Would you want a suicidal person to have an awful death?

Obviously most people’s response to the question would be that they don’t want a suicidal person to die at all and this is reinforced by suicide prevention policy which puts barriers up between information and the means to get a good quality death.

What characterises a good death? Painless, peaceful, quick and reliable are essential qualities of good deaths. They’re a basic need and an inalienable right which is best realised through legal assisted suicide. They’re what people like myself want and need.

For some people suicide is a certainty and is welcomed for the ultimate relief death provides. When you find yourself wanting to die I know you’ll understand this: suicide is good. It is an end to an unlivable life which is too bad for that individual to live through. Suicide solves continuing hurts and harms permanently. These hurts and harms have the nature of profound personal suffering by the fact that they drive someone to want to escape it by any means.

Suicide is the product of necessity rather than a neurobiological or psychological deficit. It is a place of profound desperation to escape the inequitous circumstances which so harm some people. The desire can be impetus and short lived but it can also be a reasonable decision. The latter aspect is what’s ignored in current suicide policy and by ubiquitous unregulated suicide system which seeks to force suicidal people to accept the worst quality deaths or traps them alive in their personal hell without hope.

Society hides behind the collective failure by doing the most inhumane and merciless thing: it reduces the completed suicide rate by criminalising assisted suicide and stopping people who definitely want to die from having a good death.

It is inhumane and it is a tyranny of evil which disregards the truth that suicide is good and hides behind the failures of modern life by forcing people to live through torture or die horribly. The suicide system which, I assume, is informed by public opinion wants suicidal people to live at any cost and is rubbish at helping chronically suicidal people. It denies the rationality of suicide but what’s worse is those who are sure they want to die can only have awful deaths.

So…what’s your answer to the question?

Target setting for employment equality (measure and improve)

An email to the Women and Equalities Ministers. I’d appreciate any comments on this idea.

I’ve been working on this idea for over a year and a half. I’ve written to a few people about it but have been rebuffed. Now I’d like to write to you about it.

Equality is central to good society and culture. It is stated throughout human rights legislation and the history of social progress trends towards greater equality and liberty.

Employment equality is an important domain of equality and mediates liberty. High employment equality is necessary in any society which considers itself good or fair. Conversely, high employment inequality and discrimination are unfair and ugly.

Many disadvantaged groups experience employment inequality but it’s worst for the disabled. Those who want to work still end up trapped in poverty because of discrimination effects like the glass ceiling effect (the barrier which stops disabled people and other disadvantaged groups from reaching the most senior and well paid roles in an organisation) and the ground floor effect (where they end up trapped in the lowest and most poorly paid echelons in an organisation’s hierarchy). It’s even worse for people with severe disabilities and part of the problem is due to the severity of disability not being taken into account in equal opportunities monitoring practices (it’s just Yes/No).

Organisations are also left to their own practices when it comes to monitoring and acting upon equal opportunities data. Even the government is found wanting in this respect as a recent Fawcett Society campaign highlighted. They identified the poor gender divide in appointed ministers and their campaign asked the government to set a target of one third women ministers.

Target setting is a standard tool for any area of modern life where improvement is needed and it’s clearly needed for employment equality as the Fawcett Society campaign so elegantly demonstrated. It’s not only the government who have failed to use equal opportunities monitoring to proactively work towards a diverse workforce by setting performance targets. Equal opportunities data is routinely collected by a variety of organisations but it’s often not being used to create better employment equality and it’s usually only looked at as a result of campaigning and lobbying as in the case of the Fawcett Society campaign or employment discrimination legal cases.

There should be national targets for employment equality as well as standard practices for the use of equal opportunities data and even evidence-based solutions to improve an organisation’s diversity, especially at senior levels. Target setting for employment equality is absolutely necessary in my opinion – and I hope you agree – because it’s what’s expected for any valued goal in modern times.

The bottom line for organisations has shifted in the last couple of decades towards a more complex measure of the success of an organisation (beyond the simple profit bottom line) and corporate citizenship principles require better practice in furthering aspirational, altruistic areas. Employee equality and diversity is an important area where target setting is essential but it’s not the standard. Additionally, employers who do prioritise employment equality and want to  performance manage it just like any other aspect of their business aren’t equipped with the right tools.

This is clearly unacceptable I hope you’ll agree. Employment inequality and discrimination is rife even in government. The Fawcett Society demonstrated the government’s gender inequality using a manual gender count of ministers and was able to set a reasonable target for improvement. Their approach is what should be being done on a national scale. Otherwise all talk of equality is simply rhetoric whereas setting numerical targets is science and mathematics.

If you believe in equality and fairness then you and your team must be target setting across the board. Organisations with, say, more than a hundred employees should be setting diversity targets and making the best use of equal opportunities data routinely. There should be a supported proactive empirical approach rather than what’s currently acceptable which is tantamount to chaos and any progress is led by reactionary diversity improvements.

This may sound difficult or expensive but having spent a lot of time on this I have found there are practical solutions. I’ve worked out a basic set of data which can be easily collected without lots of extra work and a rudimentary mathematical model. Obviously the experts in your department will be best able to do this however I believe what I have worked out is sufficient to work and be practical. Measurement and setting targets for employment equality is a small but important step to achieving the wider equality vision.

Instead of organisations just using their own performance data there’s the opportunity to create league tables for industries, regions and national comparisons. Poor performers can be supported to do better rather than vilified. Good performers are likely to use effective innovation which can be identified and disseminated. The severity of disability can also be taken into account using this mathematical method.

The worst case solution for this idea is to add data variables to the next Census but other data collection solutions offer a much smaller time frame between measuring employment equality. Better solutions use what’s already available in human resources management information systems (spreadsheets and databases) or HMRC tax data and GP equal opportunities data so require minimal extra effort and expense. Submitting equal opportunities data along with HMRC tax submissions is another method to get the data to measure national employment equality.

There are other solutions and several nuances to the idea. I’ve written and rewritten it a few times but I really hope this communication is the persuasive version. There’s more to it.

What do you think? Would you like to know more?

A response to the Royal College of Psychiatry inpatient care consultation

Crisis care for suicidal people: a revolution is necessary

The title says it all.

Imagine you want to die and imagine how current crisis care is negative rather than positive. Suicidal feelings are awful as is failing a suicide attempt. Society made a decision in the mid-20th century to stop criminalising suicide and instead medicalising it but little changed in practice because suicidal people ended up being incarcerated without specific therapeutic attention on solving the factors which make people suicidal.

It’s time to stop treating suicidal intent as insane and letting it lead to incarceration in a psychiatric ward. It needs to be come at from a compassionate perspective and there should  be an impetus to resolve the crisis quickly and effectively.

There has been a lot of improvement in crisis care over the last couple of decades but there’s still a long way to go. Large wards with lots of people in crisis trapped together with staff who have little time to engage and generally spend their time observing rather than treating is a tragic failure in common sense. It’s especially bad at helping people when they first experience suicidal ideation and choose to make an attempt. This is a critical moment to reduce suicidality in the long term but the opportunity is failed by current intervention techniques or lack thereof. Therapeutic environments, practices and practioners are needed not apathy and confinement.

I believe that suicide is not only natural but the right to die is an inalienable right. This is what things would be like in a humane and fair society whereas today the suicide system is so farcical it’s tragic. Attached is a document I’ve written to address the need for fundamental change in the approach of suicide policy.

Compassion, empathy and ultimately mercy are what’s required. This is what’s all but absent in current crisis care. Illegal activities still go on, for example my last major suicide attempt was treated against my explicit refusal of treatment in my advance directive. I was kept alive when I had stated I did not want treatment because I want to die. Then I was confined in a psychiatric ward against my choice. I wasn’t sectioned. Instead I was illegally detained because, I assume, the psychiatrist in charge of my care had a criminal mind. I wasn’t given advocacy support and for a period I was confined to the ward while  not on section and was told by a doctor that I would be sectioned if I tried to leave or discharge myself. This was two years ago.

This experience was inhumane and wholly unacceptable but there are evil people in healthcare. They are evil to do that to someone who wants to die. My freedom was and is infringed when instead I should be supported towards greater freedom and less suffering.

That’s what’s humane. That’s what’s right. That’s the future and you need to create it for me and all the others failed by current crisis care and suicide policy.

My instinct is to see human equality and liberty as an absolute, non-derogable truth

Science is brilliant for so many areas except those related to social order and makeup. Society and culture aren’t advanced through the application of the scientific method. Not until very recently outside the study of economics.

Sociological science and the science behind the design of society isn’t a potent thing like the application of physics to understand the material world. A lot of social change isn’t about science but instinct and gut feeling. Unfortunately these are also the source of tyranny, slavery and inequality. Hitler’s mistake in national socialism comes from the same sort of human processes as Gandhi’s peaceful rebellion for the tights of Indians in India.

When it comes to suicide and assisted suicide I might be becoming like Hitler because I believe I am right and this objective of social advancement is true. My views are as based on instinct and personal experience as they are thought through. My belief as to the certainty of my truth is as risky as any subjective belief as well as being the essential quality of most if not all of history’s recognised society changers.

Was it Edison….or Washington? “The tree of democracy is wetted by the blood of patriots and tyrants” or some similar quote resonates with what I’m trying to describe. I’d add “the tree of democracy grows from the same source” because the propensity for maniacal arrogance and revolutionary vision which changes the world is two sides of the same coin.

I feel the absolute truth is the liberty to choose your death. This is inalienable but sadly I don’t believe it’s non-derogable. Informed consent and free will are what derogates this right in my opinion. I know I’m a bit of a mad thinker but I know that I’ll informed, impetus decisions can have regrettable consequences and catastrophic consequences. Obviously a poorly chosen death is associated with an extreme negative consequence.

But beyond the quality of informed free will (including the choice to limit personal freedom on a solely personal basis) I have no qualms in demanding assisted suicide be legalised. If you are certain you want to die then you – like me – have been failed and if you can’t be saved from the torture of living while wanting to die then the moral good is suicide.

Today there is a prevailing mindset which considers suicidal ideation acceptable. There’s no thought given to suicidal people who can’t be helped by what the NHS offers. It’s accepted that these people live in perpetual suffering until they try one of the poor quality deaths available through the unregulated suicide system. These sort of deaths are not good which is the final travesty in the litany of tragedies which cause people to want death more than enduring through what they can’t endure.

My belief is that the suicide status quo is morally bankrupt and the legalisation of assisted suicide – something which will obviously kill a lot of people as well as me – is a worthy objective of bettering human rights and society.

It’s shop law: you break it you pay for it and the price is giving broken people a good death.

Perfect beings or perfect beings?

Yes. There’s a difference I choose to make.

There’s perfect beings who only accept the value of other perfect beings and there’s perfect beings which value imperfect beings as equals.

It’s an important distinction. The first aspect is Hitler’s model whereas the latter is the humanitarian libertarian model which is analogous to the social model of disability,

Perfectionism is the source of evil tyranny or wonderful liberty. I’m sure you know where I stand at We Do Big Ideas.

An email to the Mental Health Foundation about how psychiatric research doesn’t meet patient and public expectations

I’d like to write to you about a big problem with current mental health research: it’s not what patients expect and it isn’t used well in clinical practice.

I stumbled across this problem a few years ago when a friend of mine told me about her treatment experience. She had schizophrenia and wanted her hallucinations to stop so she submitted to psychiatric treatment. Her psychiatrists tried different drugs and high doses but couldn’t meet her treatment need.

That’s because of a flaw in psychiatric schizophrenia research which is that it looks at several effects at the same time. Important treatment effects which are relevant to patients can be lost amongst other effects of major tranquiliser treatments. There’s a type of research – meta-analysis – which would provide the best evidence if used retrospectively to review old trial data and just look at the effect on hallucinations to find out which treatment worked best.

I looked for this research but couldn’t find it. I tried organisations like Mind, Rethink and NICE but no one knew of its existence. It’s a cheap review to do because it requires no new trials, just unaggregated data collected from old trials. This hole in the evidence base is tragic because it would find the best treatment for what many patients accept major tranquilisers for but psychiatric research is about syndromes, not what patients want or expect. Single submeasure meta-analysis is recommended by Richard Bentall but his reasoning is about scientific accuracy whereas my point is about psychiatric research and clinical practice meeting patient expectations.

This applies to depression research too. Complex measures are used which aggregate together several submeasures. Important treatment effects can be masked by other effects which aren’t relevant to individual patients.

In fact there’s a brutal flaw in depression research and clinical practice which is about depression diagnosis. Depression is diagnosed using the operational cluster of symptoms approach. This means patients have to exhibit at least 5 symptoms from a standard list of 9 or 10 symptoms.  Only 4 symptoms or less is not sufficient for a strict diagnosis of clinical depression and symptoms of misery outside the standard list are not counted, e.g. those depression symptoms which are more common in men.

The strictness of the application of this approach is key. A GP who adheres to the strict reference cluster of symptoms diagnostic approach has the highest chance that they’ll get the treatment right first time. The science of depression depends on the strict use of the cluster of symptoms approach and deviation from the standard depression diagnostic system means those scientific answers don’t apply. Doctors deviating from this approach end up reliant on guesswork which is clearly unacceptable.

However…and this is a big however…clinicans who stick to this approach are failing patient expectations. Those who adhere to the reference diagnosis system aren’t diagnosing misery – which is what patients think depression is – but instead are diagnosing a biomedical syndrome.

The way I found to understand this is from a validity and reliability study. All patient participants reported subjective mental unwellness but as more and more symptoms from the standard list were required fewer and fewer patients met the criteria. At 5 symptoms there were a lot less patients diagnosed as depressed than reported subjective mental unwellness and the effect was more pronounced for men. (I wish I could remember the reference for this but I hope you can accept this illustration as a way of understanding this problem of mental health science versus expectations.)

Basically there are two scenarios in diagnosis in clinical practice: adhering to the strict approach and getting the value of scientific answers for the best treatment or doctors listen to their patient’s expression of misery but then have to rely on guesswork because the science is tied into the strict approach.

I hope you understand the point I’m trying to make. There’s a mess and a muddle in depression science and clinical practice which leaves good doctors to guess treatments and scientific doctors who don’t meet their patient’s expectations of treatment and might not treat at all those who don’t fit the strict diagnostic approach.

You don’t have to be a genius to realise that this is a fucked up situation. To the rescue comes the same retrospective meta-analytic review using unaggregated measures which I suggested earlier in this email for better schizophrenia science and also modern computing technology. The cluster of symptoms approach (if I remember right) was invented in the 1970s in response to criticisms that psychiatry was unscientific. It was around the DSM-III revisions. It was a practical way to turn depression research into something which could be used in clinical practice. (Research uses more complex diagnosis and interview techniques to identify depression but in clinical practice doctors have less time and specific mental health skills so the 5 of 9 or 10 standard symptoms approach was a practical necessity.)

Depression diagnosis still needs to be quick but now that computers are ubiquitous there’s a novel solution using the data from meta-analytic reviews using unaggregated single symptoms data from old trials. Simple software could allow clinicans to use this data to select treatments based on the specific symptoms a patient is displaying as well as their subjective self-report of misery. This is impossible to do quickly without computers.

Step one is to get single symptom and specific cluster results from old studies. A clinician can use these results by selecting which specific symptoms their patient is displaying. With the current approach any 5 symptoms together is enough but 5 symptoms could describe widely different presentations which would require different treatments. A computer can actually allow treatment to be specified for someone displaying symptom 1, 3, 5, 7 and 9 or totally different treatment for someone displaying symptom 2, 4, 6, 8, 10. It’s also possible to select treatment for a single symptom or a cluster of less than 5 symptoms.

I believe this is called the factoral approach and it’s clearly the best way to utilise current depression research which is otherwise useless except for those patients who do fit the strict diagnostic criteria. Obviously people displaying recognised symptoms of misery which aren’t in standard psychiatric measures still have a problem. There’s no other solution than new research to cover this. I’m sure Emily Wooster can recall the non-standard symptoms which are excluded in the ‘feminised’ diagnostic criteria for depression because it was part of Mind’s Men and mental health campaign.

This computer-enhanced clinical, diagnostic technique creates the ability to provide better scientific treatment decisions personalised to individual symptom patterns and allows good doctors to apply depression science whereas otherwise they couldn’t. This wasn’t thought possible when the cluster of symptoms approach was invented but computing has come a long way so it’s no technological challenge.

The potential benefit is clear to you I hope. Deconstructing old research and using it to personalise depression treatment allows good doctors to meet their patient’s expectations with scientific results.

I hope this makes sense to you because it really needs to be done rather than sitting on my blog as an intellectual victory against the tyranny of psychiatry.