Tuesday, September 22, 2009

C. G. Jung: Memories, Dreams & The Soul

C. G. Jung /Henri Cartier-Bresson

“The purpose of analysis is not treatment,”

“That’s the purpose of psychotherapy. The purpose of analysis, is to give life back to someone who’s lost it.”


I have picked out the various bits in Sara Corbett’s account of the publication of The Red Book that may be of interest. The Red Book may turn out to be the most important publication on the human psyche. We all struggle to understand our own lives and it is reassuring to see that one of the greatest thinkers of our time struggled too.

“Jung soon found himself in opposition not just to Freud but also to most of his field, the psychiatrists who constituted the dominant culture at the time, speaking the clinical language of symptom and diagnosis behind the deadbolts of asylum wards. Separation was not easy. As his convictions began to crystallize, Jung, who was at that point an outwardly successful and ambitious man with a young family, a thriving private practice and a big, elegant house on the shores of Lake Zurich, felt his own psyche starting to teeter and slide, until finally he was dumped into what would become a life-altering crisis.

"What happened next to Carl Jung has become, among Jungians and other scholars, the topic of enduring legend and controversy.

“It has been characterized variously as a creative illness, a descent into the underworld, a bout with insanity, a narcissistic self-deification, a transcendence, a midlife breakdown and an inner disturbance mirroring the upheaval of World War I.

“Whatever the case, in 1913, Jung, who was then 38, got lost in the soup of his own psyche. He was haunted by troubling visions and heard inner voices. Grappling with the horror of some of what he saw, he worried in moments that he was, in his own words, “menaced by a psychosis” or “doing a schizophrenia.”

“Had he been a psychiatric patient, Jung might well have been told he had a nervous disorder and encouraged to ignore the circus going on in his head. But as a psychiatrist, and one with a decidedly maverick streak, he tried instead to tear down the wall between his rational self and his psyche.

“For about six years, Jung worked to prevent his conscious mind from blocking out what his unconscious mind wanted to show him. Between appointments with patients, after dinner with his wife and children, whenever there was a spare hour or two, Jung sat in a book-lined office on the second floor of his home and actually induced hallucinations — what he called ‘active imaginations.’ ‘In order to grasp the fantasies which were stirring in me underground, ‘ Jung wrote later in his book ‘Memories, Dreams, Reflections,’ ‘I knew that I had to let myself plummet down into them.’ He found himself in a liminal place, as full of creative abundance as it was of potential ruin, believing it to be the same borderlands traveled by both lunatics and great artists.

“Jung recorded it all. First taking notes in a series of small, black journals, he then expounded upon and analyzed his fantasies, writing in a regal, prophetic tone in the big red-leather book. The book detailed an unabashedly psychedelic voyage through his own mind, a vaguely Homeric progression of encounters with strange people taking place in a curious, shifting dreamscape. Writing in German, he filled 205 oversize pages with elaborate calligraphy and with richly hued, staggeringly detailed paintings.

“What he wrote did not belong to his previous canon of dispassionate, academic essays on psychiatry. Nor was it a straightforward diary. It did not mention his wife, or his children, or his colleagues, nor for that matter did it use any psychiatric language at all. Instead, the book was a kind of phantasmagoric morality play, driven by Jung’s own wish not just to chart a course out of the mangrove swamp of his inner world but also to take some of its riches with him. It was this last part — the idea that a person might move beneficially between the poles of the rational and irrational, the light and the dark, the conscious and the unconscious — that provided the germ for his later work and for what analytical psychology would become.

“The book tells the story of Jung trying to face down his own demons as they emerged from the shadows. The results are humiliating, sometimes unsavory. In it, Jung travels the land of the dead, falls in love with a woman he later realizes is his sister, gets squeezed by a giant serpent and, in one terrifying moment, eats the liver of a little child. ‘I swallow with desperate efforts — it is impossible — once again and once again — I almost faint — it is done.’ At one point, even the devil criticizes Jung as hateful.

“He worked on his red book — and he called it just that, the Red Book — on and off for about 16 years, long after his personal crisis had passed, but he never managed to finish it. He actively fretted over it, wondering whether to have it published and face ridicule from his scientifically oriented peers or to put it in a drawer and forget it. Regarding the significance of what the book contained, however, Jung was unequivocal. “All my works, all my creative activity,” he would recall later, “has come from those initial fantasies and dreams.”

“And yet, Carl Jung’s secret Red Book — scanned, translated and footnoted — will be in stores early next month, published by W. W. Norton and billed as the “most influential unpublished work in the history of psychology.” Surely it is a victory for someone, but it is too early yet to say for whom.

“To talk to Jung’s heirs is to understand that nearly four decades after his death, they continue to reel inside the psychic tornado Jung created during his lifetime, caught between the opposing forces of his admirers and critics and between their own filial loyalties and history’s pressing tendency to judge and rejudge its own playmakers.

“The Red Book is not an easy journey — it wasn’t for Jung, it wasn’t for his family, nor for Shamdasani, and neither will it be for readers. The book is bombastic, baroque and like so much else about Carl Jung, a willful oddity, synched with an antediluvian and mystical reality. The text is dense, often poetic, always strange. The art is arresting and also strange. Even today, its publication feels risky, like an exposure. But then again, it is possible Jung intended it as such. In 1959, after having left the book more or less untouched for 30 or so years, he penned a brief epilogue, acknowledging the central dilemma in considering the book’s fate. ‘To the superficial observer,’ he wrote, ‘it will appear like madness.’ Yet the very fact he wrote an epilogue seems to indicate that he trusted his words would someday find the right audience.

“In the Red Book, after Jung’s soul urges him to embrace the madness, Jung is still doubtful. Then suddenly, as happens in dreams, his soul turns into ‘a fat, little professor,’ who expresses a kind of paternal concern for Jung.

“Jung says: ‘I too believe that I’ve completely lost myself. Am I really crazy? It’s all terribly confusing.’”

“The professor responds: ‘Have patience, everything will work out. Anyway, sleep well.’”

Jung told one of his patients:

“I should advise you to put it all down as beautifully as you can — in some beautifully bound book,” Jung instructed. “It will seem as if you were making the visions banal — but then you need to do that — then you are freed from the power of them. . . . Then when these things are in some precious book you can go to the book & turn over the pages & for you it will be your church — your cathedral — the silent places of your spirit where you will find renewal. If anyone tells you that it is morbid or neurotic and you listen to them — then you will lose your soul — for in that book is your soul.”

He obviously took his own advice and we may all in the end be thankful he did.

Related: C. G. Jung: The Red Book

Sunday, September 20, 2009

C. G. Jung: The Red Book

The New York Times Magazine:

Thomas Hannich for The New York Times
Published: September 16, 2009
"This is a story about a nearly 100-year-old book, bound in red leather, which has spent the last quarter century secreted away in a bank vault in Switzerland. The book is big and heavy and its spine is etched with gold letters that say “Liber Novus,” which is Latin for “New Book.” Its pages are made from thick cream-colored parchment and filled with paintings of otherworldly creatures and
handwritten dialogues with gods and devils. If you didn’t know the book’s vintage, you might confuse it for a lost medieval tome."
"And yet between the book’s heavy covers, a very modern story unfolds. It goes as follows: Man skids into midlife and loses his soul. Man goes looking for soul. After a lot of instructive hardship and adventure — taking place entirely in his head — he finds it again."
"Some people feel that nobody should read the book, and some feel that everybody should read it. The truth is, nobody really knows. Most of what has been said about the book — what it is, what it means — is the product of guesswork, because from the time it was begun in 1914 in a smallish town in Switzerland, it seems that only about two dozen people have managed to read or even have much of a look at it."
"Of those who did see it, at least one person, an educated Englishwoman who was allowed to read some of the book in the 1920s, thought it held infinite wisdom — “There are people in my country who would read it from cover to cover without stopping to breathe scarcely,” she wrote — while another, a well-known literary type who glimpsed it shortly after, deemed it both fascinating and worrisome, concluding that it was the work of a psychotic."
Perhaps we should be thankful that DSM did not exist then!
Sara Corbett continued:
"THIS COULD SOUND, I realize, like the start of a spy novel or a Hollywood bank caper, but it is rather a story about genius and madness, as well as possession and obsession, with one object — this old, unusual book — skating among those things. Also, there are a lot of Jungians involved, a species of thinkers who subscribe to the theories of Carl Jung, the Swiss psychiatrist and author of the big red leather book. And Jungians, almost by definition, tend to get enthused anytime something previously hidden reveals itself, when whatever’s been underground finally makes it to the surface."

C. G. Jung: The Red Book
W.W. Norton & Company

C. G. Jung: Memories, Dreams, Reflections
The Exhibition: Rubin Museum of Art

Saturday, September 19, 2009

McKinsey: NHS & Vogue

Great Barracuda, BVI/ ©2009 Am Ang Zhang

Snorkelling can be very inspirational. I have often wondered why so many fishes stay around the Great Barracuda, running the risk of being gobbled up before the end of the day. Perhaps these fishes have not been warned. The NHS certainly has.

I read that McKinsey, one of the leading Management Consultancy firms is expected to recommend 25% cost cuts at Vogue. They have already advised a 10% staffing cut in The NHS to achieve a saving of £20 billion by 2014.

In actual fact the NHS could have saved even more money by doing away with the likes of McKinsey. A new book was published by one insider Matthew Stewart on management consultants. The Independent had the details:

Thursday, 17 September 2009
I will just pick out a few points that may be of interest.

The truth:
“Wherever I was in the world, at the beginning of every consulting project, one thing was certain: I would know less about the business at hand than the people I was supposed to be advising.”

How to impress:
“Firstly, they constructed a database of the client's customers, detailing each customer's product and transaction activity over the preceding year. Next they established a clean profit and loss statement for the whole business, including all overheads but excluding extraordinary items. Then, to allocate the revenues and costs of the business to each customer, they devised algorithms based on detailed models of each kind of product and transaction. The complexity of these algorithms, naturally, was such that they were far beyond the powers of most clients to comprehend. The result was an analysis of the exact revenue, expense, and profit to the client attributable to each of its customers. Finally, the team lined up the customers according to their profitability, thus allowing the client to see how much of its profits could be attributed to its most profitable customers, and how much to the least profitable."

The Whale Chart: "The Whale" is a graph. Its official title is "Cumulative Customer Profitability" and it also goes by the generic name "skew chart".
“I eventually came to understand that it is possible to construct a Whale chart for just about any business anywhere. It makes no difference whether the business is inherently good or bad, well-managed or in the hands of chimpanzees. It doesn't even have to be a business – it can be a football game or a population chart.”

It gets better:
“In fact, you don't even have to do the analysis. You can save 80 per cent of the effort by just borrowing data from a previous analysis. There's always going to be a skew. It isn't science; it's a party trick.”

The Clients---including The NHS and Vogue:
"The management consulting industry depends on a small number of gargantuan clients; we thought we were doing pretty well out of one of our clients who spent $12m annually on our services – until we learned that this behemoth's total spending on "strategy" consultants was about $100m per year. In order to grasp why some large organisations (but not others) spend so much money on something as ethereal as "strategy," one must dispose of the naïve idea that consulting involves the transfer of knowledge."

"The most important of the all-too-human functions of shaman-consultants is to sanctify and communicate opinion. Like ministers of information, consultants condense the message, smooth out the dissonances, unify the rhetoric, and then repeat and amplify it ad nauseam through the client's rank and file."

Writing your own report card:
“The pretence of knowledge where none is to be had, after all, is also a licence to represent private interest as a public good. Managers of client organisations easily abuse this licence, using shareholder money to pay for consultants in order to confer legitimacy on actions that deserve proper scrutiny from truly independent sources. For consultants, the arrangement has all the beauty of writing your own report card.”

According to the Management Consultants' Association, the NHS spent £300m on external consultancy last year.

The ultimate message:
“……you will be expected to work much harder than you ever have before and your chances of losing your job are infinitely greater than you ever imagined.”

Birthday Grand Rounds: Residency Notes

NHS: Budget 2010-£110 Billion, McKinsey

Thursday, September 17, 2009

Medicins sans Frontier: Ethiopia & Polyclinics

I woke up to read about the abolition of frontiers in England in Jobbing Doctors.

Since I now drive 120 miles to see my favourite dentist should I do the same so that I can see my old GP.

“He has retired.” Bother!

This is not Ethiopia but do you think our politicians have your interest at heart or are they paving the way for Polyclincs as surely they cannot have frontiers if they are going to make money. Or are they just trying to catch a few votes?

NHS Blog Doctor: GP boundaries, The Guardian

Related: The Independent, The Guardian, MPs,

Monday, September 14, 2009

First Emperor, Animal Farm & Allyson Pollock

“For centuries, the brutal and tyrannical reign of Qin Shihuangdi, First Emperor of China, was summed up by a four-character phrase, fenshukengru 焚書坑儒, ‘He burned the books and buried the Confucian scholars alive.’”Anthony Barbieri-Low: 21st Sammy Yukuan Lee Lecture. See also: The Independent.

Forty years ago, Colin Douglas, geriatrician and novelist, when on a gap year in a remote secondary school in post-colonial Ghana, was summoned by the headmaster and informed that "we had in our library a book the government didn't think we should read." The book was of course Animal Farm.

Here in The BMJ, he reviewed Allyson Pollock’s Book, NHS plc.

NHS plc/Allyson Pollock

"Allyson Pollock describes her experience in November 2001 at the hands of the House of Commons Health Select Committee, then just refreshed by an influx of New Labour ultras, including one Julia Drown MP, a former health service manager. Against the advice of the committee's chairman and clerks, Ms Drown tabled a rant aimed at undermining Professor Pollock and her Health Policy and Health Services Research Unit at University College London. In the chairman's view such an attack on an individual witness was unprecedented and wrong, yet it nevertheless (by virtue of a nasty but neat little bit of committee footwork) appeared in the final report of an inquiry into the implications of the private finance initiative (PFI) for the NHS.”

Allyson Pollock must count herself lucky for not living in China during the reign of The First Emperor although she did leave the England part of The Kingdom.

“……if you are old enough, or even just curious enough, to wonder whatever happened to the British NHS as first conceived, you might find NHS plc a useful little book. An excellent early reputation—for cost effectiveness and equity based on integrated services, minimal management costs, and a vast and intensely practical pooling of risk—dwindled slowly. This was firstly because of chronic and insidious underfunding, later because a notional internal market began to take it apart, and finally (though the word may still be slightly premature) because of the current assault: a burgeoning, divisive, sometimes mendacious for-profit marketisation of a healthcare system that was once an admired public provision and a right of citizenship in the United Kingdom.”

Regarding PFI he continued:

"Since it was Pollock's views on the PFI that so upset its proponents, it is worth summarising them briefly. Costs are now intrinsically higher, because of capital borrowing at higher rates than those available to government, because of cash hungry consultancies and the vast transactional and monitoring costs of countless contracts, and because—for the first time on a large scale in the NHS—commercial profits must be made. To accommodate all these new costs clinical services have been scaled down, while matching assumptions about increased efficiency are only variably delivered. All this, along with the rigidity of a trust based strategy for building hospitals and the locking in effect of contracts fixed for decades, seems to Pollock and many others at best a bad bargain, at worst a naive betrayal that opens the NHS to piecemeal destruction and the eventual abandonment of its founding principles. And all over the country PFIs—greedy, noisy, alien cuckoos in the NHS nest—gobble up its finances and will do so for the next 30 years.”

Next 30 years!

Other concerns:

"Foundation trusts (‘public benefit corporations’—what?) will further disrupt any attempts to build effective local health services, drive the balance of care in the wrong direction, and almost certainly get choosy about the patients they treat. All this will least benefit elderly patients, whose care as our population ages ought to be explicitly identified as the core commitment of our NHS. Will elderly people be surprised? I doubt it. Their long term care was totally abandoned by the NHS in England long ago, and given the direction of current reforms any priority for their acute care would be astonishing. And meanwhile, under the Orwellian rubric of choice and diversity, all manner of dubious, expansionist corporate players, many from the United States, where these things are managed so much worse, are circling, scenting opportunities for private profit in a once great public service.”

I have to thank Dr. Grumble for pointing me to this site that has a write up too.

Rupert Read wrote in OurKingdom:

When I was at Oxford taking PPE 20 years ago, my best friend was Simon Stevens, who went on to become Tony Blair's key health policy adviser. Back then, he was a socialist. Now, he is Chair of United Health Europe, one of the US's giant corporations profiteering from the break-up of the NHS, and angling to take over doctor's surgeries across the UK. That little timeline symbolises quite a lot about what has happened to the NHS.

Why do we still have the great books of Confucious and other scholars? They have all been memorised by scholars and The First Emperor could not kill all of them. When he failed to achieve eternal life and died, the scholars just re-wrote these books again.

The last words go to Colin Douglas:

“Professor Pollock, with the help of many colleagues acknowledged in a list that reads like a roll of honour for services to the real and now threatened NHS, has written a brave, necessary book. And because you know the government thinks you shouldn't read it, you probably should.”

Sunday, September 13, 2009

Old & Young: E. Coli O157

Looks like E. Coli O157:H7 is causing mayhem again, affecting mainly children that visited a farm.

September 13, 2009

Godstone Farm/Gareth Fuller
"Thousands of children across the South of England may be at risk from the E. Coli 
bug in what looks to be the largest UK outbreak linked to transmission from farm animals.

"Godstone Farm in Surrey, a popular family attraction where children are encouraged to stroke and touch animals, is closed while the Health Protection Agency (HPA) conducts tests to find out the cause of the outbreak which has left 12 children in hospital, four of them in a serious condition.

"Thirty-six cases, including some adults, have been reported by GPs.
"About 1,000 children, mainly from South London, Surrey, Kent and Sussex, visit the farm every day during the school holidays and at weekends. It is feared that 30,000 children could be at risk of infection."

Remember Scotland 1996?
One of the first major E. Coli O157:H7 outbreak that affected mainly old people in the United Kingdom.
From the BMJ 1996;313:1424 (7 December)
E Coli O157 kills five people in Scotland
"An inquiry had been set up to examine the circumstances behind Britain's worst outbreak of food poisoning from Escherichia coli 0157, which has resulted in five deaths and left 280 people ill.
"The outbreak, in central Scotland, has been linked to cold and cooked meat products sold by a butcher, John Barr and Son, in the Lanarkshire town of Wishawand supplied to dozens of outlets in the surrounding area.

"The deaths have all occurred among elderly people, two of whom were among a group of pensioners who shared a meal at a church in Wishaw on 17 November. They had eaten a steak pie supplied by John Barr, and tests have since confirmed the presence of E coli bacteria in the gravy. It soon became clear, however, that the problem was not confined to Wishaw when people from a wider area began reporting symptoms."

E.Coli O157:H7 can be very virulent and it is believed that as little as 5 individual germs can cause serious damage especially by causing kidney failure. We have little understanding still of how bacteria act but it is now known that E. Coli O157: H7 uses Quorum Sensing. The condition at the farm must have been ideal for them.

We also need to understand about the proliferation of bacteria such as E. Coli and MRSA and C. difficile in our farm animals.

According to The Union of Concerned Scientists:
Microbial Drug Resistance 13(1):69-76.Akwar et al. 2007.
Risk factors for antimicrobial resistance among fecal Escherichia coli from residents on forty-three swine farms.
"Akwar et al. found that people living and working on swine farms where antibiotics were used in feed had increased chances of carrying resistant E. coli. In some cases, the risk of resistance for the farm workers was higher than if they had taken antibiotics themselves. Once farm workers are colonized by resistant bacteria they can transfer them to family members and others in their community."

The use of antibiotics in farm animals is widespread and is not restricted to the treatment of infections but for the enhancment of weight gain. In business terms it is the conversion ratio of feed to weight that matters. The Obama government may well be taking steps to control it due to the rising incidents of Hospital Infections. (See MRSA & Antibiotics: Obama & Farmers.) Chicken and other animals can grow up to twice as fast as 30 years ago when antibiotics were not in the feeds. Scary!
It may therefore require more than "washing hands" if we do not want more outbreaks like this and other ones.

Latest: Twins

1996 Report: Pennington Report