Tips and notes for the National Institute for Clinical Excellence on writing best practice clinical guidelines for any mental disorder

1It is not an illness. Primary care physicians need to recognise this. Secondary care too. The application of the paradigm of illness to human behaviour only empowers doctors and their idea of psychopathology (which is bollocks).

Drugs are an answer but they mustn't be forced on a person. (There may be extreme circumstances but I don't know what they are). There is a significant ethical and philosophical debate about the use of drugs in mental health. Let's take the use of the chemical cosh. Current best practice for schizophrenia is a lifetime on drugs. These drugs do many things. They suppress the expression of the schizophrenic human type. They cause illness and death. They reduce life expectancy. There is no evidence I am aware of that they can cease the inner experience of delusions and hallucinations however there is significant evidence that they are a powerful behavioural change agent and are a form of chemical restraint. This continues the illness in society created by the Great Confinement (the creation of the asylum system which incarcerated the mad enmasse and removed madness from human view for generations).

It is possible for a person to go through psychosis without medication or support from NHS mental healthcare services and survive. It is fucking dangerous but the outcomes are better than getting help from the NHS. When I say dangerous I mean the risk is death by suicide or perhaps even worse the death of someone else. It is possible for a person to keep working during psychosis. This is not a preferable option for most people and for most organisations since psychosis/mania/intense depression can be difficult for other people. However this is part of what is required for the change of society to accept that madness can happen and it is normal. It may lead to better results than incaceration in a psychiatric ward, being labelled with a pejorative 'diagnosis' and then being turfed out the ward with little support.

Those with lived experience know at least as much as a psychiatrist. It would make a lot of sense to have a peer support network of people who've been through the experience. Matching personalities is probably important for successful peer support.

An individual's social network may need to be trained with the skills to support them through a difficult time - be it any of the extremes of the human condition.

The label of schizophrenia is bollocks. It is usually used for whatever reason a society feels like.

A key thing missing in NICE's schizophrenia guidelines is the appreciation of the value of the spiritual interpretation of the experience. For some this may not be appropriate, for example an atheist would think the spiritual interpretation is a load of bollocks, but for those who have different beliefs this spiritual interpretation can be helpful. The problem, of course, is ego. "Delusions of grandeur" can be exp[erienced when a person's ego gets out of control because of the messages from the internal experience of consciousness. "You are a god" or "you are a genius" or whatever else repeated in a person's head can mean they end up believing it and this is wrong because it means their ego gets inflated above the level of another human being. All the science I know tells me that everyone can be what anyone else is with time and commitment, obsession and will.

Anger and control of anger is one of the bugbears. I'm not sure I wholly agree with relaxation techniques but they're a start. The point is anger has a purpose and anger can be useful. If a person can not scream and wail and write and fight with heart and mind when there is something they see that is wrong then...what a fucked up world we live in. The problem is when anger turns to violence and true harm. It is the problem of what happens when a person snaps, picks up a gun and goes on a killing spree. This is a problem that religion has been trying to solve far longer than psychiatry.

Psychiatry crisis can be see as an opportunity for a person if psychiatrists can see the journey in life. It may not always be an easy journey. But f psychiatrists can learn to think like entrepreneurs, that a challenge can be an opportunity, then there is a significant hope for their patients. They need to have the time and the capability to understand a person's journey to the point of psychiatric crisis, i.e. they need the time to take a proper history of the individual. A true history.

informed patient choice. Informed patient choice.

In the absence of good science there can only be trial and error. In the absence of wisdom there can only be trial and error and patient choice.

Self-stigma can be a problem because of the current interpretations of madness in Western cultures. It is important to manage this while managing an individual's ego. Knowing that Gandhi or whatever hero a person has was mad can help with this inner pain but it can also drive a person to risky states of behaviour.

Managing the suicide risk is important but understanding why a person would want to kill themselves is also important. Ultimately those who want to take their life don't talk because they've made their decision. To prevent suicide the work of mental healthcare has to happen before the decision is made.

Psychiatrists must remember that people become. This is the spirituobiopsychosocial model of cause of mental disorder or wellness by any measure. I hope the greatest minds will always pursue the understanding of the human condition, but the greatest minds are what everyone has.

dr Jo Nurse's concept of flourishing is awesome shit.

The problem of ego and delusions of grandeur....if people understood that a gift or an ability is a curse...it s a responsibility...a gift is there to serve people...a gift must be sharpened and worked upon to be better and better but not for personal gain...even the feeling of doing good or being good - the pious crap - is something to be eschewed in favour of seeking to fulfill the responsibility of whatever gift a person has.

Health economics is always the problem limiting the implementation of good ideas such as Soteria wards and other low/no dose medication treatment facilities for first episode crisis. I had a unique experience when I was a child. I ended up in a boarding school. For two yeasr I got an education from great teachers and great friends. I got enough of a good education to go to a good university. Admittedly I didn't study much when I was there but I learned a lot. It was an expensive boarding school which took in some pretty fucked up kids like me. The cost must be around the NICE QALY/DALY figure for commissioning treatments and compared to the current options and prognosis for severe mental illness I reckon it's a total fucking bargain. There were a lot of kids with rich parents. it would be good for them to meet those poor kids who often up up with diagnosis like schizophrenia. It would be a small step forward towards reducing poverty and stuff in later life. Life's journey can leave a person penniless or worse. The school I went to prided itself on their "old boy network" and when things were fucked up in later life those old friends were always there. (and I need to be there for them more). Perhaps this way those who are going to be really successful in later life can be compassionate and accepting of those who are fucked up or from poor backgrounds or whatever.

Remember that there are basic answers which don't require science. There are things which people discover as ways to help themselves when they feel shit. There are therapists everywhere who can be there at a decisive moment in a person's life. Sometimes it isn't even a person. It is a song or a photo or a memory trigger by smelling a rose. Sometimes it's a depressed person seeing a homeless person and thinking...well...it ain't that bad...or perhaps its them thinking: that homelesness is wrong...sometimes it's a suicidal person wanting to help others who've been through what they've been through so cont...blah blah blah.

Developing world nations may have better mental health and mental healthcare.Their mental healthcare system are informal. The reasopns for their better mental health...well..smarter people than I have probably worked this shit out already.

It tkaes time to understand a person. Mental health professionals often don't have the time. Too many aren't equipped with the skills. But the skills are out there. Maybe the profession needs to go out and learn instead of sitting in offices and university lecture halls trying to understand the human condition. Perhaps people just need to be able to look at their lives and reflect. Fuck knows.