Like may others, I presume, I have been gripped, horrified and intrigued by ‘The Fall’ BBC 2’s violent and disturbing thriller now well into it’s second series. This is a misnomer really as it is a straightforward continuation of where it left off. BBC this year have stolen the mantle from ITV in producing brilliantly written and acted thrillers that owe much to the success of the Scandinoir thrillers that have had audiences gripped for the last couple of years. The series is dominated by the the central performances of Gillian Anderson (Stella Gibson) and Jamie Dornan (Paul Spector). The premise of serial killer/psychopath does not break new ground and the controversy it has caused has been about its graphic portrayal of violence against women. Little has been made about the fact that the killer is a bereavement counsellor.

I suppose that anything that shows a member of one’s profession as a killer is somewhat upsetting but fair game in the name of art. It did get me to try and think if there are any precedents for this and so far I haven’t been able to find any that are really about therapists. There are heaps of psychiatrists and we need go no further than Hannibal Lector. Psychiatrists, psychologists and nurses abound as murderous sadistic villains. To give the psychologists their due they are mainly portrayed as behaviour modifying agents of state control rather than downright killers. The traditional role of the psychotherapist/psychoanalyst has been that of enlightening the plot and indeed, as in ‘Spellbound’, actually solving the crime. What is also common is an ’acting out’ of the sexual transference as in Spellbound’ (again) and “Prince of Tides’. In ‘Prince of Tides’ more criticism was heaped on Barbra Streisand for the length of her nails than for sleeping with her (sort of) patient. I never quite understood why it was considered so preposterous for a therapist to have long nails!

So ‘The Fall’ does bring us into uncharted territory. Perhaps it is merely personal, but I find Dornan’s character very disturbing because the essence of therapy lies in trust. We no longer implicitly trust the medical profession and in this I include nurses. This is most likely to do with enough awful cases in the news to shatter any previously held automatic trust. After all the well known phrase, ‘Trust me I’m a Doctor’ generally means the absolute opposite. Jokes about therapists tend to be about their refusal to be categorical about anything. You could say that we can be ‘trusted’ not to give a straightforward answer. I am not saying that therapists are above criticism or do not behave unethically and we know there are rogues out there. An area where therapists do get into trouble is when they confuse ethics with morals. This is easily done and most obviously in the area of sexual orientation. I am glad to say that in this country, at least, all the registering bodies have outlawed any therapy that purports to change sexual orientation. It is indeed an offence that leads to having registration withdrawn. Another reason for making sure your therapist has been trained appropriately.

However, I’m now slipping in to defending my profession which is not what I’m really interested in. Perhaps because the nature of our work is that our patients do need to be able to trust us, which isn’t to say they believe we are always right and a good thing too! It is perhaps unthinkable that we could be dangerous as we are mainly non-directive. Nevertheless it does bring up the question could a psychopath train as a therapist and not be spotted? One would like to be able to say categorically no but I’m not entirely sure. We are an eclectic bunch prone to infighting, splitting and acting out. Things that we try to ‘fix’ in our patients but fail miserably at doing in our professional organisations. However, training psychopaths is another matter or is it? When I began training several psychoanalytic trainings were either covertly or overtly refusing to train Lesbians and Gay Men, who identified themselves as such. The grounds were that they couldn’t be ‘successfully’ analysed. Of course Lesbians and Gay men did train with these organisations and what I find astonishing is that they went through their training analysis concealing their sexuality. I have no figures for this but several US analysts have latterly ‘come out’ as gay. So is it stretching the bounds of possibility that a ‘charming’ psychopath could get through unnoticed?

Perhaps a more reasonable explanation is that psychopaths lack empathy and our profession does require at least a modicum of it. This isn’t necessarily the case in either psychiatry, clinical psychology or CBT. The belief in this branch of the field is that they are putting a disorder right and they are the experts. In my work in the NHS, I worked with all these other disciplines and the most empathic practitioners in those disciplines were those who were also trained or wanted to train in a more psychotherapeutic approach. Often because they had had or were having their own personal therapy. In other words they were trained to be much more self reflective.

Back to ‘The Fall’. Forgive me if I now talk about it as if it was real. Paul Spector (Jamie Dornan) is a Bereavement Counsellor, not a psychotherapist so we can assume that he would not have undergone a full training analysis. I know that some counselling trainings only stipulate a minimum number of personal therapy sessions and partly to do with the cost of training trainees will only do that minimum and then grudgingly. However, having worked in Bereavement, I know that often patients are in extremis and the work is difficult because bereavement is something that no one can escape from. We are in essence probably more identified with our patients than in any other situation. Yet the majority of Bereavement work is carried out by trainees or newly qualified practitioners. So, the really awful situation in ‘The Fall’ where Paul Spector is called in to offer counselling to his only surviving victim is truly awful. Yet it makes sense that they would request him as a qualified and experienced practitioner. We know already that he has been sexually aroused by this woman as in Series 1 he doodled pictures of her breasts as he was talking to her and her husband. The husband becomes his first male victim. Of course, his continued ability to get away with his killings will increase his sense of omnipotence which will lead to greater risk taking and he will be caught.

As with all good modern thrillers Stella Gibson (Gillian Anderson) has her own demons and Spector has broken into her hotel room and taken photos of her personal journal. Spector is a great name for this character as spectre like he creeps through Belfast. The series is also littered with references to this still somewhat divided city.

I think this is a great thriller and I particularly like the fact that it has never been a whodunnit. This has opened up the possibility of making the psychopath a much more chilling figure. The series is due to finish just before Xmas and again is Spector like a satanic Santa Claus creeping into houses in the dead of night. I still don’t know whether there are any genuine psychopathic therapists out there. I have heard colleagues in rage saying about other therapists sh/he is a f*****g psychopath, but I don’t think it was a clinical diagnosis!

Happy Christmas and a Good New Year!


Many years ago I wrote a paper with an almost identical title: ‘Gay Men: Gender, Identity and Confusion’. I now find myself returning to this topic. However, this time my primary focus is heterosexual men but that doesn’t mean to say that what I am writing about is not applicable to gay men as well. The difference here is that it is about how men see themselves in relationship to women within the sexual/emotional arena. In writing this I am aware I am entering a very contentious area. At the first psychoanalytic conference I ever attended many years ago. My college and then tutor Haya Oakley began with this wonderful line, “As Scarlett O’Hara said to Rhett Butler, ‘One more turn round the dance floor and my reputation is ruined!’.” I am going to take that turn! Of course her reputation only grew and grew. I am going to take that turn as well but I feel less convinced about my own reputation. However, an ally has emerged in whom may seem unlikely, the actress Emma Watson.

In a simple but remarkable speech to a UN event in New York on the 20th of September she launched the HeForShe Campaign. In fact in reading Watson’s speech I would say that the campaign might be more aptly called HeForSheForHE. What struck me is that Watson is as equally nervous as I am about what she had to say. The gist of Watson’s argument is that equality will not be attained without men being brought on board which one cannot argue with. Watson however goes further and states quite clearly that this also means women have to play their part in their treatment of men and this is the area which makes her nervous. I will now throw my hat in the ring!!

Increasingly over the last few years I have seen a lot of men who have been finding it difficult to maintain, or indeed form lasting relationships. They seem to be echoing Freud’s now notorious statement,”woman what does she want’. I have been wrestling with these men about their totalisation of women expressed as ‘Women do this..’ or ‘Women want that..’. Now one could argue that men have always said this and that is what I have been thinking and tried to shift them into thinking about the possibility of women that are different. I should point out that these are men who are thoughtful and are not chauvinistic. They are from a different generation than me and were born into a world where feminist thought had become widespread. I have to own that as a gay man I am not party to some of their experiences and their experience of women is very different to mine. However, I have not been in sexual/emotional relationships with women and I have gradually realised through paying more attention to popular culture that there has been a profound shift between the sexes. What follows are my thoughts about this and of course there are more questions than answers.

What is certain, however, is that men and boys are in crisis. Boys are lagging behind girls educationally much in the same way before issues of equality were started to be addressed. Today in terms of employment women are still struggling to achieve anywhere near the same pay levels as men and that is appalling. However, that is not the arena I am concerned with here. I am mainly concerned with the world of social interaction and of sexual desire and this is more complex. Suicide rates have always been higher amongst young men and now more men are coming forward with depression and anxiety than ever before. Some of this is doubtless to do with awareness but there is still more stigma for men who have common mental health problems.

A question I have asked myself when looking at popular culture is, ‘Would this be acceptable if it was about a woman?’, and shockingly I have found much that wouldn’t be. I haven’t considered stand up comedy because much of it is ironic to make a point. So for example I have been thinking about advertisements and daytime TV.

There are two phrases, actually they are barely phrases, that sum up one half of the problem and they are, ‘man up’ and ‘grow some’. In my youth they were the kind of thing that men said to other men but now these phrases are increasingly being used by women. What I do know as a gay man is internalised homophobia or as it used to be called self oppression. This leads to a terrible lack of self esteem which is also confusing because in most cases our ‘esteem’ is from what we internalise from the ’other’.

The objectification of women in imagery has long been recognised for the damage it does but little consideration is given to that of men. Now one could say that it is a more even playing field but two wrongs don’t make a right. Perhaps it is worse than that for men because there is the almost universal ridicule of the penis. It is very rare for a man to think he has a beautiful penis. If it’s small it’s an object of ridicule and if it’s large it invokes horror and disgust. We live in an increasingly sexualised world which often focusses on sensation. I leafed through the satellite channels recently and on More4 there was, “The World’s Largest Penis’ and of course on the other side of the coin we have been treated to increasingly grotesque programmes about oversized breasts for years.

Once again this seems to be a balancing out exercise. I was watching, ‘Secrets of the Asylums’ recently and it is a rather tabloid title for what turned out to be an interesting and thoughtful programme. What came to me as I watched it, is that we are not really much better today than the crowds that would flock to Bedlam, but now it focusses more on the physical and the sexual.

What men are growing up with and are constantly being told is how terrible men are.

This can push men in two ways. It can either be denied and reacted against making men even more brutish or internalised, as with the men I am seeing, and creating lack of esteem but mediated by a wish to be better than that. This is the source of the confusion. Perhaps it is exemplified by the term metrosexual which is now, and maybe always was, a term of derision. What it also smacks of is a sense of not really being heterosexual, a bit ‘queer’ of suspect sexuality. OK it focusses on fashion and the use of toiletries but also ‘sensitivity’. A recent ‘pop’ survey of what young women preferred in men found that the majority wanted a ‘cave man’ not a ‘sensitive man’.

A historical complaint that women, quite rightly in my belief, have about men is that they are insensitive and thoughtless and don’t want to talk about feelings. The experience of the men I see, who are sensitive and thoughtful towards women, has been that the women on the one hand think they would make a great friend but lose sexual interest in them. When this happens in relationships this is when the call to ‘man up’ or ‘grow some’ occurs. I haven’t read, and have no wish to, ’50 Shades of Grey’ but as I understand it, it is about a sadomasochistic relationship where a woman is dominated by a man. The female partner of a man I see suggested he tied her to the bed for sex but then told him in disgust to forget it as he wasn’t doing it properly and by that I think she meant brutally enough. Feminist biology, which is a very different kind of anthropomorphising of animal behaviour, describes how females observe the ‘ball clanking’ antics of the males and rather than passively being round up, choose the male for their genetic dominance. Is the confusion of modern man and woman partly fuelled by this biological drive?

On the other side of the coin emotional abuse by men towards women is now thankfully becoming more recognised, but if a man is emotionally abused he is more likely to be described as ‘hen pecked’ which is a criticism of him rather than the woman. There are moves afoot to make emotional abuse a specific crime but it is interesting to note that in the majority of the media it was described as husbands who abuse their wives. The Daily Mirror was a notable exception and their headline was partners who abuse and was not gender specific. The day time press discussion show ‘The Wright Stuff’ is often riddled with these confusions and to be fair to them they do try to get it right. However, it can descend into the ‘double bind’ where men are damned if they do and damned if they don’t. There are often examples where things are said about men that would cause outrage if they were said about women. However, they also said one morning that they longed for the day when we talk about people not men and women.

As part of my thinking about this I watched ‘This Morning’ with husband and wife presenters Eammon Holmes and Ruth Langsford. Holmes plays along being the buffoon but throughout the programme Langsford ridiculed him about his dress sense and ‘life skills’ in general. If this was reversed there would be an outcry about misogyny and sexism. What is disturbing is the normalisation of this within popular culture. They are after all presented as a ‘wonderful loving couple’. This is not what feminism was or is about. The philosophy behind ‘Jerry Springer – the Opera’ was that in contemporary life we all need someone to blame and no one wishes to take responsibility. The show takes it to the ultimate with Jesus and Satan both looking to blame God and God plaintively singing ‘it aint easy being me’.

So the question has to be who is to blame for the current uneasy relationship between men and women? I refuse to point the finger at anyone because we all are. Of course there are gender differences, most are more likely to be cultural rather than biological and I do hold with Judith Butler’d assertion that gender is socially constructed. There may be a simple answer to the current fascination with transgendered people that we now live in a more open and tolerant society or is it symptomatic of something more confused in our society about what is a woman and what is a man? and how they ought to be. The current situation does neither gender any favours but currently it feels like men are bearing the brunt in the sexual/emotional stakes.

If you wish to read Emma Watson’s speech it can be reached at:

July 2014 – ‘All In The Mind’ 25th Anniversary Awards

‘All In The Mind’ was first broadcast 25 years ago and was fronted by Anthony Clare and is now presented by Claudia Hammond. The playfulness of the title reveals the challenging and campaigning nature of the programme and it is interesting to note that not one of the winners comes from the NHS. Listeners were asked to nominate someone or an organisation who had gone beyond the call of duty to support their mental health problems. Apparently, the programme was staggered by the number of responses they received. The winners had all gone beyond what could be expected from the NHS and, indeed, many, but not all therapists.

It was heartening to hear the stories of people who could possibly be written off as too difficult (personality disordered?) or intransigent in their condition. Additionally two of the awards were given to those who work with minority groups and was a strong recognition of the important and necessary work they are doing.

The Professional Award was given to Pat at Nilaari, a Bristol community based support service working primarily with Black and Ethnic Minority Group clients. She was nominated by Mike who credits Pat and the agency with saving his life and society from the person he could have so easily become. He began a life of crime and drugs at the age of 12 and was regularly imprisoned during his young life. He was not diagnosed with anxiety and depression until an episode of drug induced psychosis and was then introduced to the agency. During this time he became suicidal and relapsed into criminal behaviour and was again imprisoned. Pat and the agency never gave up on him and supported him through thick and thin for 15 years. He now works as a mentor for Lawrence Dallaglio’s Rugby for Change organisation.

The Project award went to Brighton based Mindout. An organisation run by and for lesbians, gay men and transgendered people. I know from my own experience of working at and being chair of Riverhouse HIV centre in Hammersmith that a significant number of people with HIV have co- morbidity with mental health and drug and alcohol problems. Many have issues around their sexuality and it makes it difficult for them to get service that is holistic and understands both their physical and mental health. I recall seeing a young deaf gay men in the NHS who also had mental health problems. He lived in a hostel for the deaf and was experiencing homophobic abuse. He had difficulty getting appropriate treatment because mental health services struggled with his deafness. When he was distressed it could be difficult to understand what he was saying which increased his frustration. on one occasion he was turned away from a mental health unit because he was ‘aggressive’.   The nominee, Sebastian, said that it was the first time he had felt understood and he was assigned to ‘allotment therapy’. He remarked that watching carrots grow was far better than any number of SSRI’s.

The Individual Award was given to Steve and was nominated by Andrew. Steve is Andrew’s employer and stood by and supported Andrew through major episodes of bipolar which are often very challenging. Steve saw through the diagnosis to the man and was prepared to give all the help he could to his employee.

Claudia Hammond speaking on BBC Breakfast with Pat and Mike really put her finger on it. She said that unless the NHS are really going to take mental health seriously and offer patients long term and ongoing support then things will never really improve. What would have happened to Mike if he had been left to the care of the NHS alone? It doesn’t bear thinking about. What does concern me is that will projects like Nilaari and Mindout be allowed to continue doing the excellent work they are clearly doing? As funding comes with more and more strings will they be allowed to work as they do or will payment by results kill this off so that the more ’difficult’ and intransigent clients get dropped or are simply deemed unsuitable. This is already happening in the NHS where recovery is all. If you don’t meet the targets for recovery then funding is cut. We were told at Riverhouse that we had to move clients on but, as the project director at the time said, “They’ve moved as far as they can and now need support to stay there”.

The medicalisation of mental health has led to notions of ‘cure’ and ‘recovery’ that are akin to measles and mumps and to seeing medication as the main way forward. This superficially appears to be the best economic option along with short term CBT. Until this is shifted to take in the social aspect of mental health we will never see a great improvement and have a lot of distressed patients. in my previous writing about Barbara Taylor’s ‘The Last Asylum’ I mentioned a moving sequence about her sitting next to a fellow patient, who she was actually frightened of, but felt her human presence a comfort. It is the genuine care and humanity expressed in these awards that tosses aside protocols, that makes that big difference.

June 2014 – Review Of Happy Valley by Sally Wainwright

‘Happy Valley’ by Sally Wainwright on BBC1

This terrific drama series has just completed its run-on BBC1 and has won both plaudits and condemnation for its graphic portrayal of violence women and indeed it has been harrowing stuff. Many have compared it to last years ‘Broadchurch’ on ITV and what it shares in common is the setting of a relatively small community and the concentration on character.

‘Broadchurch’ followed the pattern of a ‘whodunit’ and did not reveal the killer until the final episode whereas Happy Valley was about the plan to commit a crime and its terrible aftermath and consequences. What they share in common is a much more sophisticated depiction of the psychology of the protagonists and their responses to their circumstances. I loved them both, if love is the right word because after each episode I felt like I’d been put through an an emotional mangle. However, I think ‘Happy Valley’ has raised questions on a wider level than ‘Broadchurch’.

Sally Wainwright has a proven track record in television and drama and the Royal Television Society awarded her writer of the year for ‘Unforgiven’. To call her a feminist writer may pigeon hole her but she has always written terrific parts for women and for interesting women. She started her career writing for the northern soaps and this is reflected in the casting of her serial dramas as they often feature ex soap actresses/actors. Most notably Suranne Jones in Scott and Bailey and Sarah Lancashire in ‘Last Tango in Halifax’ and now in ‘Happy Valley’. ‘Happy Valley’ is the darkest of her dramas to date and it does seem to be a progression from Scott and Bailey which contained very dark themes in its last series to date.

My personal test for the quality of a drama is if I begin wondering about the characters before the action and how they arrived at where they were. I have done this in spades with ‘Happy Valley’ and perhaps this is not surprising because the past haunts every character in ‘Happy Valley’. One thing can be said for sure is that ‘Happy Valley’, in reality Hebden Bridge, is not happy. In many ways the town is a metaphor for de-industrialised north in post Thatcher Britain. High unemployment, high levels of drug abuse and a sharp distinction between the haves and have nots. On the one hand there are nice coffee shops and cafés and the squalor of sink estates that are desensitised to drug abuse and casual violence.

How history haunts the characters is gradually introduced and the character of Sgt Cawood played by Sarah Lancashire launches this in the opening sequence which is both comical and grim. A young man is threatening to set fire to himself and Cawood tells him she is divorced, looks after her grandson, doesn’t speak to her son, her daughter killed herself and she lives with her recovering heroin addict sister. Obviously this sets the scene neatly but it also gives the key to the whole series. I am trying not to give away too much plot for those who haven’t seen it. The premise for Cawood is that her daughter was raped by a young man called Tommy Lee Royce who was never charged, but was imprisoned for another crime. Her daughter became pregnant and killed herself days after giving birth to the rapist’s child. She learns that he has now been released and is back in the community. Her grandson who she takes care of is the product of her daughter’s rape. The whole family is haunted by the rape and the grandson, Ryan for some in the family, is representative of this terrible event. Ryan being brought up by his grandmother has caused major rifts in the family including her divorce and an estrangement between her and her son. Ryan is portrayed as a troubled child and possibly leads the audience to believe that it is in his nature to be like his father.

The other historical event which leads to the setting in motion a terrible set of events is the belief by accountant Kevin Weatherill that his father was cheated out of the partnership in Nevison Gallagher’s firm. Weatherill is played by Steve Pemberton in a very creepy performance that echoes his roles in The League of Gentlemen. Weatherill is so eaten up with envy that it confirms Melanie Klein’s view of its murderous nature.

The rapist Tommy Lee Royce played by James Norton, Weatherill and Cawood are brought together for a shocking and terrifying string of events. This is drama and is almost Greek in its unfolding and although in performance it is gritty realism the plot is there to serve a greater point than realism. The acting in the series is exemplary and I’m sure there will be many nominations next year at the BAFTAs. However, I must single out Sarah Lancashire and James Norton who were mesmerising. The casting of Norton is daring because he is disturbingly sexy as well as terrifying. His history is slowly revealed and firstly by him visiting his alcohol and drug ridden mother who both hates and is terrified of him. There is an extraordinary scene in the final episode where we get a glimpse of why he has turned out the way he is. One feels something akin to compassion for him in this scene despite the terrible things he has done and controversially right in front of our eyes. I worked with several men in the NHS who had a history of violence and without exception they were all fragile and damaged. I am not making excuses for them or Tommy Lee Royce or that all violent men are damaged and should be pitied rather than blamed. It does, however, give weight to the psychoanalytic endeavour that the key to the present lies in the past. Tommy Lee Royce is the terrible bogey man of our worst possible nightmare but he was once a child who was terribly damaged. It is a strength of the series that I have been left wondering what happened to him as a child.

The series was full of instances of how a chance remark can lead to terrible consequences and most shockingly when Cawood’s son in a drunken outburst at her birthday party reminds her that she said to him after the suicide of her daughter, ‘it should have been you’. Until this point the dead daughter is presumed to have been a random victim. In the family she was the problem child and, is often the case, her sibling decided to be ‘good’ but got no recognition for it. Cawood has clearly forgotten she said this to her son and her later response is I’m so sorry but people say terrible things when they’re grieving. This in my experience is sadly true.

The violence towards women, and indeed men, in this series was truly horrible but I do not think it was gratuitous. It made a terrible point about how the ravages of a community in decline and sunk into nihilism becomes casual about violence and even jokes about it. It is a horrible perversion of desperate times need desperate measures. As with Greek tragedy we watch as the fates conspire to bring about the inevitable ending. One asks oneself, ‘How did they ever think they could get way with it?’ Sadly, this happens too often but thankfully in not such a terrible way. Perhaps, Tommy Lee Royce, who is actively suicidal by the end, has always been on a ‘suicide mission’.

This has been a wonderful series and restores the BBC’s reputation for producing challenging drama. It also moves Wainwright from her previously more cozy output into a serious force to be reckoned with. My only carp is that there is talk of a second series. I hope they don’t as this beautifully crafted piece of drama would inevitably turn into another ‘cop show’. Let it remain as it is; a tribute to the writing, acting and producing skills of our television industry at its best!

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April 2014 News – Book Review – The Last Asylum: A Memoir of Madness in our Time by Barbara Taylor

Firstly, this is a beautifully written book and for this alone is a joy to read. It is also an important book for anyone who has an interest in mental health. Barbara Taylor manages to pull off a very difficult feat, which is to write a very personal memoir but at the same time write a dispassionate historical account of the history of mental health services from the building of the large mental asylums, to today’s community care. Interwoven with this is her experience of a classic psychoanalysis which, for the main part, is agonising and embattled. Perhaps what is most extraordinary about this analysis is that she never gives up even in her darkest days. She kept a journal throughout her analysis and although she acknowledges that at times this was sporadic, the reader gets a real sense of her experience.

The last asylum, of the title, is Friern Barnet which was originally known as Colney Hatch. Its change of name reminds me how the Windscale nuclear reactor was changed to Sellafield after a leak and it became associated with poor practice. Friern Barnet was, at it’s height, the largest mental asylum in Europe. It opened in 1851 and by 1857 was home to 2000 patients. From the 1970’s onwards it began to decline and finally closed its doors in 1993. It was then turned into a luxury development called Princess Park Manor. It’s reputation is as symbolic as it is actual and features in other works of literature; most recently, I believe, in Will Self’s ‘Umbrella’.

Its most famous architectural feature was the italianate corridor which was the longest in Britain and it is reputed that it would take a visitor five hours to walk all the wards. At the time of construction it was a completely self contained world that segregated the insane from the rest of the world. There would be fetes and open days where the ‘well behaved’ patients would be exhibited to the outside world to show its ’enlightened’ treatment regime. As Taylor points out, if you were moved to the back wards there was little hope of release and patients languished there for decades.

By the time Taylor enters the hospital in the 1980’s, it is in decline and heading towards closure. It was clearly a somewhat terrifying place to be admitted but Taylor’s personal and yet objective account reveals an ambivalence towards it. She does acknowledge that she was lucky to be able to be allowed to continue with her psychoanalysis, as there seems to have been little of ‘the talking cure’ available to the majority of patients. She refers to the hospital as a ‘stone mother’ which is a wonderfully evocative phrase. She certainly witnessed casual cruelty and neglect but despite this she describes something of a community of patients who looked out for each other. Indeed for some patients it really did provide asylum. Interestingly, the 1972 film about the Philadelphia Association’s houses was also called ‘Asylum’ which recognised the need for a place of safety for those with severe mental health problems. These houses fundamental philosophy was one of community and dwelling. There is something very moving in Taylor’s book that community developed in such grim conditions and the comfort that she experienced from some other patients. She recalls sitting next to someone and not speaking but how that was both comforting and containing.

Interwoven with this are her recollections of her analysis and I can’t help wondering whether at times this was making her worse rather than better. Very few people then were undergoing a ‘full analysis’ and I expect the number is even less today. As I have written previously, today we live in a ‘quick fix’ world that five times weekly analysis would be unthinkable to most people. Taylor has done it and has come through it and what she certainly shows is how hard the process can be and this certainly gives the lie to the idea that psychoanalytic psychotherapy is a self indulgent easy ride.

What comes through in her description of her time as a psychiatric patient is that it provided the basic containment to allow her to continue with her tortuous journey through her analysis. It is at the point when there is a shift in her analysis that she gradually begins to separate herself from psychiatric services. Her analysis, however, continues for several years after this point. In between her admissions to Friern Barnet as an inpatient she attends both a day hospital and a number of day centres. She writes wryly about this experience and her ambivalent feelings towards this system. Once again she is able to write a historical account of these services combined with a personal ‘what it was like for patients’. Again this is a strength of the book because it goes beyond being a polemic for any particular view of mental health services. What is clear is that the day centres were much more patient focused and indeed the nomenclature changes to service users. Perhaps what is most striking is the move away from the medical model of biological psychiatry to one which is more about ‘being in the world’. Sadly, this was not to last and all the centres she attended are now closed.

The final section of the book could be described as, ‘So where are we now?’. This makes for grim reading. During my own time of working in the NHS I saw an erosion of the possibility of longer term connection with patients. This coincides with the growth of a business management of the NHS and the internal market. Additionally, ‘Care in the Community’ has led to conflicts between Health and Social Services in to what constitutes healthcare and what constitutes social care. This is well publicised in care of the elderly but it also occurs in mental health. Taylor points out that the obsession with ‘moving patients on’ and preventing “dependency’ often means that patients are at best ill-equipped to live without support, but at worst often still too fragile to cope. It is ironic that in an attempt to de-stigmatise mental health it is now classed as a disability. However, in terms of a physical disability, we understand that by providing ongoing support we enable the disabled to achieve as much independence as they can manage. This is not the case for most mental health patients. The few remaining day centres are either strapped for cash or have closed. Those that remain must demonstrate to funders how they are ‘moving on’ service users. As with the talking therapies this is often very time limited. When I was chair of the board of an HIV organisation which ran a day Centre, the pressure to ‘move people on’ became huge. ‘Moving on’ in this instance was to stop providing service. Perhaps the most valuable service we provided was that of community and our service users, in the main, had multiple co-morbidities. When the service was set up it was their HIV diagnosis that got them service and not any of their other problems. With the arrival of combination therapy, HIV was then deemed a ‘manageable’ disease and gradually there was an erosion of services that provided non-medical social care. Day Centres aka Drop-in Centres became seen as not providing value for money or providing measurable outcomes. The fact that these centres also provided asylum was never taken into account.

The other factor that concerns mangers of mental health services is that of ‘risk’. Now this may appear to be about reducing harm happening to patients, and of course some of it is, but what risk is mainly about is reducing ‘risk’ to the organisation. Taylor makes her concerns about this at the end of the book and I would argue that current mental health services are increasing risk to patients. Patients with florid symptomatology will undoubtedly get at least out-patient treatment but those with persistent and enduring problems are likely to be rejected by secondary care as not being severe enough and by primary care as not able to achieve ‘recovery’. These patients will be left to the care of overworked GPs to manage.

Perhaps Taylor in her title is not only talking about Friern Barnet, but she is also writing about the end of the concept of asylum. This is a great book that is thought-provoking, moving, inspiring and an elegy for institutions that had a great deal wrong with them but nevertheless their closure has left a significant number of distressed people out in the cold.



February 2014 News – Book Review – The Shock Of The Fall By Nathan Filer

This first novel has recently won the Costa Book of the Year after winning Best First Novel. Nathan Filer was a psychiatric nurse so is writing from his own experiences, albeit as a worker, of mental health services. The novel is written in the first person and tells the story of Matthew Homes. The fall of the title is the fall and death of his older brother Simon ten years earlier. Simon was two years older than Matthew and had learning difficulties.

Every book about mental health services has a political element to it and this is no exception although from what Filer himself has said about the novel this may not have been his intention. It is by turns funny, touching and insightful. For me the writing grew in stature as the book went on. Although one’s heart goes out to Matthew he is not a tragic figure and I found the ending inspirational.

The novel is set ten years after the death of Simon when Matthew is nineteen but does give an account of his history from his point of view. Matthew has been diagnosed as schizophrenic and there are some very witty passages about the whole process of diagnosis and what constitutes symptoms. What does come across strongly is the lack of privacy a patient experiences either as an inpatient or as a user of a day centre. Filer describes vividly how the concept of patient involvement in their treatment is actually illusory.    Unlike some other novels it doesn’t resort to ‘splitting’ and staff are not portrayed as villains but as much subject to the system as patients.

In one sequence staff have clearly been told that the day unit is to close but they are having to reassure patients that all is well despite the distress they are experiencing. In another Matthew sees a man he has become somewhat attached to restrained and how different staff react to this. Filer hasn’t written a polemic and by not engaging in the ‘splitting’ he creates a much more realistic picture.

Matthew’s own ambivalence about how he views himself is crucial and moving. After expressing anger or difficult emotions he will berate himself as a bad person. It is set up quite clearly from the onset that Matthew is an intelligent and extremely sharp young man but he is often infantilised by staff and not treated with much respect for his intelligence or insight. Matthew at one point manages to see his notes and discovers that his absorption in the computer is described as ‘writing behaviour’. He then goes on to ponder that perhaps any interest could be pathologised as ‘behaviour’.

Filer, speaking through Matthew, has a keen awareness of some of the absurdities of biological psychiatry and mentions the Rosenhan experiment of the early 1970’s. This famous US experiment consisted of several ‘healthy’ volunteers, including Rosenhan himself, posing as prospective patients with a controlled set of symptoms. When they were admitted as inpatients they found that even their perfectly ‘normal’ behaviours were pathologised. I believe that some of the volunteers at the end of the experiment did find it difficult to get discharged!

There is a horribly funny sequence where Matthew lists all the possible side of his medication and says he has all of them. One can’t help wondering if these terrible side effects would be acceptable in any ongoing treatment other than mental health. Perhaps what comes over strongest is that of the tedium of life as an inpatient. Perhaps even more so for the younger patients and inpatient units are now predominantly filled with the younger less ‘compliant’ patient. Older patients are much more likely to be ‘managed ‘in the community as is illustrated by the pig man in the novel. Additionally, and with much rage, Mathew rails against the awful questionnaires so beloved by CBT and the current NHS.

As for Matthew’s family they have unwittingly contributed to his condition. They are not the grotesquely awful parents of Ken Loach’s, ‘Family Life’. They have been as traumatised by Simon’s death as Matthew. In particular, Matthew’s mother, who he describes as being ‘mad’, becomes so over protective that she doesn’t allow him to return to school and schools him at home until he moves to secondary school. It is very touching how Matthew describes intentionally making mistakes so that she can feel more useful. Matthew’s beloved father slips into a helpless silence which Matthew experiences as another terrible loss.

Fairly classically, Matthew’s schizophrenia emerges in late adolescence and when he leaves home. It is at the point in his life when reminiscence develops and this is when he fragments. Here the actual physical construction of the book is beautifully used. When Matthew is an inpatient or regularly attending the Day Centre he writes on computer and the text is in a standard book font. However when he is not, the text becomes that of the old fashioned typewriter his adoring grandmother buys him. It is here that the extent of his struggles are revealed. It is very revealing about why he has difficulty complying with oral medication and thus, as part of his care order, he is forced to have fortnightly injections. If he doesn’t have medication he has both visual and auditory hallucinations of Simon. Simon repeats over and over to him, ‘We’ll play together for ever’. These bring some form of comfort to Matthew even though he recognises he is no longer the nine year o!ld he once was but Simon. of course, remains an eleven year old boy with learning difficulties.

Several years ago I went to a day conference on risk and risky behaviour. One of the speakers was a young man from an online group of self harmers. He spoke eloquently and movingly for the group. He said something that has stayed with me. He said that to simply remove the ability to cut or self harm was not a good idea as it removed the established coping mechanism and that other ‘healthier’ mechanisms needed to be in place before that could happen. Similarly, Matthew needs to find some way to begin grieving the loss of Simon. In terms of ‘talking therapy’ there seems to be little available and Matthew clearly doesn’t feel safe enough to open up to staff. The medication takes away from him all that he feels he has left of Simon and this is devastating. I have worked with patients who have had baric surgery for obesity who have become suicidal because they have lost the ability to manage their psychological problems. They have lost their only means at that time to stem their feelings of emptiness.

‘The Shock of the Fall’ is a worthy winner of the Costa main prize and deserves to be widely read. Filer has managed to create a very vivid character and explore the devastating effects of trauma on a family. He shows how bereavement can so easily become disordered under these circumstances reveal the state of mental health services today and how it not only affects patients, but staff as well.



January 2014 News – Goldfinch by Donna Tartt – A Book Review

Donna Tartt’s third novel, ‘Goldfinch’, was published at the end of last year. She is not a prolific novelist and it is eleven years since she published her second novel, ‘The little Friend’, in 2002. Her first novel, ‘The Secret History’, was published ten years previously in 1992. I suppose one could describe the genre in which she writes as the literary thriller. It is interesting that ‘The Secret History’ is dedicated to Brett Easton Ellis, author of ‘American Psycho’. Along with Tom Wolfe, they are probably the best known current writers of novels that use pretty sensational plots to comment on contemporary US society. These form part of the genre sometimes known as, ‘State of the Nation’ novels. Perhaps because a new novel from Tartt doesn’t happen very often it becomes something of a literary event.

I have to own, that I too was very excited to discover a new novel was to be published and bought it soon after publication. After ‘The Secret History’ I have always approached her novels with a mixture of anticipation and anxiety. I’m anticipating an enthralling plot and a substantial read, but I expect that I will be put through a story that is disturbing and anxiety making. ‘Goldfinch’ is no exception. It has received almost universally good reviews but they differ somewhat on what the novel is actually about because, as with her previous novels, it does feel like a parable. That it is open to several interpretations does link to the inevitable question, ‘What is she trying to tell us about the the world we live in today?’. It would be easy to say that her view is simply about US society and has nothing to do with ‘old world’ Europe and indeed some of the extremes she writes about perhaps seem very alien to us.

As the book is a kind of thriller I am going to try and give away as little of the plot as possible, so as not to spoil the experience for anyone wishing to read it. As with her previous novels, ‘Goldfinch’ has themes that are particularly interesting for those interested in psychotherapy and, dare I say it, philosophy.

The premise of the book is interesting in that it pits an actual priceless painting against an imaginary event. There is a painting called Goldfinch but there has never been a bomb attack on The Metropolitan Museum of Art in New York. Actually, it is never fully identified as the Met and is simply called the Museum. It is also never revealed what the bomb attack was about. All of this takes place within the early chapters of the book. The protagonist of the book, 13 year old Theo, is visiting the museum with his mother because she has loved the painting since she first saw it in a book, and it is now on show in New York as part of a visiting exhibition. Theo survives the attack relatively physically unscathed but his mother dies. He regains consciousness and in the aftermath is given the Goldfinch by a dying old man.

This may appear to be a lot of the plot that I am giving away, but this all happens within the early section of the book. What Tartt goes on to explore is the nature of loss and what ‘value’ is placed on loss. The loss of the painting by society is attributed as being a loss beyond monetary value and irrecoverable, but the loss of Theo’s mother is something that the ‘authorities’ feel he should recover from. The therapy and social work he receives or, perhaps, is subjected to, do not appear to help at all. Theo becomes a ‘problem’ that must be sorted. It is only now that I am writing this that I realise that the reason for the bombing is never explained nor is there anyone brought to justice. The loss of the incredibly valuable painting remains frequently in the news despite the passage of time.

Theo becomes a ‘displaced person’ and along the way he meets other displaced and ‘lost souls’. He forms a strong bond with a young motherless Russian boy, called Boris, who is probably the most fascinating character in the book. There is a kind of sexual tension between them that is never fully expressed, but the bond they have is certainly love, but it is a negative identification. This relationship is destructive and sets the tone for a kind of ethical bankruptcy which is a major theme running through the novel. The world that Theo finds himself in and indeed partly creates for himself is where worth is nothing more than money. It is a world of selfishness, greed and betrayal, and the honourable are few and far between. The novel offers little of redemption however hard Theo tries. There are two characters who are the exception to this but I will not name them as the novel does not make you feel secure that this will be the case. It is a grim picture of a world that is nomadic, where any sense of loyalty has become perverse. This is particularly true of the extraordinary Boris who it could be said is a kind of a metaphor for the new capitalist class of the former Soviet block.

Tartt seems to be demonstrating on an International scale that we know the price of everything and the value of nothing. This is a bleak view and the world in which it takes place may feel alien from our own. But is it? Are we in danger in a consumerist society of valuing the material over the personal? I would hope not. From a psychotherapist’s perspective, are both Theo and Boris engaged, singly and in a ‘folie à deux’, in a manic defence against loss? In a very moving sequence at the end of the book, it is clear that Theo has never been able to begin grieving for his mother. Additionally, both the boys are presented as homeless, but only Theo brings this into consciousness. Boris has converted his homelessness into a kind of amoral bravado. Once again, Tartt has written a compelling and challenging novel where there are no comfortable endings but there is much to ponder.

November 2013 News – Who Cares In The NHS?

I retired from the NHS on Friday the 1st of March. I had worked initially as a sessional Psychotherapist for an individual GP Practice and following the formation of the Primary Care Trusts in 1984 joined a managed Counselling Service. I retired not simply because I had reached retirement age but because the levels of stress being placed on clinicians was becoming intolerable.

I had been encouraged to write about my experience of the new NHS by friends as soon as I had decided to retire and had thought it might be of some interest but events in the media have changed my feelings about this. First of all there was the publication of the Francis Report and then the trial and conviction of Nicola Edgington.    You may remember Ms Edginton was a diagnosed schizophrenic who had previously murdered her mother. She had contacted mental health services because she was experiencing a return of her symptoms. She was not admitted and a few days later semi-decapitated a woman in a car park. Marjorie Wallace of Sane when referring to the latter pointed out that if a woman who had a diagnosis of schizophrenia that resulted in her murdering her mother could not be contained in a safe and secure environment then what hope for all the more common patients who present no risk to others. However, they may pose a considerable risk to themselves. This immediately links these two separate events to a failure of care within the NHS.

Does this mean that clinical staff within the NHS too often don’t care about their patients? Do we have a new breed of staff who just want to do the minimum and take home their inflated salaries and wait for their over generous pensions? In my experience neither of these statements are true. Of course there will be clinical staff who fall below standards of what we should rightly expect but from what I have observed these are few and far between. The vast majority are deeply committed to their patients and try to do their best for them. I can only speak from direct experience about Mental Health Services but the culture in which they are run can be applied to aspects of the NHS.

So what has happened to care? Before I offer my thoughts on this perhaps it is important to think about the NHS as an institution. I was born in 1948 and have never known a world without it. I take it for granted, quite rightly I believe, that it will take care of me and the nation from cradle to grave. It is a monolith and considering that of all public services it is the one that the vast majority of citizens will have experience of. Even those with private health insurance mainly use an NHS GP service. Yet it lacks the accountability that local authority services have by being run by elected members. It is only accountable nationally. However, many attempts to devolve to a more local level have made the situation worse.

This stems from the philosophy of the internal market that was introduced in the Thatcher era and taken up and advanced, sadly, by the Blair Government. This has led to money washing around and creating credits and deficits all over the place. What is much worse, however, is how it pits Trust against Trust with individual organisations vying with each other for contracts. The language is of commerce not health. In corporate speak we now hear mainly about customers and not patients. Patients are lumped in with anyone that has dealings with the NHS. I worked for Central London Community Healthcare Trust which provides clinical services in Primary Care to the London Boroughs of Hammersmith, Kensington and Chelsea, Westminster and Barnet. On their launch they trumpeted in a staff wide email that they wished to be like CocaCola and Disney. Not what I wanted to hear about an organisation that was going to be providing fundamental and vital services to people who could often be very vulnerable and not empowered.

There has subsequently been a drive to obtain Foundation Trust status which is the so called gold standard. This partly involves showing the organisation being financially viable ie having a healthy bank balance. This is achieved by making year on year cuts so saying there are no NHS cuts is just not true. This in itself can have an impact on clinicians’ ability to care as their patient load increases but the added factor which is making a significant impact on clinicians ability to care is data! Data is needed to obtain and I presume retain Foundation Trust status. I remember at one team meeting we were told, “You are not producing enough data!”.

The collection of data is inextricably linked to targets and outcomes and much is misleading to the point of being clinically fraudulent. The Labour Government were obsessed by targets. My belief is that they were determined to show that they were not Old Labour who just spent willy nilly and couldn’t be trusted with the economy which has reared its ugly head again following world financial collapse. The Conservatives promised before the election that they would do away with this culture. On the contrary, since they have been in power the amount of data required to be collected appears to be increasing on a monthly basis.

The philosophy now is that if it hasn’t been recorded it never happened! Much of this stems from that awful phrase of John Reid’s, “Fit for purpose”. The need to ‘prove’ that you are doing the work of course means that it takes away from time to actually do the work. However, in many instances this leads to a pile up of admin and little or no time to actually think or reflect on the work. This reduces everything down to a task. I would propose that caring is beyond a task it is a state of being with patients. Staff and patients in the NHS come well below the requirement to provide data. You can record that you have done a task but how do you record meaningfully that you have done it in a caring fashion? Patients are also asked to fill satisfaction questionnaires for most services they receive. I cannot speak for Secondary Care but this is becoming the norm for Primary Care.

If you transpose this to staff on a ward they may have to record that they have delivered food to a patient and at what time but how can we tell how that food was delivered? If staff are under pressure to fill in forms they will have to log in to their computers . The computer most likely will have logged them off because they have been away for twenty minutes doing clinical work. Therefore what becomes uppermost in the mind of the staff is the admin and not the patient because this is what will get them grief from their managers.
At the last staff meeting I attended we were handed a sheet of paper that was merely a series of numbers and could have been about anything. These numbers contained nothing about the highly skilled and dedicated work of the clinicians but represented response times, length of treatment (too long is bad) and recovery rates. Mental Health is highly complex and it is increasingly being reduced to simplistic diagnoses which are always highly subjective anyway.

Whilst I am all for accountability and high professional standards the monitoring and evaluation takes precedence over all. Treatment within the NHS is becoming increasingly burdened by clinical governance and manualised treatments. Staff are reprimanded for stepping outside these protocols. By its very nature care involves stepping outside these boundaries and is what used to be called,”Going the extra mile”. No one is going to do that if they fear that they will be disciplined for it. It is my belief that it isn’t that clinicians don’t care but the systems and structure make it extremely difficult.

October 2013 News

Site Trauma Conference

The Site Trauma Conference took place last Saturday and, as always, it was challenging and thought provoking. It highlighted how trauma has more than one face and how, particularly, in a world of twenty four hour media it is played out both publicly and privately. I canʼt help feeling that the thirst for immediacy from the media is a trauma in itself and that people can find themselves giving interviews to the media when they are not truly able to give consent. Writers are very aware of this intrusion and its effects and an example of this would be the television series Broadchurch which presented a collective trauma.

On the night before I attended a screening of an Israeli Documentary about holocaust survivors and their children. What it illustrated so vividly was how trauma is passed on and down through the generations. What it also showed was that speaking about the trauma in itself is not enough. The speaking of the holocaust by the survivors may ease the symptoms of trauma for them but it quite clearly had traumatised their children. I fully support that it must be spoken of in a very public way but perhaps more care needs to be given to children and grandchildren of survivors. You may think that this only applies to families of holocaust survivors but these kind of horrors have continued and are continuing albeit not on such an industrial scale. In my work in the NHS it was not particularly rare to speak to refugees who were survivors of some horrific atrocities. Not all of these are well known but it is a grave concern that the trauma will be passed down to their children.

The Site Conference itself, in general, focused on a more meta-psychological understanding of how trauma is constructed and processed. The phrase, the image, whatever you wish to call it, came from Rob Weissʼ paper, that has stayed with me. He described how when something like a painting or a childʼs drawing is removed from the wall it leaves a trace. It is gone but something of it remains and can be both seen and not seen. Perhaps, this an important clue to working with trauma. Perhaps we are often dealing with the very vivid trace but not always the trauma itself. I have a personal experience of this. I was badly scalded two weeks before I was two and this forms my earliest memory. I donʼt recall being scalded at all but I remember the seconds before it and again a memory from my recovery and they are not bad memories. So all that remains for me are the traces and I have to say, in my case, I am glad that it is so.

Literacy and Numeracy

There has been a lot of wringing hands in the press and television on Englandʼs place in the international league tables on numeracy and literacy published by the OECD. England was the only country in the UK to submit data so we must assume that the rest of the UK would have achieved a similar place in the tables. England was placed 21 out of 24 for literacy and 22 out of 24 for numeracy. Inevitably, it is back to failing schools, failing teachers and even sometimes failing parents. Nowhere has there been less than a cursory nod to the developmental psychology of children.It is well acknowledged that children in Finland do considerably better than children in the UK and it is also acknowledged that they start school at the age of 7. We have a school starting age of 5 or do we? We have a school starting age of children who are 5 during the school year. In other words, there are some children starting school who are only just turned 4. You donʼt have to be a child psychologist to know that childrenʼs development is rapid at this age. Is it possible that children are getting left behind simply because they are not ready? If you factor in the additional pressures of stats and key stage indicators on both children and teachers is something going awry?

In James Davies book ʻCrackedʼ on page 41 he reports on a Canadian study of 1 million children in which they discovered that the increase in diagnoses of children with ADHD correlated strongly with their age in the school year. The study saw a marked increase in diagnosis of children born later in the year and this rose month by month. What is worrying about this is that these children are being pathologised and even worse being medicated. Perhaps all that is wrong is that they are just not able to concentrate because they are too young. I cannot help wondering if this cannot be transposed to our literacy and numeracy problems.

I went to a small village school when I was 5 and I mean 5. I was born at the end of February and I started school after Easter and it was the same with all my classmates. I am a baby boomer so there was considerable pressure of numbers on this tiny 3 classroom school. I certainly believe my teachers were good but they probably werenʼt outstanding. I couldnʼt read or write when I went to school, I might have been able to count but I donʼt recall. What I do recall is that I developed a love of reading that has never left me. We didnʼt have class positions or school reports or parents evenings. I passed the 11+ and went to the Grammar School but many of my classmates didn’t and that has made me a firm believer in comprehensive education. However, as far as I am aware no one left my primary school without basic literacy and numeracy. I believe that this was influenced by our age when we started but also the teachers had the freedom to teach us in a fluid way that was organic and in no way anxiety inducing. I think that began to be lost at the same time as our place in the league table started to drop.

A Warm Welcome

Welcome to the News section where I will be keeping you up to date with what I am doing and my interests in the field of psychotherapy. There will be discussion of what current affairs have struck me as interesting from a mental health perspective.

This page will hopefully keep you informed about what I am up to professionally but I also want it to be much more eclectic than simply publicising upcoming events.

I will also be sharing my thoughts on current reading that has inspired me. This could be psychoanalytic texts and non-fiction but could equally be novels that illuminate the human experience. Additionally I hope to comment on theatre, film or TV that I have found provocative or stimulating.

I’ll be updating the News sections on a fairly regular basis and Steph, my web designer, will be pushing me to make sure that happens!

News Round-up

Publications and Reading

Professionally, for the last few months I have been involved with James Davies as I am very passionate about his latest book, ʻCracked – Why Psychiatry is Doing More Harm than Goodʼ.

Links to purchase via Amazon Bookshop: Paperback | Kindle

You will see from my publications page that I have a review of the book and an interview with James about to be published.


For colleagues I would like to draw your attention to the Site Conference on Trauma – ʻCanʼt we just let the past Be the past?.
ʼ Why we need to talk about trauma, and what might happen if we donʼt. Keynote speaker: Karl Figlio.

This is being held at Resource for London, Holloway Road, London N7 6PA on Saturday October the 5th 2013 from 9.30am to 4.30pm.

Site conferences are always lively affairs and are often challenging to accepted norms around the therapeutic endeavour. For further details contact: or