the brain.

My disagreement is nuanced, schizophrenia (accepting the diagnostic term for the moment) is indeed a disorder of the brain, just like depression and anxiety are disorders of the brain.  Just as one’s thoughts are clearly a function of the brain, problems with one’s thoughts will always be a function of the brain.  But schizophrenia is very clearly also a disorder of society, something that this documentary appears to totally miss.  As something of a response to this overly ‘medical model’ approach, which I’ve witnessed time and again, I’ve invented another diagnosis (somewhat tongue in cheek):

IED.  Inappropriate Environment Disorder.

Schizophrenia, like pretty much all the other psychiatric disorders might commonly fall under the category of IED.  Society often triggers psychosis, and then makes it worse by stigmatising the people it has hurt.  The fact that the documentary singularly fails to give real consideration to this is a real shame.   Nevertheless, it’s worth a watch, especially as an introduction to the topic.

I Am Not A Monster: Schizophrenia | Cecilia McGough

Another first person account of schizophrenia, this time a TED talk by Cecilia McGough, an astronomer diagnosed with schizophrenia.

In this talk, she briefly uses one of my favourite ways of demystifying auditory and visual hallucinations:  dreams.  Dreams (and daydreams) show that we all have an inbuilt capacity to conjure up realistic sounding conversations with other people who are not in the room with us and realistic seeming visions of people and objects that are not in the room with us… and when we are dreaming, we don’t realise that we are dreaming.

Strangely, mental health professionals often seemingly fall into the trap of thinking that voices are something bizarre and beyond the understanding of people who don’t experience them in waking life.  We almost start believing that these voices are indeed something supernatural.  They are not.  One possible explanation (which I generally subscribe to) of voices are that they are simply our normal inner world (albeit generally the negative side of it), but that the part of the brain that recognises this fact is somehow offline (like in dreaming) and thus the brain (which always tries to make sense of what it is experiencing), simply comes up with it’s best explanation of what’s happening.  Something like:

Subconscious Brain:  I notice that there are voices, but as far as I’m aware, I’m not currently generating these voices.  Also, I can’t see those people right now.  Therefore these voices must be from real entities that I can’t see.  That could mean: I’m hearing devils, someone has put speakers in the room, or that thoughts are being inserted into my head.
Conscious Owner of Brain: That’s really really scary.

A key part of the talk is about coming out as a person with schizophrenia.  And interestingly, after McGough came out, she found unbeknown to her, some of her friends also had the same diagnosis.  Her mission is to be a patient representative and to confront the stigma associated with the diagnosis.  As part of this she has started a non-profit organisation to help students with schizophrenia.

The voices in my head | Eleanor Longden

Sometimes it snows as late as May, but summer always comes eventually.

A tale of resilience, survival, empowerment and recovery.  Probably one of the world’s most watched talks on schizophrenia, for good reason.  Again the video is from TED, and has 1.4 million views on YouTube alone.

As so often, the ‘psychotic break’ happened in the first year of university.  In her case Eleanor experienced a voice constantly commenting on her activities in the third person, ‘neither sinister nor disturbing’ that seemed to be trying to communicating something about her inaccessible emotions.  In fact the voices only took on a negative connotation once she’d told a friend and observed the negative reaction.

Eleanor talks about how once a person has a diagnosis, often normal behaviours are misinterpreted as aspects of schizophrenia, as the are viewed though the aperture of the diagnosis.  She very clearly describes many of the negative consequences of receiving the diagnosis, from stupid throwaway comments from psychiatrists to physical and sexual assault.  At the same time she pays tribute to those that helped her recover and thrive.

Eleanor proposes that mental health professionals stop asking: ‘what’s wrong with you’, and start asking ‘when happened to you’.  I could not agree more.  She also argues (along with organisations such as inter voice) that voices are a “sane reaction to insane circumstances”, a functional coping mechanism.

Essential viewing

A tale of mental illness | Elyn Saks.

To Work and To Love.  My last video for the post (for the moment), and the third TED talk.  I’m too tired now to provide a good description, but be sure it’s worth a watch. Elyn Saks has a diagnosis of schizophrenia and is a professor of law, psychology and psychiatry – and author of the book The Centre Cannot Hold, which shamefully I’ve not read.  Yet.

Oh before I go, just one more quote… from Saks:

There are no schizophrenics, there are people with schizophrenia, and these people may be your spouse, they may be your child, they may be your neighbour, they may be your friend, they may be your co-worker.

Part 2:

I’ve decided to add new discoveries and suggestions to a separate part 2 post.  Click here to see!

Lithium and A Manic Episode on the Radio.

Screen Shot 2017-04-10 at 21.48.28



It’s been a while now.. but now back to the first purpose of this blog, to share interesting media items related to mental health.  This time something from the wonderful Radiolab.  Here, in a set of pieces called ‘Elements’, the team interview Jaime Low about her experiences with Lithium, and in the process play an old recording of one of her manic episodes.  Well worth a listen, and I think a good item for teaching and it seems also (according to the comments) for some people coming to terms with their diagnosis and medication.


Water Filtration and Autonomy

This post became a bit longer than I’d planned, so I’ve separated it into two parts:

Part 1. Some background to my research on filters.
Part 2.  A description of the various types of filters available and their pros and cons.  To be written!

Potable Water Everywhere.  Not Just a Dream.

Living in a country like Ecuador, where the quality of the tap water is far from assured, leads one to consider alternative options for obtaining healthy drinking water.  In Ecuador, one can generally trust that bottled water is of good quality – while in other countries, one must be more cautious, as bottles may just be filled with tap water.  Regardless, drinking bottled water has unnecessary costs, both financial and ecological.  Ecologically, transporting non-reusable plastic bottles of water is unjustifiable in the majority of situations.  Financially, buying bottled water all the time can be… well just silly.

While I have long used water filters on my travels, two things focussed my mind on water treatment in 2016.  The first was that I was lucky enough to have the opportunity to help build an ‘Earthship’ school in Uruguay in February.  The second was the devastating earthquake that hit the coast of Ecuador on the 16th April.  Both made me think very seriously about one concept in particular: autonomy.  What has become very clear to me over the last year, is that with a combination of fairly basic technology and education, access to cheap clean water for everyone can be more than an aspiration, it can be a reality.

What’s an Earthship?

Earthship in El Bolson, Argentina.
Earthship in El Bolson, Argentina.

The ‘Earthship‘ was dreamed up by the North American architect, Michael Reynolds.  To cut a fascinating story short (sorry)*, Mike was fed up with the wasteful way in which buildings are constructed and run, and thus decided to make something better; this journey eventually led to the Earthship.  Key to the Earthship design are two concepts: 1. Using other peoples’ junk, and 2.  Finding a way to live autonomously and ‘sustainably’.  Mike believes that an Earthship should ‘encounter’ the world, not use it up, nor contaminate it.

Mike on site at the school build

Put briefly, an Earthship is a house that collects its own energy and water, that uses its water intelligently and efficiently and which treats its grey and black-water waste as a resource to enrich it’s environment.  Perhaps most importantly for areas with large temperature ranges, it uses passive solar gain and thermal  mass to do all its heating and cooling.   Often people who live in Earthships also grow a fair amount of their own food.  Importantly, the house does not need to be connected to electricity, gas or water networks.  This has huge advantages for both the environment and for those who live in the house.  In particular once you have built an Earthship (or similar design), you are free from having to pay for electricity, heating, cooling water and sewage treatment.  You now ‘just’ have to think about how to pay for healthcare, education, food and perhaps some fuel for cooking.  Most relevant to us right now however, is how an earthship deals with water, of which more later.

Potable water on the coast of Ecuador.

Before the April 16th Earthquake, people on the coast of Ecuador either relied on rudimentary water collection (pretty rare in Ecuador), rivers, municipal water supplies or bottled water/coke**.  Following the earthquake, those people who were reliant on municipal supplies of piped water found themselves with nothing other than sea water and dirty, untreated river water.  They most certainly did not have control over their own water supply.   Fortunately a rapid reaction by the people of Ecuador meant that supplies of food and water were immediately on their way to the coast, brought by people in their own pick-up trucks.  Indeed, many Ford F150 trucks got their first day’s real work – and went off to do something more appropriate than shopping in Supermaxi and driving to the bar.

It was a beautiful display of shared humanity, but also somewhat absurd.  The shops of Quito were immediately emptied of all their bottled water as millions of bottles, big and small, were shipped to the coast – for weeks and weeks.  In the process the supermarkets and water companies received an lovely earthquake bonus.

Things could have been much worse.

Although the earthquake was devastating and although the death and destruction was magnified by terrible building control, things could have been much worse.  If the epicentre of this earthquake had been somewhere else, such Guayaquil or Quito, we would have been looking at a totally different scale of disaster.  At the time, Quito’s local volcano, Cotapaxi was also threatening to erupt or unleash deadly lahars..  In a worst case scenario, a combination of eruption and earthquake would certainly have overwhelmed the country’s very limited and unprepared emergency resources – and would have left many many people to survive on their own for much longer.

How things can be better with autonomy.

An autonomous house does not rely on functioning municipal water systems. Thus it is the perfect ‘ship’ for surviving after an earthquake (assuming the building survives – which is another topic).  Ruptured pipes?  No problem.  Contaminated rivers?  No problem.

In an Earthship, rainwater is captured from the roof and stored in cisterns, which then feed a Water Organising Module (WOM).  The WOM is a series of  progressively finer filters, which clean the water for washing and, with the finest filter, for drinking.  Such a system has a number of advantages over relying on municipal water.  Firstly, water captured from the rain is about as reliably non-contaminated as one can find.  A municipal water supply can be contaminated at many points, from the input, through the processing stage, though to the delivery pipes.  This contamination can be accidental or deliberate.  When collecting rainwater, the only possible sources of contamination are the atmosphere, the rooftop, the cisterns and the filters.  The only one of these over which the owner has no control is the atmosphere.  Secondly, short of your cisterns being damaged, you will always have water available.

Would an Earthship system be suitable for Ecuador, especially at the coast which is very dry?

Cisterns for the school

The Earthship concept was conceived in Taos, New Mexico, a place with just 50cm of rain per year, most of which comes in torrential downpours.  This is enough to classify Taos as a high altitude desert, yet an Earthship in Taos can collect and treat enough water from its roof to drink, wash and shower all year round.  By way of comparison, Quito gets 100cm and Pedernales, which was close to the epicentre of the earthquake, gets 92cm.  This suggests there is not reason we can’t do the same on the coast of Ecuador, at least in the wetter areas.

I’d consider the Earthship rooftop collection system as the ideal solution for most places, however the full system has one serious limitation – price.  Firstly, one must design a decent rooftop collector with sufficient surface area and which must be made of suitable materials (long lasting, non-contaminating).  Secondly, one needs a large storage capacity, normally in the form of a set of cisterns, which can be expensive.  Thirdly, one needs a filter and pump system.  A second limitation is that all of this needs maintenance – and maintenance requires both understanding and motivation.  This is where a lot of well intentioned NGOs fail… they provide expensive systems that end up being abandoned for lack of local buy in.  Fortunately, however, there are an almost infinite way of adjusting the systems to local requirements.

After the earthquake

Two days after the earthquake, I went down to the coast with a group of local Ecuadorians and a fellow immigrant to bring supplies help build shelters on the coast.  As well as a bunch of shovels, saws and other tools, I had my trusty Sawyer filter.  This meant that instead of using the water that was being taken to give to those affected, I could filter my own water.  It also meant that in the worst case scenario of getting stranded and/or injured in an aftershock, I would have access to clean drinking water as long as I had a source of non-saline water.  One of the sources of water I used was a swimming pool, which got progressively greener as the weeks went on.. but which made a lovely example for demonstrating the filter to local people.  The water goes in green and comes out clear.  I’m just sad now I did not take any pictures.

Seeing the need for potable water, and seeing the incredible waste involved in bringing millions upon millions of tiny plastic water bottles down to the coast, the first thing I did upon my return to Quito was start researching as to what was available in Ecuador by way of water filters.  At the same time, a variety of groups and people started to bring water filters down to the coast (for example Waves for Water).  The majority of these small filter systems came from Sawyer or LifeStraw.

We also saw donations of larger scale systems from countries around the world.  Not that you’d know much about this, as the government seemed keen to take credit for all the work done by other organisations.  Here I should note that the apparent lack of emergency planning by the Ecuadorian government was fairly shocking.  But that’s another post.

It immediately became apparent to me, that all these different smaller organisations were doing pretty much the same thing, but without any coordination.  I therefore tried to put people in touch via WhatsApp and eventually via a Facebook group, which remains active.  If you are interested in joining us, please have a look here.  The group is dedicated to joining all people working with potable water and sanitation in Ecuador.

Delivering the promise of the filters is not easy.

LifeStraw Filter in El Matal
LifeStraw Filter in El Matal

Our group received a small donation of Sawyer filters and an offer of many more.  However, having attempted to train local people in the use of the filters, we realised that getting people to use the filters and use them well was not going to be easy.  Not all of the filters we handed out were actually used, and it was not clear that they were going to be used correctly.  Part of the problem was that in the town of El Matal, in which we were building shelters, people had been given free bottled water, and later, free tanks of potable water.  This, although very welcome, reduced the incentive to use the filters.  We thus decided to hold off until things had settled down before trying again.

We did anticipate these problems, as they are to be expected when such things are delivered rapidly AFTER a natural disaster.  Post-disaster is exactly the wrong time to be delivering new technologies.  The recipients are very unlikely to be in the right frame of mind to want even more change in their lives.  More than anything, they want things to go back to normal.  Thus the best time to deliver these initiatives is likely when people are more settled.

This is not to say that some of the water filters provides were used extremely effectively.  Some of ours were, and various filters provided by other organisations were clearly well set up and well used.  The LifeStraw filter pictured above, was one example of a well organised filter point.  A specific person had been given responsibility, there were clear instructions (in the right language) and a banner clearly advertising where people could get clean water.

Today at the coast.

All of which brings us to today, 8 months after the earthquake.  Having returned to my native Britain for several months, I’m somewhat out of date on how the filter systems that have been provided by the various groups are being used today.  I have my doubts that many of them will be in daily use, but we will need to do more research to find out.

Which means what?

Which means the real work starts now.  Hundreds, if not thousands of water filters have been delivered to the coast, all of which are suitable to provide a family with clean drinking water for years.  The challenge (IMHO!) is to provide workable, cheap systems for collecting and filtering the water.  But perhaps more important is the formidable process of providing proper education about sanitation and correct use of the filters we have provided.

Part Two To Follow:

Part two will actually be the more useful bit for most people. It’s here.



*It’s definitely worth learning more about Earthships. An easy way to do this is to watch the film Garbage Warrior.

**Believe it or not, I’ve met people on the coast who don’t drink water, but just drink soft drinks.  Often coke is cheaper than bottled water.