What is love?

“… romantic love is a syndrome because it is an arational, projected attitude with a plethora of symptoms that vary across cultures and individuals. Some core symptoms have been identified by Tennov’s concept of limerence, including obsessive thinking and idealization.”

“… all norms applicable to romantic love are extrinsic rather than intrinsic to it because romantic love is arational. For this reason, it is up to the lovers to accept, reject, and modify the norms that govern their loves.”

This looks an interesting doctoral thesis, by Arina Pismenny (2018), The Syndrome of Romantic Love.

A psychoanalyst walks into a bar(red subject)

A psychoanalyst walks into a bar with a book on logic and set theory. He orders a whisky. And another. Twelve hours and a lock-in later, all he has to show for the evening is a throbbing headache and some indecipherable nonsense scribbled on a napkin.

That’s the only conceivable explanation for these diagrams from The Subversion of the Subject and the Dialectic of Desire in the Freudian Unconscious, by Jacques Lacan (published in the Écrits collection):

But, I hear you ask, surely this notation means something? After all, Lacan is famous and studied across the world, and f(x) is well-recognised as a function, f, applied to argument x. So the I(A) and s(A) must mean something?

Here is a brief interlude on functions. The Fibonacci sequence, which pops up in all kinds of interesting places in nature, can be defined as following:

f(0) = 0,
f(1) = 1,
f(n) = f(n-1) + f(n-2), for n > 1.

In English, this says that the first two numbers in the sequence are 0 and 1. The numbers following are obtained by summing the previous two: 0, 1, 1, 2, 3, 5, 8, 13, 21, 34, …

If you tell it a number (e.g., 0, 1, 2, …) then it replies with the respective number in the sequence (first, second, third, …). It might look a bit scary if you haven’t seen the notation before, but check out these examples demonstrating how the arithmetic is carried out:

  • f(0)  =  0
  • f(1)  =  1
  • f(2)  =  f(1) + f(0)  =  1 + 0 = 1
  • f(3)  =  f(2) + f(1)  =  1 + 1 = 2
  • f(4)  =  f(3) + f(2)  =  2 + 1 = 3
  • f(5)  =  f(4) + f(3)  =  3 + 5 = 5
  • f(6)  =  f(5) + f(4)  =  5 + 3 = 8

The point here is that the function notation “does something”. It provides a way of defining and referring to (here, mathematical) objects.

Less well-known, but appearing in university philosophy courses, is the lozenge symbol, ◊, which means “possible” in a particular kind of logic called modal logic. It seems plausible that there is something meaningful here in Lacan’s use of the symbol too.

Here is Lacan, “explaining” his notation for non-mathematicians:

Huh?

Lacan doesn’t try to explain what the notion means; he doesn’t seem to want readers to understand. Maybe he is just too clever and if only we persevered we would get what he means. However, elsewhere in the same text Lacan uses arithmetic to argue that “the erectile organ can be equated with √(-1)”. Personally, I am unconvinced.

Alan Sokal and Jean Bricmont have written a book-length critique of Lacan’s maths and others’ similar use of natural science concepts. Having read lots of mathematical texts and seen how authors make an effort to introduce their notation, I think it’s entirely possible Lacan is a fraud. That might sound harsh, but just look at how he writes. I reckon anyone can see for themselves that Lacan is writing nonsense if they take a look and forget for a moment how famous he is.

 

Lightly edited 18 Sept 2018, hopefully making clearer!

NHS England mental health clustering implementation “disappointing”

A document is circulating from NHS England and NHS Improvement (13 Aug 2018) on the current state of payment systems and clustering in mental health services in England.

It cites “local pricing rule 7” from the 2017/18 and 2018/19 National Tariff Payment System (NTPS) and reports on a survey of progress towards implementing the rule.

Here is what rule 7 said (p. 114):

Rule 7: Local prices for mental health services for working age adults and older people
a. Providers and commissioners must link prices for mental health services for working age adults and older people to locally agreed quality and outcome measures and the delivery of access and wait standards.
b. Providers and commissioners must adopt one of the following payment approaches in relation to mental health services for working age adults and older people:

i. episode of care based on care cluster currencies
ii. capitation, having regard to the care cluster currencies and any other relevant information, in accordance with the requirements of Rule 4(b) to (e)
iii. an alternative payment approach agreed in accordance with the
requirements of Rule 4 (b) to (e).

Commissioners and providers (233 in total) were asked, “What payment approach do you have in place with your contracts for working age adults and older people in 2017/18?”

Here are the results:

So only 14 out of 223 responses (6%) reported a move away from block contracts – the whole point of the new payment systems! The report notes, “The results were disappointing.”

Reasons given by respondents for the poor implementation included:

  • “limited local capacity to implement a new payment approach”
  • “lack of shared confidence in cost and activity data”
  • “uncertainty about how the proposed payment approaches would relate to the new operating models that would develop as part of integrated care systems.”

Services are supposed to be “clustering” the patients they see, irrespective of whether the clusters are used for payment. Rule 6 (p. 114):

Rule 6: Using the mental healthcare clusters
All providers of services covered by the care cluster currencies (see Annex B3) must record and submit the cluster data to NHS Digital as part of the Mental Health Services Dataset, whether or not they have used the care clusters as the basis of payment. This should be completed in line with the mental health clustering tool (Annex B3) and mental health clustering booklet to assign a care cluster classification to patients.

The research on clusters is damning. A recent study (Jacobs, et al., 2018) found that clusters were not very good at characterising the costs of different kinds of treatment and support (p. 7):

“Clusters are therefore not performing very well as a classification system to capture similarities and differences between patients. The categories of the current classification system appear to be neither case-mix nor resource homogeneous. We find evidence of large variation in terms of activity and costs within clusters and between providers.”

Surprisingly, the authors argue that clustering should continue (p. 7):

“… any payment approach needs to be underpinned by a solid classification system and to abandon the clustering approach now will thwart all progress. The clustering approach is already relatively well-established among most providers. Scrapping it all and starting from scratch risks putting mental health services back a decade in terms of developing a more transparent and fair funding system.”

Given the survey results above, it’s unclear how much progress would actually be thwarted by ditching clusters.

 

If you enjoy this sort of thing, you might also be interested in:

Mr Justice Mostyn vs. vague, rhetorical applications of theory

A court case (GM v Carmarthenshire County Council [2018] EWFC 36) has ruled that a social worker’s “generalised statements, or tropes” based on attachment theory are not admissible evidence.

The full judgement by Mr Justice Mostyn has interesting thoughts on the valid application of theory and balance between theory and observation.

“… the local authority’s evidence in opposition to the mother’s application was contained in an extremely long, 44-page, witness statement made by the social worker […]. This witness statement was very long on rhetoric and generalised criticism but very short indeed on any concrete examples of where and how the mother’s parenting had been deficient. Indeed, it was very hard to pin down within the swathes of text what exactly was being said against the mother. […] [The social worker] was asked to identify her best example of the mother failing to meet L’s emotional needs. Her response was that until prompted by the local authority mother had not spent sufficient one-to-one time with L and had failed on one occasion to take him out for an ice cream. […] A further criticism in this vein was that the mother had failed to arrange for L’s hair to be cut in the way that he liked.”

There is also a detailed section on attachment theory:

“… the theory is only a theory. It might be regarded as a statement of the obvious, namely that primate infants develop attachments to familiar caregivers as a result of evolutionary pressures, since attachment behaviour would facilitate the infant’s survival in the face of dangers such as predation or exposure to the elements. Certainly, this was the view of John Bowlby, the psychologist, psychiatrist, and psychoanalyst and originator of the theory in the 1960s. It might be thought to be obvious that the better the quality of the care given by the primary caregiver the better the chance of the recipient of that care forming stable relationships later in life. However, it must also be recognised that some people who have received highly abusive care in childhood have developed into completely well-adjusted adults. Further, the central premise of the theory – that quality attachments depend on quality care from a primary caregiver – begins to fall down when you consider that plenty of children are brought up collectively (whether in a boarding school, a kibbutz or a village in Africa) and yet develop into perfectly normal and well-adjusted adults.”

Much to discuss!

On evidence in psychological therapy

It sometimes feels that the demand for evidence for psychological therapies is seen as offensive. How dare researchers, commissioners, and policymakers reduce therapeutic relationships to tickbox questionnaires and symptom reduction! Therapy is something larger, broader, more holistic than that.

There are clearly problems with using short questionnaires consisting of a handful of closed-questions, and then summing these to a distress score before and after care. But the other extreme, trusting the professionals who are paid to provide therapy to say how effective their therapy is, doesn’t sound convincing either – especially for therapists in private practice who charge by the session. If a therapist depends on long-term therapy for their income, it might be challenging for them to think through different perspectives on how helpful their brand of therapy actually is.

Improving Access to Psychological Therapy (IAPT) is criticised for being heavily manualised, too brief, and offering only a narrow range of therapeutic approaches. However, perhaps IAPT is helpful for some people; for instance people experiencing panic attacks triggered by certain situations or specific phobia, in the context of an otherwise typically but not unusually bumpy life. The research evidence and testimony seems to lend support to this.

I am particularly suspicious of wealthy “woke” psychoanalysts arguing passionately for their Freudian or Lacanian approach. People can need long-term – in some cases life-long – and frequent support, especially for conditions and predicaments which have complex causes and in the context of brutal cuts to social security (welfare “benefits”). It is not obvious that this support needs to be steeped in psychoanalytic jargon.

Having someone there who is kind, listens, and is trustworthy might make all the difference to someone’s quality of life and ability to survive a harsh world. There is no need to run a multi-million pound clinical study to demonstrate the efficacy of kindness. However, therapeutic relationships need to foreground honesty concerning their limits. A paid professional who is there for us each week is not the same as a friend, and that needs to be clear before a relationship begins.

How to find money to save the NHS

This morning was the launch of the Resolution Foundation report, Healthy finances? Options for funding an NHS spending increase – a response to the rumoured government “birthday present” for the NHS as it turns 70 on 5 July 2018.

The audience included party advisers (I spotted a Whatsapp group chat for a party’s comms team), people from various think-tanks, academics (including an Emeritus Professor from Imperial who had a lot to say), and a representative from at least one (non-militant, at least in the room) campaigning group.

The line up:

  • Sarah Wollaston MP, Chair of the Health Select Committee and medic who worked as a GP up until 2010. (Given her generally sensible views, I keep having to remind myself that she’s a Tory).
  • Jon Ashworth MP, Shadow Secretary of State for Health, who has a long history as a Labour professional, including as Special Adviser in the Treasury for Gordon Brown.
  • Ben Page, Chief Executive of Ipsos MORI and fellow of the Academy of Social Sciences.
  • Matt Whittaker, Deputy Director at the Resolution Foundation, who previously worked for the House of Commons Library where he provided stats and economics advice.

The event was chaired by Torsten Bell, Director of the Resolution Foundation, former adviser to Ed Miliband (and, incidentally, architect of the Ed Stone).

Interlude: What is the Resolution Foundation?

The launch was set at Resolution HQ in a bright, wide room, with cosy luxurious seats which wouldn’t be out of place in an up-market indie cinema, so I was curious who they are and how it’s all funded.

Resolution Foundation’s website describes it as “a non-partisan and award-winning think-tank that works to improve the living standards of those in Britain on low to middle incomes.” In their most recent annual report, they defined “low to middle” as those in income deciles 2 to 5, whom they say are overlooked in policy debates. Their focus is on working households.

They receive most of their funding via donations from Resolution Trust, founded by Clive Cowdery with a £50m donation, “believed to be one of the largest endowments for public policy research made in the UK”.

Cowdery made his wealth from “sponsoring insurance vehicles” (an FT article says more) and is also founder of financial services investment firm called (again) Resolution.

Resolution Trust backs Prospect Magazine and, intriguingly, WorkerTech, which seems to be about encouraging alternatives to trade unions for the precarious world of Uberified work. (Here are slides from its launch.)

What did they say on health funding?

All agreed that the NHS needs more funding, so the question is how much more funding and where the money is coming from. The issue was framed as a tug-of-war between Treasury and Jeremy Hunt (with Hunt wanting more money, in case not clear – it’s not always obvious), constrained by a complex parliament and a wish to keep voters happy.

Matt Whitaker took us through some headlines from the Resolution report, emphasising that it was a prediction of what the government was likely to announce rather than what it should do. (Though it sounded very much like advice.)

Borrowing was seen as likely necessary, so long as the total was below 2% of the projected GDP in 2020-21 (to meet a Tory fiscal target). But borrowing alone would not suffice, so some sort of tax raise is almost certainly on the cards – the problem is how to keep keep Tory voters and donors on side, whilst getting it through parliament.

One possibility is increasing National Insurance contributions (or NICs, pronounced “nicks”), which Gordon Brown did when he was chancellor. This is a progressive tax for workers; however, increased NICs was seen by the report authors as “unfair from a generational perspective” since older people who rely more on healthcare don’t pay national insurance (this generational perspective might need some analysis). A solution proposed was to extend NICs to include those above state pension age who are still working.

Increasing income tax could be another way to get the money. LibDems and SNP might support this, and Scotland recently introduced a change to its tax bands meaning some pay more and others pay less tax. Labour, the authors argue, would likely oppose increases for anyone earning under £80k and some Tory MPs might oppose too.

Another approach suggested was to adjust thresholds for (i) when income tax is payable and (ii) the higher rate of payment. Threshold changes were Tory manifesto promises, but the authors suggest a fiddle (p. 24):

“An alternative approach would be to lift the Income Tax thresholds to those pledged in the manifesto in 2020-21, but to freeze both them and the NICs thresholds in the final two years of the parliament. This would of course cost money in 2020-21, but by 2022-23 it would raise £3.7 billion relative to the default of uprating in line with inflation every year.”

Another promising source of funding would come from reversing George Osborne’s 2016 pledge to cut corporation tax by 2020. This tax uncut could provide £5.2 billion in 2020-21 and £5.7 billion by 2022-23. Other political parties would likely support the move and the authors argue (p. 27):

“The Chancellor might also feel emboldened to act given the way in which the estimated costings of the move from 19 per cent to 17 per cent have shifted since George Osborne first announced it.”

Remarkably little was said about Brexit. Will it torpedo all the projections and render the suggestions (sorry, predictions?) unimplementable? The exception was Sarah Wollaston, who noted that she never believed the infamous £350m bus claim; she expressed reasonable worries about the effects Brexit would have.

What might more money mean for mental health?

Although the focus was very much top-level – where’s the money? – speakers did say a little about how it should be spent. For instance, Jon Ashworth quoted numbers on additional doctors and nurses required (it’s thousands), citing a report from IFS – also cited by Sarah Wollaston.

Reassuringly, mental healthcare was mentioned a few times as being important and in need of improvement (though note the history of “warm words”). Ben Page cited public support for increased spending, with mental health being second on the list in an April Ipsos MORI survey of priorities, after Accident and Emergency. Jon Ashworth mentioned improving support for addictions, in particular.

Sarah Wollaston cited the Health and Social Care Committee’s report into integrated care, published yesterday, which discusses detailed contractual changes needed to improve how, e.g., mental healthcare integrates with other services, including discussion of accountable care organisations (ACOs). (Perusing this report just now highlights how difficult it is to have public debates on these issues – it’s technical stuff.)

The coming weeks as we approach July 5th would be a good time to campaign for key specifics on how much money mental healthcare should receive and what it should be spent on. If the NHS received £20 billion more in 2022-23, how much should go to mental health and where?

Vote Labour… but…

I am writing to tender my resignation from the Labour Party and to inform you that I have cancelled my direct debit.

I will continue to vote Labour and support many of its policies and its much-needed shift Left. However, I am opposed to Labour’s approach to Brexit – and I have been patient. I have gradually but now completely lost faith in the leadership.

  1. The Brexit ballot was only advisory – even Farage accepts that.
  2. Leave misused official statistics to lie about £350/week for the NHS.
  3. Leave.eu broke electoral law.
  4. All convincing estimates point to Brexit being a disaster for the economy.
  5. There’s a high risk the Northern Ireland peace process will be harmed too.

Corbyn was too quick to call for triggering article 50. Since then Labour’s approach to Brexit has been confused, putting it mildly.

There is enough evidence now to consider the “will of the people” to be uninformed at best and deliberately manipulated through lies and cheating at worst. Brexit could and should be stopped.

I initially joined Labour in 2010. After a brief spell away, rejoined to vote for Corbyn in 2015. I voted again for Corbyn in 2016. For what it’s worth, I wrote a non-resignation letter nearly two years ago in support of Corbyn. I was hopeful for the party and supported Corbyn despite numerous criticisms.

It’s great to see the membership grow and surely Corbyn deserves praise for enabling this. I’m just not convinced that the Corbyn, McDonnell, and Abbott leadership are electable, and mainstream media bias – though partly responsible – is only a partial explanation.

The problems are too many to enumerate. Salient and illustrative examples include Corbyn refusing to condemn the IRA for its bombing campaign which killed civilians; sharing a platform with SWP members despite being asked and promising not to (given the “Comrade Delta” affair); appearing on a platform alongside a CPGB flag fluttering merrily in the wind; employing a former Sinn Féin staffer. The last straw for me was Corbyn publicly expressing sadness that Ken Livingstone resigned – after all the harm Livingstone has caused recently to Labour.

Given the targets Corbyn’s critics choose, these are clearly misguided decisions, and harm the chances of a democratic socialist government taking power from the Tories.

As I said I will vote Labour and encourage others to do so, to try to get the Tories out so there’s a chance the welfare state can be restored with sanctions and other conditionality stopped; to undo marketisation of the NHS; improve mental health care; and for a range of other important issues. I continue to be an active trade unionist in higher education. But I don’t feel I can be a member of Labour under the current leadership and with its current approach to Brexit.

 

Samaritans

Today Samaritans announced that Esther McVey has left its advisory board.

This is great news, thanks to hard work by groups like Disabled People Against Cuts, Recovery in the Bin, and Black Triangle — groups led by disabled people, mental health service users and survivors. Their investigations revealed McVey’s membership on the board.

These groups should be confident Samaritans is on their side and should be more involved in informing policy.

This episode reveals a need for a review of advisory board membership. Samaritans must win back the trust of disabled people and others who have been harmed by disability (re)assessment policies, “sanctioning”, and cuts to welfare payments.

Additionally, there should be an urgent review of Samaritans’ communications policy. It is not acceptable for the same message to be copied and pasted to multiple people who are concerned about serious conflicts of interest which harm Samaritans’ reputation, potentially affecting donations and most worryingly putting people off calling.

Mental healthcare funding: Letter to Jeremy Corbyn 22 September 2017

Dear Jeremy,

I submitted a series of Freedom of Information (FOI) requests to Treasury, Department of Health, and NHS England, asking:

  1. Who is responsible for decisions made in relation to mental health care budgets?
  2. How are budgetary decisions made, including evidence of how, in calculating the total health budget, mental health needs have been taken into consideration?

Treasury and DH both replied citing s35 of the FOI act. Releasing discussion of options available, Treasury argued, might inhibit future “rigorous and candid assessments of options available” [1]. DH replied similarly: “Premature disclosure of information protected under sec tion 35 could prejudice good working relationships, the neutrality of civil servants” [2].

NHS England did reveal something of their decision making processes, naming Paul Baumann, Chief Financial Officer for NHS England, as responsible for budgets, and citing a technical document [3], the technical annex of which [4] sketches an estimate of likely growth in mental health costs over the coming years.

But Treasury and DH’s responses indicate that other factors have been taken into consideration that are not currently in the public domain. A rigorous debate about options, involving the people who need mental health services as well as those who provide them, requires transparency.

I am therefore writing to ask for more information concerning the reasoning behind decisions made. In particular, what discussion has there been of the following?

  1. The effectiveness of mental healthcare treatments and support, e.g., in comparison to physical health care;
  2. The costs of the various treatments; and
  3. The potential for reducing costs, e.g., by employing lower band staff or increasing involvement of voluntary services.

It is important that reasoning on these issues is made public so they can be openly debated.

Thanks,

Andy

[1] https://www.whatdotheyknow.com/request/293922/response/723453/attach/html/3/DOC231015%2023102015120744.pdf.html

[2] https://www.whatdotheyknow.com/request/299123/response/734036/attach/html/2/966789%20Fugard.pdf.html

[3] https://www.whatdotheyknow.com/request/mental_health_budgets_2#incoming-736647

[4] https://www.england.nhs.uk/wp-content/uploads/2013/12/cta-tech-Annex.pdf