My review of Allan Beveridge’s ‘Portrait of the psychiatrist as a young man: the early writing and work of RD Laing’ is now viewable early online at the Journal of Mental Health’s website You can also read it here.

 

RD Laing book cover

 

Could there be merit in reviewing the origins, intellectual development and clinical work of a maverick healer whose reputation and life collapsed, Icarus-like from the heights of international acclaim? Can an evaluation offer anything more than a social perspective and cautionary warning?

In Portrait of the Psychiatrist as a Young Man, Scottish psychiatrist Allan Beveridge argues for a partial rehabilitation of Laing’s existential approach towards understanding mental illness. As the neurosciences have failed to deliver fully effective treatments, Beveridge states that the Laingian approach of “treating the patient as a person rather than a malfunctioning mechanism has new-found appeal”.

Thus, Portrait… provides a comprehensive account of the personal, historical and social context that led a bold (‘gallus’), working-class Glaswegian to become ‘R.D. Laing’; for a time the most famous psychiatrist in the world. While previous biographers, among them his son, Adrian Laing (1994), have provided vivid accounts of a dynamic yet troubled man with a notoriously flawed relationship towards his own family, Portrait… is an academically researched work that focuses on Laing’s intellectual life up to 1960, when his first and most well known work, The Divided Self, was published.

Half a century later and through access to his countryman’s recently acquired private papers, Beveridge’s knowledge of philosophical and literary theory on mental illness makes him particularly well placed for such an undertaking. However, among the numerous sides of Laing that are described is a tendency to embellish clinical material to enhance his personal theories and reputation. While such revelations may prove terminal to Laing’s clinical legitimacy, Portrait… provides an engaging insight into an enigmatic figure who continues to influence Western public perception towards mental illness and psychiatry.

In Part I, on ‘Laing and theory’, Beveridge begins with an account of Laing’s peculiar upbringing as an only child, from which his ‘narrative of a Hero’ developed, with an ambition to complete his first book before he was 30. This is followed by individual chapters that detail how the young psychiatrist’s thinking was shaped by psychiatric theory, existential philosophy, religion and the arts. The result is a tightly summarised and readable guide to the notable figures within these fields and their significance towards Laing. Along the way, the myth of an autodidact who emerged from a distant outpost is exposed. In its place is a charismatic and at times conventional psychiatrist who was inspired by his Presbyterianism, continental philosophy and Glasgow’s intellectual climate, the recent beneficiary of an influx of intellectual Jewish, émigré doctors.

Part II, on ‘Laing and practice’, examines Laing’s private papers from medical school through to his psychiatric training. Here many of the individual patients that were memorably described in The Divided Self and Laing’s later works are identified, including several from the famous ‘Rumpus Room’ experiment at Glasgow’s Gartnavel Hospital. This clinical trial to observe how chronic in-patients responded towards a more informal environment would later influence the liberal and permissive approach that was adopted at Kingsley Hall, the infamous sanctuary for mental illness that Laing co-founded. However, while the ‘Rumpus Room’ was crucial in developing his view that mental illness could be demonstrably understood and treatable using an existentially-based approach, Beveridge also reveals a familiar narrative of Laing taking disproportionate credit and exaggerating outcomes.

Despite the breadth of views that Beveridge considers, including an assessment of Laing’s Scottish credentials, Portrait... notably lacks a modern psychoanalytic criticism as argued by Lucas (2009). Although Laing was to achieve his first publication ambition whilst training at London’s Tavistock Centre and was present when many of its leading figures made significant contributions to psychoanalytic theory, his reputation within the Tavistock (despite being their most widely read author) is conspicuously absent. While supportive of his championing of patient’s rights, Lucas denounced Laing for showing “no interest in Bion’s seminal work on schizophrenia” that viewed psychosis as being driven by an envious hatred of psychic reality and an attack on the individual’s capacity to think. By this omission, it could be argued that like his subject, Beveridge fails to consider psychoanalytic theories that do not suit the Laingian model.

Nevertheless, where Beveridge succeeds is by providing an understanding of the diversity of Laing’s interests and their relevance to all in psychiatry when considering mental illness and the patient’s experience. While Laing’s manipulation of clinical material might consign a lesser figure to historical oblivion, by considering his bridging position midway through the 20th century, the past century of psychiatry’s history is brought to life.

Laing, A. (1994) R.D. Laing: A Life, Gloucestershire: Sutton Publishing.

Lucas, R. (2009) The Psychotic Wavelength, London: Routledge.

Portrait of the psychiatrist as a young man: the early writing and work of RD Laing 

Allan Beveridge

Oxford University Press, 2011.

350 p. £39.99 pbk isbn: 9780199583577

Earlier book review for the Journal of Mental Health: 
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Last month, the mental health charity, Rethink Mental Illness, published The Abandoned Illness, an 88 page report about schizophrenia and its care in England.

For its report, Rethink commissioned a panel of 14 individuals with professional and personal experience of this severe mental illness, which for many can be debilitating and chronic. In preparing their very readable report, the panel, known as the Schizophrenia Commission, visited services and gathered evidence from a wide range of sources who are affected by or involved in their care.

While the illness often causes confusion, uncertainty and sometimes fear, The Abandoned Illness provides a good explanation of psychosis, schizophrenia and the issues involved. The report’s publication also brought an opportunity to raise awareness and receive more sympathetic media attention than usual. However, among this coverage there was an emphasis on “catastrophic failings” in care and the “scandal” of schizophrenia’s reduced life expectancy, though neither of these quoted descriptions appear in the report itself.

The Abandoned Illness cover

Findings and Progress

The Abandoned Illness reports an estimated prevalence for schizophrenia of 0.5% and particularly emphasises the costs incurred. These are both personal (a reported reduction in life expectancy between 15 – 20 years) and financial (an estimated £11.8 billion cost to society in England). Yet despite initiatives for equity of care, such as the UK Government’s recently published strategy ‘No Health without Mental Health’, there remains a disparity in funding; “mental illness accounts for 23% of the disease burden and 13% of resources”.[1]

The Schizophrenia Commission also uncovered serious concerns over some hospital settings. “We heard of many acute units which were stressful, chaotic and scary places. No one seemed to be in charge. Violence, theft and sexual harassment against staff and patients, boredom, poor environments, lack of activity or staff-patient engagement were highlighted as criticisms. Un-therapeutic services, characterised by a sense of hopelessness, staff who do not engage with patients, together with bleak décor and furnishings, can lead to people reacting badly to their hospitalisation.” They also observed that in some units “medication is prioritised at the expense of the psychological interventions and social rehabilitation which are also necessary.”

The report concludes that “the current system of care and support for people with schizophrenia and psychosis, and their families, is failing both them and the taxpayer”. With such a dim description of care, you might be surprised that anyone with psychosis could ever have a positive experience within the NHS.

Fortunately, The Abandoned Illness also reports that there is more understanding and improvements in treatment. The report observes “in the last 20 years much progress has been made in understanding schizophrenia and psychosis. There have been many positive developments including the growth of the service user movement, initiatives like crisis resolution teams and early intervention for psychosis services, exercise prescriptions, investment in new IT systems and direct payments. There are now more single sex acute care units with individual rooms, flexible day centre provision and multi-disciplinary team working”.

There is also acknowledgement that “the mental health workforce is made up of very many committed individuals who strive, sometimes in very difficult circumstances, to provide quality support to people living with severe mental illness. This is recognised by service users and their families.” The Commission adds “we have been impressed by accounts of how individual practitioners or whole services have transformed lives through approaches emphasising the potential for recovery and through listening to people’s experiences”. One Commission member even states “what has struck me from listening to evidence and visiting services is how far we have come since my mum was first diagnosed with schizophrenia in the 1960s.”

Discrepancies in presentation and media coverage

Given those favourable observations, the report’s title seems inconsistent and isn’t fully explained. Nor is it clear why media coverage quoted findings of “catastrophic failings” when the Abandoned Illness doesn’t include any version of the word “catastrophe”. That comes from Rethink’s press release, which begins ominously; “Inquiry highlights ‘catastrophic failings’ in treatment of  people with schizophrenia and psychosis…”

On enquiry with Rethink’s media department, assurance was given that the title and “catastrophic” quotes were agreed by the Commission who “felt it was necessary to draw attention to these problems in order to get action taken, and the tone of the press release and the title of the report reflect that”. Further communication with individual Commission members confirmed agreement with this approach. Meanwhile, such concerns over presentation may seem trivial when the Commission’s Chair, Professor Sir Robin Murray, states in the report’s forward “what we found was a broken and demoralised system that does not deliver the quality of treatment that is needed for people to recover. This is clearly unacceptable in England in the 21st century.”

However, eye-catching descriptions of ‘abandoned’ and ‘catastrophic’ did indeed set the tone for how the Abandoned Illness was reported to the general public. Furthermore, as the title is derived from ‘The Forgotten Illness’ – a series of reports about the lack of services and treatments for people with schizophrenia written 25 years ago by Marjorie Wallace, founder of the mental health charity SANE – there is an impression that care for schizophrenia has always been bad and at best, remains so. Certainly what other conclusion could be drawn from the headline “Patient care of schizophrenics at ‘all-time low’, claim experts”, which featured in the Independent on the day the Abandoned Illness was published in a piece written by Jeremy Laurance, the paper’s health editor and the only journalist member of the Schizophrenia Commission.

My concern about this approach is not for being blind to the state of psychiatric care. I can well believe that the Commission heard examples of “shameful” care as outlined in their findings above. These resonate with what a personal source observed in 2010 during a week-long voluntary admission on an acute ward in England which included;

1. For some of the time there was just one toilet between 22 men. Other WCs were broken, locked, blocked.

2. Electricity went off twice as rewiring was carried out leading to a most unwelcome Halloween atmosphere.

3. Patients had to ask staff to open showers and baths to wash. Sinks were regularly blocked. Faeces was found in the shower tray, urine was found in a bath. Patients were left to clean these alone.

4. Patients were not given copies of their care plan and in some cases were unaware of their named nurse.

5. The activity room on the ward was permanently closed leaving detained or observed patients with only the chance to continually walk the short corridors of the locked ward as our exercise.

Clearly such conditions would not pass the Commission’s “friends and family” test and its bar-setting standard “would you want your relative treated in such a unit?” Thus, I entirely agree that the Abandoned Illness is right to highlight the acute care that some patients encounter.

My fear is that despite the progress that the Abandoned Illness describes and its advice to health professionals to encourage hope, the report’s presentation practically emphasised expectations of failings in care. Although some positive stories did appear in the media – particularly Commission member, Liz Meek, speaking on Radio 4’s You and Yours about her daughter’s experience – often these were presented as occurring in spite of faulty services. There was also reinforcement of many of the associations that the Abandoned Illness wants to reduce, such as describing acute units as ‘madhouses’.

Prof Appleby tweet

One mental health expert who shared my discomfort about the presentation of the Abandoned Illness was Professor Louis Appleby, National Director for Health and Criminal Justice and Professor of Psychiatry at the University of Manchester. Through twitter (@ProfLAppleby), he described the report as a “thoughtful, modern account of how mh [mental health] care can work – almost lost in media message of “madhouse” & catastrophic failure.” He also tweeted concern that such descriptions could have a negative effect on the “patient needing admission next wk (to a madhouse?) & morale of staff who are “failing””.

While it’s understandable that the Abandoned Illness would want to promote a message of recovery and hope, it often downplays issues around risk, both to the public and the individual’s health and well-being. Asserting that increasing use of measures of coercion such as Community Treatment Orders are indicative of failure may also be misleading when this measure was only introduced in England in 2007, is subject to a high degree of legal scrutiny and can indicate good practice, which facilitates autonomy and reduces relapses outside of acute settings. There is also limited indication in the report of why caring for people with psychosis and schizophrenia can be very difficult for health professionals because mistrust is itself a feature of their presentations.

The life expectancy ‘scandal’

Criticism of a different order concerns the attention that the Abandoned Illness makes about schizophrenia’s reduced life expectancy while also calling for evidence-based interventions. The implication being that through the report’s favoured programmes such as Early Intervention Services (EIS) – a dedicated service provided for up to three years to young people presenting with first signs of psychosis – and specialist psychological therapies for psychosis, these measures that currently have limited accessibility across the UK will improve life expectancy to levels approaching the general population.

While such interventions sound attractive and EIS may have some effectiveness in initial care and reduce suicidality, it remains to be seen whether life expectancy is extended. Meanwhile, the impression is given that what’s beneficial about these treatments aren’t available in any other form of mainstream mental health care, even though much of how nurses, social workers, doctors and psychologists work is by listening, engaging and working with individuals and their families. This may even include cognitive behavioural approaches that are at the limits of what some individuals with psychosis can tolerate. Thus, while it is likely that levels of care across the UK still need to improve, that’s not to say that current services that lack EIS or specialist psychological interventions are providing inadequate care.

Additionally deserving of scrutiny is the frequently cited figure of a 15 – 20 year reduction in life expectancy. Often the Abandoned Illness appears to imply that the reason for this discrepancy – which Schizophrenia Commission members Jeremy Laurance and Rethink’s Chief Executive, Paul Jenkins subsequently described as a ‘scandal’ – is due to health care deficiencies.

Clearly a reduced life expectancy is cause for concern by anyone involved in caring for those with schizophrenia. However what remains unclear is how much of this is unique to schizophrenia, as other serious mental illnesses such as bipolar affective disorder and depression also have reduced life expectancies of approximately 10 years (Chang et al 2011). Certainly people with schizophrenia are more vulnerable to developing physical health problems, some of which are associated with side-effects from antipsychotic medications that have risks but can improve outcomes. There are also many barriers to care for people with schizophrenia, though the illness itself reduces motivation for seeking health care in individuals, who are also more prone towards unhealthy lifestyles such as smoking, poor diet and inactivity.

While that shouldn’t be grounds for complacency, by emphasising total reduced life expectancy without context, the Abandoned Illness and Rethink risks creating unrealistic expectations of care that no health service, however well resourced, can achieve.

Recommendations and costs

Despite these issues over presentation and an ambiguous title, there is much to commend about the Abandoned Illness. As well as the points described above, the report directly addresses current themes about schizophrenia such as the debate over its diagnosis, the impact of ethnicity and the role of families and carers. It also considers how to raise greater awareness, reduce stigma and highlights social issues around employment, housing and welfare reform.

In addition, the report provides 42 recommendations for agencies such as the UK government, professional bodies like the Royal College of Psychiatrists and mental health providers among others. As a general adult psychiatrist, I particularly welcome;

A radical overhaul of poor acute care units including better use of alternatives to admission (No. 19) 

Greater partnership and shared decision-making with service users (No. 4)

Much better prescribing and a right to a second opinion on medication (No. 12)

Delivering effective physical health care to people with severe mental illness (No. 13)

A stronger focus on prevention including clear warnings about the risks of cannabis. (No. 16)

Psychiatrists must be extremely cautious in making a diagnosis of schizophrenia (No. 32)

NB: Numbers in brackets refer to the respective recommendation listed on pages 79-83 of the report.

Meanwhile, the Abandoned Illness is under no illusion that the most likely future concern is cost – particularly the disproportionate funding given to secure (forensic) care, which they state should be better distributed – and that “no one should claim that we can afford to leave things as they are.”

Thus for forensic consultant psychiatrist and Commission member, Dr Shubulade Smith, the report’s importance is as a reminder “that what we are providing is not quite good enough at a time when the economic crisis means that mental health services are likely to be cut further and therefore suffer”.

[1] The costs to society and the public sector are outlined in more detail in a supplementary 44 page report, Effective Interventions in Schizophrenia, which Rethink commissioned from the London School of Economics

Chang et al (2011) Life Expectancy at Birth for People with Serious Mental Illness and Other Major Disorders from a Secondary Mental Health Care Register in London. PLoS ONE 6(5): e19590. doi:10.1371/journal.pone.0019590


As it’s nearly a year since I arrived in Glasgow, I thought it timely to write about just what I’ve been doing here.

While my appointment as a locum consultant psychiatrist was initially agreed for 12 months, next week I’ll begin a further six month extension. This will be more new territory, as I’ve never been in a post for more than a year and as well as continuity, I’m increasingly appreciating the full range of my caseload. In addition, while juggling clinical roles across two different services, I’m seeing ever more of the local mental health picture.

Community Mental Health Services

Local remedy delivery at our Health Centre

As part of a general adult community mental health team based in a small town 10 miles outside of Glasgow, our catchment area includes parts that are well-known for being well-off with some areas of deprivation. It’s the same as I’ve done before in England and involves assessments of new referrals and reviews of current patients, while working jointly with community psychiatric nurses (CPNs), psychologists, social workers and occupational therapists.

There are two other consultants of a similar age who I get along with well, though we’re pretty busy with our individual caseloads. For my part, I’m here purely in a service delivery role, providing out-patient reviews and consultant support to my colleagues. That’s been enough to be getting on with, particularly as I’ve taken over a caseload that had been managed by a succession of short-term locums. Many of the patients and their carers would say they were pleased that there would now be consistency though I wasn’t so sure that I would stay this long myself. One year later and I’m close to having seen most patients at least twice, which has been a helpful experience, even if they’re not always as keen to see me!

After establishing myself in post, I’ve since gone on to review long-term issues over diagnosis and prescriptions. While there are differing views within psychiatry, I’ve been surprised at how medicalised some patient’s management has been with medication regimes that have increased in quantity and complexity with limited monitoring. That said, there are also strong demands from patient and families for solutions through medication. While I’ve made some in-roads towards reducing doses, there has been some symptom recurrence and withdrawal effects, requiring full dose restoration.

It’s also been notable that although there are some chronically unwell people, some of the diagnoses and prognoses (predicated outcomes for illnesses) are more severe than I would suggest. I’ve since carried out a number of detailed reviews and while accepting that some previous observations were broadly right, I remain concerned about how little indication there is about how that decision was reached.

I’ve also discovered some discrepancies in the prescriptions recorded in the patient’s notes and what they actually receive. This happens because specialists in the NHS, like psychiatrists, make recommendations for GPs to prescribe, though changes made by one service may not be realised by the other. Conversely, there are some patients who have been on the same medication doses for over ten years and thus, even though the service moved into a modern building three years ago, parts of the service have been clinical drifting.

There has also been further changes and cuts in services since I arrived, though staff moral is steady and I’ve had good experiences with all of my new colleagues. I’ve also been particularly fortunate to have a secretary who is super-efficient at organising my clinics, though sometimes I regret my suggested time intervals for follow-up appointments as my recommendations are always followed. Still, with her help, I’ve been able to see nearly 200 individual patients and complete over 500 direct patient contacts. Thus, for all those reasons and more, this role has at times overshadowed what is arguably the more interesting and demanding part of my appointment.

Homeless Mental Health Services

Sunset over Bell Street hostel

Sunset on the former Bell Street hostel

Glasgow’s Homelessness Health and Resource Services began in Glasgow in 1992 as it was recognised that the environment within the East End’s former industrial-sized hostels often perpetuated unhealthy lifestyles for its residents. Thus, the service sought to reach this mostly male population and help individuals take up and maintain more settled accommodation. Now with the large hostels having closed, much of the service’s original purpose has been achieved though at any one time, there are over 1500 people registered as homeless across the city.

While homeless services remain located on the city’s east side (and very close to where I live), the profile of people using services now is somewhat different. As might be expected, there remain many destitute Glaswegians with alcohol and substance abuse issues while others only come to our attention when they’ve been evicted for their disturbed behaviour or non-payment of rents. There’s also a sizeable population of migrants with a dedicated local service for registered asylum seekers, but for those foreign nationals who arrive here independently, homeless services can be a necessary safety-net. Thus, my training in Ghana two years ago remains relevant for seeing people from non-Western cultures, which has included people from Africa, Asia, the Middle East and a few from Europe. Sometimes we even see some English!

Homeless health services are based in its own building, operating as a ‘one-stop shop’ with clinical facilities for General Practice and Addictions care. While I work specifically with the Homeless Mental Health Team, there’s often joint collaboration and some patients may see all three specialties. I’m still picking up on the social issues and themes involved, which includes increased recognition that homelessness in itself is an increased risk for mortality (Morrison, 2009) and that childhood trauma is both predictive and a greater risk for homelessness than childhood poverty (Fitzpatrick, 2011).

End of the Red Road flats

End of the Red Road flats

My main role is overseeing mental health assessments and medication recommendations for our client group, while working with my nursing colleagues. The CPNs here are all veterans of the service and their local knowledge is invaluable for maintaining contacts with patients, some of whom can be hard to engage and may frequently change accommodation. On occasions, I’ll also travel with the CPNs and along the way, I’ve seen a number of hidden locations within the city, including tower blocks flats and b&b’s for the destitute, as well as some purposely designed placements that prepare people for moving into their own tenancies. However, when we visit, there’s often no guarantee that the patients will be there.

Over this past year, I’ve assessed an extreme range of individuals and it’s been enthralling to review their backgrounds while trying to engage them therapeutically. For a few patients we use mental health legislation (Scotland has its own Mental Health Act) to ensure they remain in contact with us and accept medication. Many patients though are resistant to our efforts and will fall back into familiar patterns. Sometimes we’ll conclude that a person’s problematic behaviour is not due to mental illness and our contact will then end, while others have gone on to be imprisoned. Mostly though we try to work steadily towards improving people’s health and functioning, while establishing their own accommodation with some success.

The homeless service has also had to make savings and it was feared that it might even have to close. To some extent, closure is its purpose and would be a successful indicator that homeless people had been incorporated into mainstream services; though for now, the service continues with further streamlining to come.

My own long-term role isn’t so clear as I’ve stepped in to fill a short-term gap for both services. While it has been demanding at times, it’s brought a remarkable exposure to the issues going on, as well as a sustained experience as a consultant psychiatrist. Thus, in the birthplace of R.D. Laing there’s been plenty to consider about the influence of trauma, social opportunities, families and culture; as well as extremes in daylight and weather (it’s not stopped raining this summer!), on the presentation of mental illness. Meanwhile among the other themes going on includes more recession, benefits review anxiety, NHS and pension reforms, Scottish independence, minimum pricing for alcohol, the demise of Rangers FC and the Commonwealth Games to come in 2014. It’s all involving, though I really must get out and have that proper holiday in Scotland soon.

References

Fitzpatrick S, Johnsen S & White M (2011) Multiple exclusion homelessness in the UK: key patterns and intersections. Social Policy & Society, 10 (4): 501-512.

Morrison D (2009) Homelessness as an independent risk factor for mortality: results from a retrospective cohort study. International Journal of Epidemiology, 38: 877-883.


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Traditional healer, Kofie Munufie, describes his beliefs and informal healing centre near Kokuma, Ghana – July 2010.

Background

In May 2010, I taught at the Kintampo Rural Health Training School in central Ghana as part of the recently established Kintampo Project that provides formal training in psychiatry to middle grade health workers (see Opening of the MAP blog). The students were a group of experienced Medical Assistants (MAs), former experienced nurses who had undertaken further training to perform a doctor-like role. While MAs now make a significant contribution towards Ghana’s health care, within psychiatry they are increasingly necessary as there are less than 15 psychiatrists in this country of 22 million people [1].

During our teaching programme, a field trip was arranged to visit a fetish priest and the ‘informal healing centre’ that he runs for people with mental illness. Typically a fetish priest serves a ‘Spirit’ that inhabits a shrine within their community. Through the performance of rituals, it is believed that the shrine’s Spirit can take possession of the priest, who then speaks on its behalf ‘in tongues’. As mental illness in Ghana is associated with being spiritually unwell, family members often approach these priests to treat their relative, as an alternative to seeking medical advice [2].

We thus visited Kofi Munufie at his remote, rural community, near the slightly larger community of Kokuma, to observe his approach and the conditions at the healing centre. To get there involved a 30 minute drive south from Kintampo, including 10 minutes along an uneven, unpaved road and then walked for a further 10 minutes. For over an hour, our host answered questions from the students, which were translated for the non-Twi speakers among us. During this time we also met with some of the ten or so patients, who may remain here for between six and 12 months at a time.

When I returned to Kintampo six weeks later to provide additional teaching, I was keen to speak to him for longer, along with my girlfriend, Wendy, who has a personal interest in shamanic healing. We thus arranged by mobile phone to visit on Saturday morning along with one of the MAP students, Ernestina Agyei Yobo, providing translation. This time, when we turned off the main road, there was a modern sign with his photograph and directions, with a similar sign displayed at Kokuma. As before, we then made our way on foot for the remaining distance, attracting a trail of local children along the way.

On arrival at Kofi Munufie’s community we were led to his reception area which consisted of a three-sided building that faced towards a central compound surrounded by other buildings. When he appeared wearing a white woven smock, dark knee-length shorts and sandals, this charismatic, athletic man in his 30s with short dreadlocks was claerly in charge. While he initially had a serious, formidable expression, this gradually eased and later, he was prone to smiling and laughing easily. Among his assistants included a subdued, thin, shaven-headed man, who I knew from my previous visit was his ‘linguist’ and whose role would be more fully explained.

After presenting the priest with our gift of gin schnapps and cash, we then sat on a bench to speak. On his own dedicated chair, Kofi Munufie, who like other fetish priests is referred to as ‘Nana’, sat nearest to. This was followed by the linguist, with other men and women from the community completing the semi-circle, while a number of children played and watched with curiosity from a distance.

The recording and transcript

Before we began, Nana agreed that the interview could be recorded. While this would not have been possible without Ernestina and to whom I am extremely grateful, as with any non-professional translation there were occasions when the dialogue didn’t always match the reply. Although many of our questions were answered directly, undoubtedly some conversation was ‘lost in translation’ and further reduced when transcribed amongst the intermittent drumming and other stirring background activity. Where possible I have tried to retain Ernestina’s descriptions, though I’ve added words to aid meaning and clarified when there may be uncertainty about who was being referred to.

Since the interview I have since communicated with Ursula Read [3], a London-based Occupational Therapist, who has extensively researched informal healing centres and attitudes towards mental illness around Kintampo. Her experience confirms that Nana Munufie’s practice is consistent with most Akan priests in Ghana’s Ashanti and Brong Ahafo regions. On reading the transcript, Ursula confirmed there is a specific Spirit, known as an obosom, that resides within the shrine at Kokuma. On occasions this Spirit was translated as ‘He’, which I have capitalised. Ernestina also refers to ‘Spirits’, known as abosom, which translates as ‘gods’ or ‘deities’, who inhabit objects like rocks, trees and rivers. Sometimes though the singular and plural forms appeared to have been used inconsistently and I have retained what I believe was said at the time.

Ursula also advises that in Ghana references to ‘Spirits’ are influenced by the terminology that Christian missionaries introduced and which continues within the popular Pentecostal churches. Although Christian leaders often denounce traditional practices, many Ghanaians still incorporate elements of both beliefs in their lives.

The Interview

As the recording starts Ernestina translates Nana’s reply to her own question.

Ernestina: I asked him, “How does he recognise illness and what is the way he diagnoses and treats it?” He says if somebody comes for healing, he will call the Spirits to come and they will tell him the type of illness the person has brought and the treatment he can give. Then he will either make a request to pacify the Spirits or they may advise him to give the patient some medications.

Greg: Can he say, how he feels physically and emotionally after he speaks with the Spirit?

E: He says, he doesn’t feel anything physically and emotionally. When the Spirit comes to him, he doesn’t see or know anything, so he doesn’t know whatever he says or [what he] is doing. After the Spirit goes, he doesn’t feel anything physically and he is able to recognise everyone around him.

Tomorrow will be a ‘special day’. People will come around and they will beat drums and they will call [for] Nana. Then the Spirit will come on him and he will be dancing! He will be talking! The language can be French or other languages but it will not be in the local dialect. The linguist understands any language that the Spirit talks through, so after the Spirit has gone, the linguist will say “When the Spirit came, he ordered you to do these things for the patient.”

G: Can you ask, “how long that lasts for?” and also does he communicate about a number of patients at once or one at a time?

E: It depends upon the number of patients who are there. He works on every patient individually and the Spirit says what brought the person to come for healing, their disease and the treatment. At times, maybe a group of people will come and he will give a treatment. At other times he will say he cannot come and that patient has to come back another time.

G: This area we are visiting now, is it only for the healing or do other people live here?

E: The community is for him. He is here with his relatives because he cannot work alone. And some people here are patients, who don’t want to leave even after healing. But there is nobody else [who] stays here.

The recording then picks up the shaking of a rattle, which it is explained, is used on the evenings before the ‘special days’. There is lots of laughter.

Wendy: (admiring the rattle) It’s very beautiful. Can you ask him does he have a few spirits he communicates with or could they be the spirits of the patient?

E: It’s not the same but the elder Spirit [presumably the obosom – see above] is always there. Also there are many spiritual assistants, so if you call, any of the Spirits can come.

W: OK. Can you ask him, “has he always been able to do this or did he work with a teacher before?”

E: He didn’t learn it and it’s not from him. The Spirits ‘called’ him to come. It was like a prophecy [that took place] in his uncle’s home. So after his uncle died, the Spirit called him to come and work. He didn’t learn it.

Some of the men then bring out a large framed portrait of Nana’s uncle, who was the previous priest at the shrine and had died recently. The portrait is of an older man seated in traditional robes but superimposed against a spotless hotel lobby.

E: That is the uncle he was speaking about. The first group (who visited from the school over a year ago) came to meet him before he died.

G: Can you ask, “why does it have a modern setting in the background?”

E: I think it’s a studio.

Further communication occurs between Ernestina and Nana.

E: The background is from Kumasi. The photo of the uncle was taken here but they placed him in the studio to ‘beautify’ it.

W: Can you ask, “in Europe and America, healers are training students like myself to be healers and we may ‘hear the call’, because we want to do it”. Does he think that this work can be passed on like that?

E: He says, it’s not possible because the Spirits calls whoever He wants. So if I say, “I want to be trained”, Nana can train me but the Spirits cannot, will not work with me. The Spirits choose who He wants to work with. Nana can train me but it’s not possible that the Spirits can work with me.

G: And has the linguist undergone a training or did the Spirits suggest that he should do this work?

E: The Spirits called the linguist too. It’s a call. Other healers also can come for a training, to make them stronger. If I am weak [as a healer], then I can come and undergo some training and my Spirits will become stronger.

G: Is there a special significance here? Does this place have a history or is it just where his uncle lived?

E: There’s nothing special here but it was the Spirits that directed the uncle that he should come and build this place.

G And how long have people been living here?

E: They came to settle here, even before the fetish priest was born. So it’s a long time.

G: Since we were last here, he now has a sign on the road. Has that made a difference to his work?

E: This place is difficult for people to know it’s here. Now the visitors are coming in numbers, so he has to show where he can be located.

W: Would you tell him about the tradition that I have been training in? I have a beehive for honeybees. As part of my training I sit and listen to what the bees tell me. In England there is an old tradition to ask the bees when you want help. You also tell them about births and deaths and they will listen. One day I sat in front of them and asked for help because I was coming to Ghana. Then one of them came out and stung me straight there (points under her eye). It was funny and also an answer for me.

As Ernestina translates there is laughter, which continues after Nana replies.

E: The bee sting! He says, “it’s a ‘go-ahead’”. You can come (to Ghana)… nothing will happen to you!

G: Does he ever believe that insects or animals have a special significance?

E: He believes in that and that’s what Wendy reminded him of. During war, fetish priests can command and call bees to come and fight their opponents, who will die. Some [can also] use snakes or other animals and insects. So they believe in that.

W: So they are helpers, the bees and the snakes.

G: Does he ever have any concerns about the treatments the patients receive and whether they may have a bad reaction?

E: He has no concerns about the reactions of the drugs as those who come want to come. He gives a little treatment at a time and then he will be ‘topping it up’ until he sees that the patient has calmed down. As for side effects and reactions, he hasn’t seen much. If the person is on a treatment for two or three days and is not making any improvements, then he calls [the Spirits] again and they direct him to make a change in medication.

G: When I came here before there was a young man who said that he felt some pain from the medication he was given but he believed it was helpful. (This man who spoke English also said that he preferred Nana’s care than when he had been a patient at two of Ghana’s psychiatric hospitals) Does Nana think that sometimes, patients will feel worse before they become better?

E: Some patient come taking orthodox drugs and he will give them an antidote before he starts his medications. But if he doesn’t know this and he gives his medication, then there may be a reaction.

G: Could you tell him, in England I specialise in care for mental illness and I have been in Ghana for nearly three months. Is there anything he would like to ask me?

E: (after laughter from the group) He says he will come with you and work in England!

G: He will come with me? I would be happy to show him!

E: He’s asking you, “How do you manage psychiatric patients?”

G: In England, many patients come asking for help or their families will suggest they come. If they’re really unwell, the police will bring them. Then I will ask questions like a doctor about their health and about what they think is the problem. Often I am interested to know is there something they think will help them.

E: Will it be acceptable that when he comes over he can use herbs to see the patients?

G: (hesitantly) If a patient asks for assistance and he wants to help them, we would call that consent. An agreement. Now the police might be interested as well… It’s a hard question!

E: He asks do you ever see mental patients healed completely?

G: In Europe and America we sometimes see mental illness as a life long condition that has times when its better and times it relapses.

E: Its true that they relapse, if the person has offended somebody and the person has cursed him in order that he should go mad. If the patient comes to the hospital, you will give psychotropic drugs and the patient will get well. Meanwhile what the patient did is still there, so that brings the relapse. But if a fetish priest sees what’s actually caused the problem and removes it, then it will not come up again.

G: Can you just add that sometimes I see people and I don’t think there is a mental illness and I will give advice. So sometimes my job is to say to people when I don’t think there is a mental illness.

E: He says that they also have the same thing. Some people come with psychological problems like a relationship or a marital problem. He will give advice and let the person go without medication. They also believe in that.

G: Can you ask him, “does he have any views on epilepsy?”, particularly in children and what are his thoughts on the cause of epilepsy?

E: He says, epilepsy is given to them by other people, especially when the person is born. The person who delivers the child can give it to the child and then it would be in someone else. If you don’t know the actual cause and where it came from, then you cannot treat it. So he believes epilepsy is given by other people.

G Yes. OK… (resignedly) alright. I have a colleague who will be coming here in a few months time. Would he be happy for her to visit and and is there anything he would like to be brought. Anything from the UK?

E: (after some laughter) He says, the only things he needs here is a lighting system!

Further communication from Nana follows.

E: If there are people that are difficult for you to treat, you can bring the patients here and you will see how they work.

G: He’s saying he would be happy to receive patients here? Could they be treated as a day patient or would they need to stay here several days?

E: He can treat people on an out-patient basis but difficult ones, he has to observe the patient before treating.

Sensing the interview was ending I asked whether he follows events that are happening in Ghana and the wider world, like the World Cup. Nana replied that they have a radio. Ernestina then asked how do people know that the Spirit comes on Sundays and Wednesdays? Does he make an announcement through the radio? His reply suggests that like any good tradesman, he relies on ‘word of mouth’.

E: He says, that after people come here, they will send a message. So if I’m not well and I come here and I get healed, then when I see someone who is sick, I will say, “go to this man”.

W: So if I wanted a healing myself would I have to come on a Sunday or a Wednesday?

E: He said [he works] all days but Sundays and Wednesdays are ‘special days’. They will beat drums and then dance and then call him and the Spirit comes.

G: Where does he do that here? Where does it happen here?

E: He would like to show you.

Touring the compound

Interview over, we’re then taken as a group to see Nana’s consulting area, which I hadn’t seen before. As we pass through the compound, there’s a cleared area with a single thatched hut on the far side behind wooden fencing. Its significance wasn’t explained, though later I learn this was the shrine where the Spirit resides, which only the priest and his assistants may enter.

Then we’re led down a straight cleared path further into the bush towards a small clearing with an altar-like table at the back that’s covered with a cloth. We’re not allowed to enter any further but this is likely to be where the patients are brought when Nana is possessed with the Spirit.

We walk back towards the path’s entrance and the clearing next to the shrine, where the children of the community are drumming underneath a shelter. We’re treated to a demonstration of how they will prepare this evening, ahead of tomorrow’s ‘special day’. Here an impromptu burst of dancing breaks out which Wendy and I take turns joining in with, resulting in much laughter among the community, which Nana observes approvingly. After catching our breaths, we return to the reception area where we have photographs taken with Nana before leaving with a feeling of accomplishment.

During both of my visits, it was clear that there were people with mental illness present, some of whom spoke to us freely. Whether there were others being treated out of view wasn’t clear but when I visited before, we were told that a number of patients were asleep at 10:00 a.m. after having been given herbal treatments.

While I did not see any maltreatment myself, there are concerns about the conditions at some informal healing centres, both those run by traditional healers and at Christian prayer camps. For example, some patients may be held in shackles and reliant on their relatives to ensure that they are fed and cared for, while other treatments may include enforced fasting and beatings. The issues involved are discussed in considerably more detail in an excellent paper by Ursula Read et al [2].

As can be gathered from Nana Munufie’s forthcoming replies, he clearly has a strong belief in his own ability and the causality of illness. While his recent contact with the school at Kintampo may suggest an appreciation of ‘hospital medicine’, he may also be seeking to demonstrate the superiority of his methods for treating conditions that ‘white-man’s medicine’ cannot cure. For instance, this may have been the motivation for his question about whether I have seen “mental patients healed completely” [4]. I can only wonder what Nana would think of Western approaches to mental illness if he ever did actually visit.

References

[1] Asare, J. Mental health profile of Ghana. International Psychiatry 2010; 7, 67-8.

[2] Read U, Adiibokah E, Nyame S. Local suffering and the global discourse of mental health and human rights: An ethnographic study of responses to mental illness in rural Ghana. Globalization and Health 5:13. 2009. [Accessed 10 October 2010].

[3] Personal correspondence

[4] Read, U. (in press) “I want the one that will heal me completely so it won’t come back again”: The limits of antipsychotic medication in rural Ghana. Transcultural Psychiatry.


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Teaching on the Kintampo Project’s Medical Assistant Psychiatry degree course

The Need for MAPs

For a population of 22 million people, Ghana has just 13 psychiatrists (Asare 2010). Thus within the country’s three psychiatric hospitals, Medical Assistants (MAs) regularly perform a much-needed doctor-like role, though their psychiatric education has not previously been formalised. Furthermore, there is recognition that mental health services need to shift from being focused at the three, south coast based hospitals to the wider community.

The Kintampo Project has thus been developed by the Kintampo Rural Health Training School (KHRTS) in conjunction with Hampshire Partnership NHS Foundation Trust (HPFT) and the University of Winchester to deliver Ghana’s first dedicated psychiatric training for middle level health workers. This consists of two courses to train two new types of mental health worker known as Medical Assistant Psychiatry (MAP) and Community Mental Health Officer (CMHO). Consequently it is hoped that as this psychiatric workforce develops, mental health care can be spread more equitably across Ghana’s 170 districts.

The MAP opens

In May 2010, the Project’s inaugural 18 month MAP degree course welcomed its first intake of students. Each of the nine students were experienced MAs who had previously attended KHRTS in central Ghana for their initial MA training. While they were supported by their employers to attend, it was still a significant commitment to make towards an unprecedented course and most had left young families during the week to share dormitories with classes starting at 7:00 a.m.

For the MAP course’s first two weeks, I joined a UK-led teaching programme which included HPFT employees clinical psychologist, Dr Tess Maguire, and community psychiatric nurse, Patrice Fugah. I had only arrived in Ghana two weeks earlier as part of a three-month volunteer placement based at Pantang Psychiatric Hospital on the outskirts of the capital, Accra and a nine-hour drive south from Kintampo. While I was the fifth UK trainee to volunteer for this Royal College of Psychiatrists’ approved training opportunity (Neate 2011), the Kintampo Project was a new experience for everyone.

Although my initial time at Pantang had been brief, it provided an invaluable introduction to Ghana’s culture and its health service. Thus during my presentations on psychosis, mood disorders and performing mental state examinations, I was able to include descriptions of actual patients that I had seen. These presentations were also then linked with the corresponding chapter in the Oxford Handbook of Psychiatry, which each student had received a copy of.

In keeping with the approach of my fellow teachers, student interaction was encouraged, particularly during the reflective session that ended each day. While the students had expected a more traditional, didactic style of teaching, after some hesitancy they became more personally involved, which we hoped would encourage their future learning.

Meanwhile outside of class, Dr Mark Roberts, the Project’s UK lead, collaborated with the tutors at KHRTS on the curriculum for both courses and supervised the tutor’s personal development plans. With such measures being undertaken to ‘educate the educators’, it is intended that the Project will become sustainable and the development of an excellent mental health workforce can be maintained.

Further Collective Learning

In addition to our teaching presentations, two field trips were arranged to observe the local context in which mental illness is perceived and managed. While these were valuable learning experiences for the students, they were as much of an education for us, their UK-based teachers.

Our first trip involved visiting two spiritually based, informal healing centres that provide treatment for people with mental illness. Both functioned as communities in themselves and who welcomed us warmly, offering us seats in a circle that faced their leader’s designated, elevated chair. In the Ghanaian custom, our hosts then shook hands with us in turn, following in an anti-clockwise direction to ensure that none were approached with the backs of their hands. After prayers were said to their inspirational source, all eyes remained on the group’s charismatic healer who led through his aura and authority. Understandable really as both the traditional healer and Evangelical pastor said they could remove illness by communicating with a supernatural force!

In Ghana many traditional healers are known as fetish priests who serve a shrine, which a ‘Spirit’ inhabits. The priest at the remote, rural community that we visited said that he had been called by the Spirit of his community’s shrine to succeed his deceased uncle. Subsequently, when he underwent twice-weekly possession, this Spirit communicated through him ‘in tongues’. While the priest said he lacked for any memory whilst possessed, with the assistance of his ‘linguist’ who transcribed his unintelligible speech, he could identify what ails and which herbal preparation would treat those who sought his help.

We then met the pastor of an Evangelical church and prayer camp who provides a similar link between this world and a spiritual one through the word of God. Citing the Bible’s account of how Jesus healed a man with ‘evil spirits’ through prayer, the pastor told us that as all illnesses are caused by ‘evil spirits’, then prayer is the only effective treatment.

At one location we were shaken to see shackles used to detain and treat people with disturbed behaviour, though it has been reported that their removal may have a symbolic value as a “dramatic demonstration of the efficacy of healing” (Read et al, 2009). Other ‘healing’ treatments reported include enforced fasting and even beatings, though we did not see evidence of the latter. Back in the classroom we discussed and reflected on the role these spiritual healers play in providing culturally acceptable explanations for mental illness.

Our second field trip also revealed some unexpected approaches at the nurse-led psychiatric outpatient clinic at the nearby hospital. Here our students met with a young woman complaining of headaches and depressed mood. Although the consultation was unevenly matched, we were interested to observe the student’s assessment skills, particularly after my session on mental state examinations. What we didn’t expect was for the besieged woman to face questions in a free-for-all style that matched the busy waiting area outside.

Clearly more work was required to reinforce what appeared understood in the classroom but abandoned in the field. Therefore we arranged interview practice for the students with us, their teachers, simulating the presentations of patients. Then using their peer’s observations, we encouraged each student’s strengths and made suggestions that linked with our earlier teaching. We particularly recommended this approach to the MAP tutors and later heard that KHRTS plan to establish teaching clinics where students are supervised while assessing local patients.

Return to Kintampo

Six weeks later I returned to Kintampo to provide three more days of teaching. The students remained committed and had been taught psychology, ethics, research and management as outlined in the curriculum by the tutors at KHRTS but had lacked further actual psychiatry.

Thus, I expanded upon my earlier teaching and delivered a presentation on perinatal psychiatry. In addition, with my visiting girlfriend, Wendy, we developed a simulation of postnatal depression with and without psychotic features, which allowed for comparison and provided more interview practice. The students also presented projects that they had completed in pairs between my visits and I suggested further topics for them to prepare.

While my experience at Kintampo was personally positive, more importantly it appeared to have been a good start for the Project. The students were appreciative too but asked what would happen between UK visits? At times I wondered myself, were we just psychiatry colonialists visiting temporarily with our own values?

Here though our purpose was clear; to contribute as guests of KHRTS to a course that would receive ongoing support and further support from the UK to supplement their own resources. Thus while it was the responsibility of the tutors at KHRTS to ensure that the teaching programme was delivered, I hoped that my ongoing interest would encourage the student’s own development and that of Ghana’s future mental health service.

References

Neate, G. Out of Programme Experience in Ghana. Royal College of Psychiatrists. Retrieved July 9 2011 from http://www.rcpsych.ac.uk/members/internationalaffairsunit/volunteersprogramm/ghana-maytoaugust2010.aspx

Asare, J. Mental health profile of Ghana. International Psychiatry 2010; 7, 67-8.

Read U, Adiibokah E, Nyame S. Local suffering and the global discourse of mental health and human rights: An ethnographic study of responses to mental illness in rural Ghana. Globalization and Health 5:13. 2009

Declaration of Interest

The Royal College of Psychiatrists provided my airfare to Ghana as a registered volunteer with the College. The Kintampo Project provided my transport and accommodation while teaching in Kintampo.


Leaving England

24Sep11

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Soundtrack by Brakes

“Should I stay or should I go?” is the obvious soundtrack for any feted footballer faced with transferring between teams. Having completed higher training in psychiatry, I was confronted with this question when considering whether to move 450 miles from Sussex to Scotland. Employment-wise, changing jobs was surprisingly straightforward. Relocating itself though – despite being a previous familiar experience – proved even more challenging and draining than expected. While it might have been cathartic, given the choice again, perhaps I’d question its costs.

Technically I was ‘out of contract’ after qualifying and now working as a locum (freelance) consultant. I’d completed three short-term posts covering for other colleagues’ leave but after six months without clarity about my next placement, an opportunity to jump arose and I thought to swap one ‘known unknown’ for an ‘unknown unknown’. Glasgow might be new territory but surely it beat commuting from Brighton to Hastings!

The job offer was an intriguing proposition that I sensed couldn’t be refused. Part consultant within a suburban community mental health team, part psychiatric cover for the city’s homeless service – a crash course into Glaswegian culture! The 12 month contract also offered substantial experience and an escape route. When contacted the day after my 18-hour round-trip commute for interview, I accepted.

Still would something else turn up in Sussex? With my address of the past three years, I had my ideal home. Three stories high with panoramic sea views, I may have been renting but I’d made it my own. It would take a lot to move me.

When Glasgow called, the medical director said police and occupational health clearance would take weeks. I relaxed knowing I’d have a final summer by the sea and plenty of work soon enough. However, on returning to Glasgow a few weeks later to confirm the job plan and view my new working environment, she asked if I’d start as soon as possible! My predecessor with the Homeless Team was retiring in a week’s time, the other post was ready and waiting. Sooner I figured, would be better for all as I’d receive a direct handover, a gentler introduction and be closer to knowing where I’d be in 12 months time. Within four weeks of interview, I was in post.

Moving home though was another matter and ended up taking just as long. While in Glasgow, I’d agreed terms swiftly on the first flat I viewed, partly for its modern features, central location and underground parking. However what sealed it was the walk-in closet that I’d use for storage, ensuring both access and separation from my life’s possessions.

To get them there a removals company would have been sensible. However the one quote I took had hourly rates that would rapidly accumulate with the journey times involved and I’d never get everything done for someone else’s timetable. By hiring a van I could do this myself and squeeze in a boot sale with Lorne, who had his own CDs, comics, clothes and children’s toys to shift. We thus loaded up on Sunday morning for Brighton Racecourse with what we hoped would be a one-way journey for our cast-offs and returned somewhat lighter with pounds of coins and paper.

I still faced the first of three, 10 hour van journeys and driving late into the night. Far too late as it happened to unpack and an extra day’s hire fees were needed while working the following day. Perhaps it could have all been done as planned with two journeys but I’d underestimated the size of the second van required and just how much there was to do. Fortunately my landlady graciously allowed me an extra week, though the bills were accumulating further, my carbon footprint expanding and more time lost between homes.

Removing all I owned from the flat on Marine Parade revealed a reasonably sized space with stunning light that my stacked furniture had previously absorbed. I regretted how I allow my possessions to intrude into my world. While my Glasgow home had some space for storage – even without the bed, mattress and couch that I sold on cheaply for Matt’s unexpected flat makeover – I feared that too would soon fill and overspill. Of course, it wasn’t just the view that I was leaving behind. Over those weeks a team of friends rallied and proved memorably helpful with either accepting stuff for safekeeping, heavy lifting or hearing me out as I wobbled over my decision. I also saw how some friend’s children were growing up further with greater personal recognition and I wondered whether I’d experience that more directly.

On my final return to Brighton, I heard that new work was now available. A colleague had begun a post that I’d likely have been offered and which wasn’t in Hastings! It was a welcome opportunity for him and also likely that my former employers would have noticed my absence. Maybe I’d been too impatient or perhaps had strengthened my future negotiation position. Whatever, I was now Glasgow bound and I reasoned again if it was good enough for (football reference alert!) fellow Irish via Leicester old boys, Martin O’Neil and Neil Lennon, then for now, it would be for me.

Thanks to Lorne, Sam, Jon, Graham & Alison, Al & Rona, Matt & Craig, Rob, Lucy and Barinder for helping me with the above. I made it.


Fantasy coffin heaven

One of the many buried treasures that fell from my archives during my move from Brighton to Glasgow was this feature on fantasy coffins in the Independent Magazine from 27 May 1995! Unfortunately I only kept the centre spread (part of a feature from a book, Going into darkness: Fantastic coffins from Africa by Thierry Secretan) but 15 years ago I must have known something then that I’d go on to have a personal connection with such a culture. Apparently the practice of having your own bespoke coffin made to commemorate your significant contribution in life mainly occurs in the Ga region around Accra. Also, I didn’t see an actual fantasy coffin in use, but there’s an artist’s gallery near Labadi beach that had models available to view

Also while making one of my four separate road journeys from Brighton to Glasgow, I realised what my fantasy coffin preference would be. Should any of you ever wish to organise such a send off, then please note I would like a replica white van stuffed with as much of my vinyl, CDs, photographs, negative, photo equipment, books, journal, medical notes, clothes and other crap I can never throw away. It needn’t go in the ground either but can be rolled into an incinerator will do fine.

Anyway, I’m now all moved from Marine Parade to Merchant City with just a few more boxes to unpack and still space!. Thanks to Lorne, Sam, Al & Rona, Graham, Matt & Craig for all your help. I’ll miss you Brighton x