For the first 27 years of my life, I was intellectually happy. I spoke with my fellow physicists about topics without cognitive collapse. The meaning of a wavefunction, who should be the next prime minister (answer: try everyone), why are there so many variations of bowling… life was simple, the world made sense, I never banged my head on the table.

Then I started reading health science articles and came across a word that has turned my sunny-side-up neural wiring into a scrambled mess: Reductive.

The word changes meaning every time I set my eyes upon it – it shapeshifts depending on the writer’s intention. I think most use it seriously, but the more literature I read, the more I get the impression that many simply use it as a socially acceptable way to professionally insult a colleague.

Bluntly, I do not know what the word objectively means. I have parsed dictionaries named after upper-class institutions, each vying to be the one true language compendium,1 hoping for a simple answer. I have scoured articles written by philosophers, believing their highly skilled pedantry would provide the desperate clarity my mind desired. Alas, all I managed to do was make things worse. Apparently, there are different kinds of reductionism: methodological, ontological, theoretical, epistemological, and probably more. I am stuck in a reductive labyrinth without a minotaur to put me out of my misery.2

Reductive roundabouts

The first entryway to our semantically challenged maze is a roundabout of contradictory reductive criticisms.

Say, for example, I tell you that planetary orbits can be calculated by assuming planets are point masses – we take all the complexity of a planet and simplify it into a single dot. Without hesitation, many will cry “that’s reductionist!”

But consider the alternative. To fix the reductive model, maybe I start by making the planets spherical, rather than a point. Perhaps I give the planets cores, some magma, a few mountains. Then maybe I model the atmospheres. For life-containing planets like Earth, I add buildings, roads and creatures big and small. If I continue down this road to greater and greater detail, I end up with planets modelled right down to the interactions of atoms. Which many, without hesitation, will also cry “that’s reductionist!”

We are left with nowhere to go, stuck forever circling a reductive roundabout with no exits.

Schrödinger’s stairwells

If we choose the second entryway, a narrow slit in the outer wall of the reducible warren, the passage is split into an infinite superposition of Escherian stairwells.

Before we even get to the philosophical varieties, the ordinary word “reduce” has so many different meanings, it is a wonder any of us are able to understand each other when we use it. Generally, however, a reduction requires us to specify the type intended: a quantity being decreased, a form being reached, or how objects are being compared. For example, “reducing the water” requires us to specify that we intend to decrease the amount (an alternative may be chemical reduction).

So, when I read something like “Can we really reduce the brain down to the interactions of atoms?” my brain swirls into a headache of intellectual dizziness. Reduce down what? Scale? Composition? Explanation? Complexity? Number of doughnuts? When I see the word “reduce” within psychiatric articles, the type of reduction is rarely, if ever, mentioned. Usually, all that will be specified is a vague mention of lower or higher “levels”.

Fractal Reductionisn’t

Our final entryway into reductivist puzzle hell starts with us trapped in the labyrinth’s centre. Instead of being able to find a way out, we end up at the centre of ever larger labyrinths.

When an analysis of a complex system is criticised for being reductive, the proposed remedy is usually to make it more holistic. Sometimes arguing that the analysis should be widened to include the whole environment.

The problem with this solution can be illustrated through the medium of a bad bar joke:

A physicist, biochemist, psychiatrist, World Health Organization official, Buddhist monk and the ghost of Alan Watts walk into a bar.

The physicist starts by arguing that mental illness can be explained through fundamental particles and their interactions. “That’s reductive!” the biochemist decries “Clearly we must consider biochemical reactions as a whole to explain mental illness!” The psychiatrist slams down their pint “That’s reductive! We have to consider the mind and body as a whole to treat mental illness.” Returning from a zoned-out state, the WHO official nearly chokes on their kombucha “That’s reductive! Mental illness is a global phenomenon caused by wider problems like poverty, lack of government funding, lack of community and limited mental health initiatives. We have to consider societal issues as a whole.” The Buddhist monk, free from anger, politely indicates to the WHO official that they are perhaps being reductive “Really, we are all one” he surmises “If we so wish to explain mental illness, we must consider the whole universe. Every human being, plant, rock and star.” The ghost of Alan Watts, levitating slightly while smoking his ghost pipe, chuckles “Isn’t that quite reductive? I think you will find the whole universe is all really nothing. If we search deep into our fundamental nothingness, we can begin to explain the nature of mental illness.” The physicist pipes up again “Well, actually, that is being pretty reductive. The fundamental particles that make up the universe were formed shortly after the Big Bang, which could be argued came from nothing.” The biochemist decries “That’s reductive! Clearly biochemical reactions explain…”.

In other words, those advocating for a widened holistic analysis aren’t arguing for a whole without bounds, they are arguing for a larger, or differently bounded, part.

Where Isn’t Waldo

I have been desperately trying to find an explanation, a reductive sat-nav that would be able to guide me through the labyrinth of reductionist critiques. But I remain as lost as when I first spotted the godforsaken word.

Like a Where’s Waldo book where the artist forgot to include the bespectacled main character, I feel like I am searching for a very specific meaning, when, in fact, reductionism is represented by a plethora of other characters. To be honest, I have the funny feeling everyone else is reading from the same book.

We are the ones who draw lines over the canvas of the universe. If we wish to understand anything at all, we have no choice in the matter. It is not possible to measure the entirety of existence to infinite resolution. Consequently, we split the universe into representations of interacting phenomena that we hope best agree with data from our finite resolution measurement instruments. This is a “model”. A system is the domain of the universe we have chosen to represent with a model; its boundary divides the system from the rest of the environment.3

But the representations of interacting phenomena are much more diverse than the popularly assumed Newtonian view of the universe. For instance, at the atomic scale we often don’t use spherical “objects”. We characterise the microscale through bonds, fields, distributions, wavefunctions, spins, angular momenta, potentials, densities; the list goes on. If we want to study interactions at the microscale, accounting for these characteristics makes sense.

The macroscale is a different story. It would be pointless, verging on idiotic, to model an entire brain using atomic interactions. Most pertinently, it’s astronomically computationally expensive. Extrapolating from one of the fastest proposed machine learning molecular dynamics simulations, trained to reproduce ab initio (from first principles) calculations, it would probably take something like 5 trillion years to simulate 1 millimetre cubed of water for 1 millisecond. A brain approximated as just a lump of water would take roughly half a billion times the age of our universe to simulate 1 millisecond of action.4

But say you have a lot of time on your hands and somehow lucked into finding a universe-sized computer just sitting in God’s knapsack. You would still run into the problem of measurement. Because we cannot measure to infinite resolution, every model, no matter its domain, will have assumptions, simplifications and approximations. Every model will be incomplete. If you apply a model outside of the scope it is intended for, the omitted details can become sources of error.

We could potentially end up with a result less representative of our macroscopic brain than a model which purposely averages out fundamental microscopic properties into simpler coarse-grained ones. Why add microscopic complexity onto an already complex macroscopic system, when there is a simpler, more efficient model that does a better job?

Depending on what we want to study, we adjust the model we use. Sometimes it makes sense to represent a planet with a point mass, other times we need a fine-grained gravitational field. The critiques, therefore, should be specific and focused on whether the models and system boundaries are appropriate for the phenomena we are measuring.

Building an unreductive vocabulary

Psychiatric and psychotherapeutic model critiques need a vocabulary upgrade. I think there are better words that more accurately conceptualise things reductionism is trying to describe.5

Oversimplification

I think this is what is most often meant when reductive is used. This is illustrated in the Cambridge Dictionary:

Reductive: “considering or presenting something in a simple way, especially a way that is too simple”

Oversimplification: “the action of describing or explaining something in such a simple way that it is no longer correct or true”

If you are writing a scientific paper on the causal landscape of depression and come up with a model that is three categories called Psychological, Biological & Environmental with causes listed underneath, this would be an oversimplification. Yes, the three categories technically extend over the entire causal landscape, but the list format doesn’t capture the inherent complexity of interactions between causes, and how these interactions may vary from patient to patient.

Ironically, I think the Cambridge Dictionary’s definition of oversimplification is an oversimplification with respect to scientific models. An oversimplified model is one where the simplifications go too far for the intended application of the model.

Overemphasis

This is where too much focus is put on one aspect, component, or interaction in a model to explain the entire system. So, for example, saying that all mental disorders are metabolic disorders of the brain. Metabolism is likely one part of the puzzle to varying degrees. But saying it is the main component probably stretches into overemphasis.

Omission

The model does not mention a factor/component/phenomenon that has a significant influence on the system in question. This might hypothetically be a neural pathway not mentioned that was previously shown to have a significant influence on the symptom of anhedonia in depression, for example.

Misapplication

A model is not applicable when it is used beyond the scope of its intended purpose. An extreme example would be using a model meant for train signalling to describe neural signalling in bipolar disorder.

Faulty approximation

Approximation refers to a specific method of simplification. Essentially, it is a substitution of a complex component of a model with an inexact representation. Most of the time this is done to make outputs from the model easier to calculate. An example might be substituting the shape of a vaguely spherical cell in a 2D video with an annotated circle to computationally track its movement. A problem with the approximation may be if you found out that the shape of the cell changed considerably while it moved, causing the centre of the annotated circle to move inaccurately.

Faulty assumption

An assumption is a claim or condition that the model takes as a given. Often it is a claim that an effect is negligible, constant or non-existent.6 For example, a model of genetic predisposition to depression could assume environmental influences are negligible. This assumption could be faulty because environmental conditions may influence gene regulation through epigenetic processes.

The linearity trap

I have often seen claims about psychiatric models that confuse different meanings of “linear” and “nonlinear”. Ladyman et al. (2013) make a similar complaint:

In the popular and philosophical literature on complex systems a lot of heat and very little light is liable to be generated by talk of linearity and non-linearity. For example, Klaus Mainzer claims that “[l]inear thinking and the belief that the whole is only the sum of its parts are evidently obsolete” (33, p. 1). It is not explained what is meant by linear thinking nor what non-linearity has to do with the denial of ontological reductionism. Furthermore, an obvious response to this kind of claim is to point out that it is perfectly possible to think in a linear way about systems that exhibit non-linear dynamics. Unfortunately the discussion of complexity abounds with nonsequiters involving nonlinearity.

When it comes to mathematically modelled systems, linearity and nonlinearity correspond to the relationship between inputs and outputs of the functions that describe the system. Linear functions abide by the superposition principle. Nonlinear functions do not.

The linearity trap is therefore mixing up metaphorical meanings of linear with the mathematical one. For example, a unidirectional chain of events could be metaphorically described as linear, but the relationships between them could be mathematically modelled as linear or nonlinear. Neither of the meanings unilaterally defines whether the system involving the chain of events is complex or not.

It is encouraging to hear more psychiatric researchers advocating greater use of nonlinear dynamical models. However, critiques of previous models must reference mathematical relationships, rather than metaphorical descriptions.

The end of reductionism

No one understands reductionism because the term has so many potential meanings, trying to determine the correct one for each use becomes a near impossible task. There is a crude paradoxical irony that due to the complexity underneath the word’s surface, one could suggest that any argument accusing something of being reductive, is itself reductive.

Quite a few actors in psychiatry have argued for the end of reductionism. I would tend to agree – though not in the way these actors would like. Exploration of the universe through models is here to stay. But, using "reductive" to inaccurately describe this exploration only leads to confusion. Therefore, I don’t think we should use the word at all.

To find out, I chatted with Gunnar De Winter. He is a science writer and storyteller based in Ghent, Belgium. He has written both fiction and non-fiction, with pieces published in Clarkesworld magazine, Tractor Beam, Heartlines Spec and The Deadlands. He has a PhD in Ecology and Evolutionary Biology, a Master’s in Philosophy and works as a science communicator for a biotech research institute.

Perhaps slightly awkward to admit, I have fallen in love with Gunnar’s Substack, Subtle Sparks. He has a way of writing unlike anyone I have come across. So I wanted to talk to him about the origins of his writing style, how science and writing can go together and the upside of the long way round to evolutionary thinking.

(Gunnar’s Substack recommendations are: Lessons on Drugs, Cognitive Wonderland & Reminders for Humans)

Full conversation

Edited transcript

Alex Mendelsohn: Welcome, Gunnar. Very happy to have you on and lovely to see you.

Gunnar: Thank you. Thanks for having me.

Alex Mendelsohn: So our society sort of splits the arts and the sciences, the stereotype being that you kind of have to choose between the two. But your career involves both. Was your interest in science and writing a chicken or egg situation, or did one interest start before the other?

Gunnar: I think it’s been both from the start. Even when I was very young, I was fascinated by animals and bugs, but I was also fascinated by stories and books. And I’ve been fortunate to grow up in a house with a lot of books. So it’s been both eggs, I would say.

Alex Mendelsohn: So did your parents then encourage you to read?

Gunnar: Yeah. My dad was a voracious, still is, a voracious reader. So he definitely encouraged it. Whenever I wanted a book or wanted to read something, there were plenty of options available. I always had books to lose myself in and that’s been part of my life since I was, I don’t know, three years old or something.

Alex Mendelsohn: Do you experience a particular emotion when you pick up a book? Is there something specific about books that captivates you?

Gunnar: I’ve always felt excitement when I pick up a book. I’m always excited about what the story might be or what I might learn. There’s always this sort of excitement of, in some way, the unknown. Something is in that book that I don’t know yet or haven’t encountered yet, and I’m excited to find out.

Alex Mendelsohn: Do you think there is a connection between the excitement of discovering new things when you’re reading a book and the excitement of discovering new things in science?

Gunnar: Yeah, I think for me they’re very similar, if not identical. It’s all about finding out what life is all about, what the universe is about. I think it’s probably a mistake to think that one can give the full answer, that it’s either science or art. I think they both are very complementary. And they each have their own approach to the question.

Alex Mendelsohn: I’m quite intrigued by your experience of finding that books are a way of discovering new ways to think about the universe. How do books tease out the nature of how things work, how things are?

Gunnar: That really depends on the book. Nonfiction is pretty clear in this case. But in fiction, I often feel a sort of connection with the person who wrote it, as well as the characters in the story. And that kind of gives me the feeling of… I don’t want to say something universal because that sounds a bit “New Agey”… but there is this connection that I feel to the writer, to the characters, to the story. And that’s a very similar feeling to me as it is when reading a non-fiction book or learning something entirely new.

Alex Mendelsohn: In terms of science now, when did your interest in the subject start? What was it that spurred you to want to be involved in science and particularly biology? Why biology rather than physics or chemistry or something else?

Gunnar: Again, it started really young. I was always fascinated by animals and even like bugs around the house or stuff like that. And then, you know, you get books with animals and it sort of, it gets perhaps unknowingly encouraged. But I just, I’ve been fascinated by animals in the living world and that has never gone away. So going through high school, university, for me it was always kind of clear. I want to know what’s behind all of this diversity, what’s behind animals, the living world. So biology was pretty much a given for me since I was pretty young.

Alex Mendelsohn: It sounds really quite innate. That it’s something that you couldn’t help but do.

Gunnar: Yes exactly.

Alex Mendelsohn: To be personal, I’ve never had, even with myself being a physicist, I’ve never had that innate positive feeling. This might be a difficult question to answer. What is it like to have that feeling? Is it something that is with you all day? Is it something really, really innate so that you don’t even really notice? If you can, can you please try to describe what it’s like to live with these two passions inside you?

Gunnar: It’s very quiet. It’s not this overwhelming positive feeling. It’s more like I notice a lacking feeling if I don’t engage in those two things. It’s almost like it’s nutrition or something. I need a little bit of both. And then some moments when I’m really into writing something, the feeling peaks a little, but it’s more like a background hum basically.

Alex Mendelsohn: Let’s then move on to when you get to university. What does biology look like at university?

Gunnar: In my case, at least, the bachelor’s is really broad. You get a taste of all kinds of different subfields, animal behaviour, cell biology, lab techniques, statistics, computational stuff. You get a taste of everything. Then in your master’s you can start picking more of what you are interested in, which in my case was the behaviour and evolution part. I think because evolution is so common ground for a lot of biology, I think that’s why I was always able to find stuff that interested me in many different subfields of biology.

Alex Mendelsohn: So evolution was something that particularly interested you out of all the other subjects.

Gunnar: Yeah. That was the first course in my first year, I think. Where I was like, yep, this is so cool. This is what I’m going to do.

Alex Mendelsohn: This might be a silly question. What is evolution? Fundamentally, what is it?

Gunnar: Fundamentally, evolution is, it requires just three things. It’s a heritable variation in fitness. So it’s kind of like no two organisms are perfectly alike. So you have some variation in traits.

Alex Mendelsohn: Sorry, what does “heritable” mean?

Gunnar: You pass it along to the next generation. So it’s a trait that to some extent is genetic and is passed along from parents to children and so on. And those traits can differ because there’s no perfect duplicate of an organism. Some of those traits affect how well you reproduce, how well you survive. And if those traits have a heritable component or a genetic component, that affects the distribution of that trait in the next generation and so on and so on and so on. And if you repeat that for a few billion years, you go from a little cell to all the diversity we have on the planet right now. And that’s, for me, that’s both very simple and very profound because it’s such a strong explanatory framework for a lot of things in biology and beyond.

Alex Mendelsohn: What kind of things is evolution an explanatory framework for within the biology field?

Gunnar: Honestly, almost everything. There’s a saying in biology, nothing in biology makes sense except in the light of evolution. So it’s sort of biodiversity, but also how specific traits work, tools we use in biotechnology. Almost all of them come from evolved mechanisms in bacteria and things like that. Disease, ecosystem functioning, it’s very… Everything that has to do with life has evolved. All life, everything that life does, has evolved. And so understanding the process or understanding the mechanism behind it can help you in a way trace it back or understand why it became the way it became.

Alex Mendelsohn: It’s like… the picture I’m getting in my head is like a map…

Gunnar: Yeah. It’s so funny that you say that. There’s a concept called a fitness landscape. And that’s what you imagine a 3D landscape with peaks and valleys. And the peaks correspond to a combination of traits that has high fitness. The valleys are low fitness. And so animals can crawl up a peak by evolving more fit combinations of traits. But if it doesn’t go wrong or negative mutations happen, they can descend more to a valley. So it’s funny that you say map because it exists… it’s a concept that exists.

Alex Mendelsohn: So you’ve done the biology degree, and you’ve then moved on to a master’s, but not in, from my understanding, not in biology. What did you pivot to?

Gunnar: Yeah, I pivoted to philosophy of science. It was a program specifically for people with a science background as well. And that’s sort of my interest in the sort of the conceptual parts. Like I wasn’t, I wasn’t the guy who needs to spend time in a lab or I’m not necessarily the guy who needs to spend time doing fieldwork and stuff like that. I was more interested in the theory behind it, assumptions behind it and all those things. I just thought, I’m not done studying yet, so what’s the next thing I can do? And this was like a nice pivot.

I also have a biology master’s. I have the straight trajectory in biology, but then like the little side quest. Why the side quest? Sheer interest. I noticed in the biology part, there was always the more theoretical conceptual side that you didn’t really have the time to dive into because you needed to do science. And I thought to myself, I want a year where I can just work on the ideas, where you have the time to just look into the theory or the assumptions and the concepts behind it.

Alex Mendelsohn: I get the impression from reading your writing, where you often talk about concepts and theories, that a lot of it comes from philosophy. When you started your Substack, Subtle Sparks, was that side of you, the philosophy side of you, the main driver in your writing?

Gunnar: I don’t know if it comes from the philosophy, because I started playing around with writing before that, but it definitely helped when I make an argument or when I structure an essay. Philosophy is all about making a convincing argument or how structure affects how your argument feels. So it’s definitely in there. But the writing started sooner. So it doesn’t come from the philosophy, but philosophy definitely helped refine it into what it is now.

Alex Mendelsohn: What was it then… the reason why you started to write?

Gunnar: I think originally I started writing because I wanted to tell stories. I have a very vivid imagination. And at some point I was like, I need to write this down! And so that’s how it started. But then you go on to study science and I started to see like, hey, this is also really interesting to write about. And there are ways to write about this that are really interesting in contrast to some kinds of science writing, especially academic writing. In academic papers and stuff, the writing is kind of boring. I thought there was a better way to communicate really cool stuff. That’s where I started to play around with trying to bridge the gap a little bit. Write about science, be accurate, include nuance, but also make it fun to read, play with metaphors and just enjoy it, make it fun.

Alex Mendelsohn: Is that… the mixture of the imagination, the metaphors, the playing around with words, as well as including factual information… Is that hard? Do you find that a difficult process or is it something that just comes completely naturally to you?

Gunnar: At this point it feels kind of natural, but I am aware that when I do that or when I try to do that, I can go overboard in either direction. So I try to find a balance.

Alex Mendelsohn: Was it hard to start when you started writing? Do you remember it being difficult? What was it like when you started to try?

Gunnar: The first pieces… this must be when I was, I don’t know, 14 or 15, something like that… The first pieces weren’t great, but they also weren’t bad because I read a lot and I continue to read a lot.

So you kind of develop a feeling for when it doesn’t work, when you write something and it’s just like, nope, this, this is not going to read well. You kind of get a feeling for that. And then over time, you just keep trying and trying and you start to develop a way of writing that feels like your own. And that’s sort of for me that, when was that? I want to say that maybe just before I came on Substack or something, when I started to write and send out short stories and get published here and there. That’s when I started feeling like, okay, there’s a style, there is a voice to my writing that feels like me.

And this combination, sometimes between hard science… I’m never going to make a scientific claim that I can’t back up… but also like having fun, playing with words, including a metaphor, I think that’s sort of when it clicked. That’s where I was like, okay, this sounds a lot like me when I’m writing.

Alex Mendelsohn: Your style is a personal fascination of mine, because you somehow get the… it’s the smoothness of the language in your writing. And I can’t quite put my finger on why, why I find it a very good and different type of voice.

Gunnar: That’s so amazing to hear. Thank you.

Alex Mendelsohn: Other scientific writers often have that hard quality, hard hitting quality to the language. But with your writing… the picture that comes to mind is, I don’t know, you’ve had a rough day and then there’s this sort of gentleman you’ve hardly noticed that just taps you on the shoulder and just quietly talks you through what’s going on and what’s happening. That’s the feeling I get when I’m reading. You’re the quiet, softly spoken sort of person who’s just going through the problems, but they don’t feel like problems when I’m reading it.

Gunnar: That is an amazing description. That’s so good.

Alex Mendelsohn: I’ve not been obsessively looking over it, but it’s something that I just can’t quite been able to put my finger on. How? With the scientific facts as well, with the input of science, I have not seen it anywhere else. So, my question is a very simple one. How?

Or rather, do you have any inspirations? I suppose is the better question. Do you have any inspiration of someone who’s written in a similar type of style to you? Or is it something that has come completely organically?

Gunnar: I think it’s a little bit of everything. I think part of it is organically because it’s fairly close to how I would speak in real life or how I would address things in real life. And I think it’s because I draw inspiration from both nonfiction science writers, as well as more literary writers. So it’s not just that I take the science and use the science and explain what’s happening, but I also pay attention to how it sounds, like literally how the words sound together and how sentences flow from one to the next. So there’s sort of this… I hate calling myself literary because I don’t really feel like that… There’s a sort of, I pay some attention to the lyricism of what I’m writing.

Alex Mendelsohn: Phonetic. It sounds sort of like a phonetic way of thinking about writing.

Gunnar: Yeah. I think I don’t consciously think about it like that, but that definitely adds to how it sounds and how it flows and how it feels.

Alex Mendelsohn: You’ve also been interested in writing fiction, specifically science fiction. Why science fiction, rather than fiction?

Gunnar: Part of that is just interest. It’s always been my favourite genre. But also for me, it’s a playground. It’s a playground for ideas. It’s fun. You can take what you learned from science, but just say, okay, let’s dial it up to 11 and shoot a thousand years forward and see what happens. It’s almost like a testing ground for ideas. Like, what if this would happen? What, what would that be like? How would that change the world, life, whatever?

Alex Mendelsohn: So thinking interdisciplinaraly, inter-disciplin-arilly, it’s a very difficult word that one, interdisciplinarily, if you could take an idea from one area of biology and implant it in another area of life, what would that idea be?

Gunnar: That idea would for me be evolution, like variation, selection and replication or iteration. And implant that on honestly almost anything. Because I think it’s such a powerful, powerful framework or explanatory framework. And you can apply that to culture, you can apply that to health, markets, business, product design, language. I think it could be valuable in a lot of fields.

Alex Mendelsohn: So we’ll have 20 minutes to go through everything. We’ll be fine, we’ll be fine Gunnar!

Okay, let’s start with culture. First of all, what is the larger framework surrounding evolution that you are talking about?

Gunnar: That not everything works, and some things work better than others, and the things that work will become the basis for whatever comes next. So in culture, for example, you have certain rituals or certain foods or something, and there’s going to be regional variations in those. But they’re not all going to be equally popular. Then as generations pass along, some will become more popular or less popular. That’s a very simple example of how cultures evolve. And then especially when they meet other cultures and they integrate parts of another culture and their customs change again. So it’s sort of this constant, almost, iterative design or subconscious iterative design.

Alex Mendelsohn: So you say it’s subconscious, is it ever conscious? Or is the framework you’re talking about always going to be this subconscious natural selection type thing that’s going on?

Gunnar: I think in many cases it will be subconscious, but I think it doesn’t have to be. There are fields where they’re almost harnessing evolution. There’s directed evolution in biology where you start with a test tube of bacteria and you impose a very specific selection pressure and you do that over and over and over again. And eventually you end up with bacteria that eat plastic or stuff like that.

But you can do the same in genetic algorithms in computer science where you start with an almost random algorithm. You spin off numerous variations and you try to make them do something and some will fail completely and some will fail only 99%. You take the one that fails 99% and you start over.

I recently saw an interview with Demis Hassabis from DeepMind and that’s basically how AlphaZero worked. So it started learning, playing the game Go with no rules, and almost everything it tried failed, but a few things worked really badly, but they kind of worked. And then the next generation started with the “kind of worked” trials, spun off many variations of those and kept going and kept going. And a day later, it could beat, like, everyone.

So you can harness it if you’re aware of it. And if you have enough constraints you can choose a specific selection pressure.

Alex Mendelsohn: Right, so in terms of its usefulness, could a selection pressure be a policy? I think I can think of potentially an example. So in the UK, more than 10 years ago, when people shopped in supermarkets they would get to the till, take like five disposable plastic bags, put all the groceries in them and then trundle off home throwing out the plastic bags when finished. So the government put a five pence charge on plastic bags and slowly but surely people stopped using these disposable bags and started like bringing their own reusable ones.

In my own mind I imagine this was an instant behaviour, but I don’t think it was. I think it was kind of this progressive process.

First of all, does my example match the idea of evolution? And secondly, do you think there might be other policies which, which we could use and implement by our understanding of evolution?

Gunnar: Yeah, I think it’s a great example. I think it wasn’t done with evolution in mind, but I think it’s a great example of you change something that’s relatively small, like a 5 pence charge, and over time it causes this major shift in a certain trade, as in what people take or use to carry their groceries. I don’t think it was done with evolution in mind, but it’s a good example.

I think a lot of long-term policies, which we’re very short on these days, but I think a lot of long-term policies probably can use small behavioural nudges to over time really shift the trade. I’m thinking stuff like smoking. In the 1950s, everybody smoked, right? And you can still buy cigarettes, but it’s just, it’s very discouraged. You can’t do it wherever you want anymore. It’s gotten probably more expensive or is taxed more. Those are all small things that really do have a profound cultural effect. Like in the 1950s, 1960s, everyone was smoking. Everyone was smoking in movies.

We’ve had a cultural change that has happened for the benefit and health of a lot of people, but it’s still this cultural shift that in hindsight you could probably analyse with methods from evolutionary biology if you wanted to.1

Alex Mendelsohn: I personally understand evolution as something that’s slow, that will happen over millions of years, but the example you just described happens in, well, 70-80 years or so…

Gunnar: Cultural evolution goes a lot faster than biological evolution. Because the important part is the “generation time”. A generation of a person, a human is a lot longer than let’s say a cultural generation, which is a fad that maybe lasts a few months, for example. So it’s about how quickly you can generate variation, how strongly you can select and how quickly you can iterate the process. So, yeah, that’s faster in culture and even a lot faster in machine learning, for example. That’s why AlphaZero and similar machine learning programs can evolve really quickly because they can just iterate like crazy.

Alex Mendelsohn: Are there any other ways which you think that the framework of evolution could help?

Gunnar: Yeah. I think language is part of culture, but language has also evolved. An interesting one though is medicine. And one I’m thinking about specifically is cancer treatments. Right now it’s chemotherapy and like just blast away and hope that the bad things die and the good things don’t. But there is sort of a burgeoning field of looking at a tumour as an evolving population of cells. And not every tumour cell is the same. They have different traits. So if you can suppress the more aggressive traits by encouraging the more beneficial ones, you could technically control the growth of a tumour or stop it from spreading. But it’s still very, very speculative.

Alex Mendelsohn: That’s so fascinating, so you’d have like a conglomerate of tumour cell empires?

Gunnar: For example, yeah.

Alex Mendelsohn: You say the evolutionary framework is something that would be very useful to us. I’m curious, how is it that we’re not really thinking about the framework? What is it that we’re not doing which you think evolutionary frameworks would help with? I think you mentioned briefly long-term thinking. Can you expand on that?

Gunnar: I think that’s a big one. Evolution, like you said, it’s usually a slower incremental process. Cultural evolution can go a lot faster, but it still takes time. It feels like everything needs to go faster these days. Like even with policy, it can switch from one election cycle to the next. But if you really want to have long-term beneficial stable effects, it’s probably going to take more than one or two election cycles. There is a lack, I feel, of long-term thinking in general, and that prevents that evolutionary framework from really being used as much as it probably could be.

Alex Mendelsohn: Going back to earlier about the map and the positive pressures and the negative pressures, I’m wondering perhaps, do we not then account for the negative, the bits where evolution feels, from my understanding, like a messy process. It’s not something where it’s a straight line to utopia. There’s going to be periods of downturn. Do you think that part of the problem is that when those periods of downturn happen, we then panic and try to change? When what you’d actually want is, in terms of thinking about the long term, to stick to your guns? Or is it more complicated than that?

Gunnar: I would say it’s a bit more complicated, but there’s definitely a point of truth in that. When things aren’t going well and whatever metric you want to use for that, economically, culturally, whatever, we have a very understandable reaction of we need to fix this now, like we need to fix this yesterday, which is totally understandable from an individual life’s perspective. But things like investing in public transport or other areas, it’s going to be uncomfortable at first, right? There’s going to be a lot of changes, new infrastructure. It’s going to suck for a while, you don’t want to be in a downturn at all and you definitely don’t want to be in a downturn for too long. Of course not. But it’s finding that balance of thinking about the long term and then charting a path toward it that doesn’t have too many downturns and that has downturns that are understandable and I want to say sort of equitably dispersed, which is also probably never going to be the case.

But yeah, I think panic and trying to turn around a downturn as fast as possible is totally human. But in the long term, in terms of sort of society, evolution, population, whatever. Sometimes you have to get through a bit of a valley to go to the next peak. But it’s hard. It’s hard to put that into policy or it’s hard to convince people of that. Personally, it’s hard to go through that.

Alex Mendelsohn: A lot of the problem that I see with scientific communicators is that they don’t really tell stories. They will say, if you just understand the facts, you will be convinced. And it works in academia to some degree. But with the general population, I found that almost never works. And you love telling stories. What’s the story that you’d, if you wanted to sell the framework of evolution, what is the story you would tell to sell it to the public?

Gunnar: That’s a great question. I would try to tell the story of humanity so far. As we’ve come so far to show that evolution has shaped us to where we are. Then I would try to explain that it’s not done. We’re not finished. This is not the peak of humanity. We have several different routes that are open to us. Being able to think in the longer term, being able to see ourselves as one species among many, as part of an ecosystem, as part of nature, those things will help us build a future that feels more, I almost want to say more balanced or that feels more in line with long-term objectives that most people I hope would agree on. Like less pain, better healthcare, all the good things. Those are long-term objectives and the evolution of humanity so far up until this point doesn’t contain anything that says we can’t reach those. We can, but we just need to think about things that last for maybe a decade, maybe two, maybe three. That’s sort of the shape of the story that I would go for.

Alex Mendelsohn: It’s a good start. Very good start. So we’ve covered culture, we’ve covered policy. Do you have any other areas burning in your mind that you think that we could cover with evolution?

Gunnar: Well, I also already mentioned machine learning and things. There’s definitely robotics as well. That’s a very specific part, but there’s a lot of work on robots as they learn to move naturally. That’s an evolutionary process. They fumble around at first and then they take the moves that work and build on those.

To some degree or some extent, I want to say it can help people personally with mental health as well. Which sounds a bit out there, but I think it could help, because there’s work on things like depression and schizophrenia and other conditions. They’re not random evils, right? Depression is sometimes, in some theories, seen as an adaptation of having to meet demands that you can’t, and you sort of shut down to conserve energy. But I think it’s more on a sort of metaphorical or conceptual level, like understanding that a downturn is not the end. It doesn’t mean that you will inevitably end up in the valley, for example.

But also evolution is the antithesis of the idea that perfection is achievable. And for someone who struggles with perfectionism like myself, that’s a good reminder. Like sometimes you need to try stuff. Sometimes you just try stuff, and if it fails, you learn something. And if you try it again and try it a bit differently, maybe it fails a bit less. I enjoy writing, which is why I’m still writing, but I’ve been writing for more than a decade and the first seven years it didn’t go anywhere. So you just keep trying stuff and you keep going. And that sounds so, so silly and simple. But for me, that’s sort of an evolutionary mindset. Like, okay, you vary your approaches. Most of them will suck. Some of them will work. You build on the ones that work and you try again.

Alex Mendelsohn: I’m interested in, you said evolution is the antithesis of perfection. Can you expand on that? How is evolution the antithesis of perfection?

Gunnar: Yeah. Firstly in evolution in biology, there’s no end point to any organism’s evolution. There’s no perfect form. There’s no perfect shark, even though sharks are probably close to it! But there’s no perfectly adapted organism. And because the environment is never completely stable and things change, everything changes all the time, there is no perfection. All you can do is the best you can and try to adapt to whatever you are facing. And that’s hard and exhausting, but it’s also kind of freeing in the sense that there is no, there is no perfect Gunnar that I get to shoot for. He doesn’t exist. So I can do the best that I can with what I have now and see where that goes. And if it doesn’t work, try something else.

Alex Mendelsohn: I wish we could cover so many more different topics, but if you could say that, click of our fingers, everyone is fully onboard about the framework of evolution… What does that world look like?

Gunnar: I think we would value diversity a lot more than we would now. I think, I don’t want to get too political, but I think that the current climate of let’s reduce diversity, diversity is bad, or promote our culture above any other culture. I think, and this plays into a lot of things, but I think conservative movements would be less powerful if we can avoid misunderstandings of social Darwinism and eugenics and things like that.

But I think evolution is so powerful because it has variation to work with. So if you live in a world or an ideology or a system where we are being pushed into a monoculture, whether it’s crops or human culture, if you’re pushed into a monoculture, that’s inherently evolutionary and an incredibly fragile place to be in. Because it just takes one thing to drop you in a deep valley and you’re not going to get out of it because there’s no variation. I think the biggest thing probably beyond the long-term thinking is valuing diversity and understanding that diversity can bring variation in culture, in ideas, in people, and those things are a substrate for solutions to whatever we may have to face as a culture or a species even.

So I think the big things, if people would adopt a more evolutionary mindset, is more long-term thinking, like more actually thinking about stuff that’s beneficial, not just tomorrow, but in 10 years. That is kind of reminiscent of sort of the indigenous, I think Native American idea, of the seven-generation principle. As in you only change a policy if it is going to be beneficial for at least the next seven generations. For me, that’s an example of evolutionary thinking. There’s a lot of politics and people and countries that would benefit from that right now, I would think. So the long-term thinking and the diversity, the embrace of diversity, I think those would be two very big changes in a world with more evolutionary thought.

Alex Mendelsohn: I think that is a wonderful place to end, a very optimistic place to end. As always, the final question for this series. What are three Substacks, publications or individual articles that you’d recommend to our readers?

Gunnar: Lessons on Drugs by , which is about pharmacology and medicine. But not just the science. It’s also about the social aspect and pop culture. It’s also very fun to read.

Cognitive Wonderland by is a very good newsletter that sits right at that combination of neuroscience and philosophy. He also combines those two really well.

And then the last one would be Reminders for Humans by . She’s an environmental scientist, but also writes very well. She combines insights from biology with personal essays and beautiful writing, all wrapped into one.

Those would be my three to suggest to people.

Alex Mendelsohn: It was absolutely a pleasure to have you on, Gunnar. Thank you so much for coming and having a chat with me.

Gunnar: Yeah, thank you for having me. I really enjoyed it as well.

1

Editor’s note: I found a 2014 Surgeon General report by the CDC, which contains a figure that illustrates how smoking declined through the introduction of many long-term policies:

Yet, unlike nuggets of real-life gold, there is no rush to find them. Most people leave these shining fragments of human thought alone, destined to rest at the bottom of articles.

I have thoroughly enjoyed exploring Substack through the footnotes other people have written, and wanted to share some of my favourites. It is my own, opposite, way of sharing other people’s work. Letting the footnotes entice the reader to the treasure trove of the full article.

Arguing in style

There is something special about the formality of academic lingo when mixed with the quirky characters found in science. managed to find a paper abstract about an argument, written in the style of an actual argument. Remarkably, the authors have managed to go beyond “Show, don’t Tell” to “Show and Tell.”

It’s a trap!

Not all diamonds are pristine. Some footnotes boldly venture into the off-putting, so that we may all avoid potential literary embarrassment. isn’t the hero we deserve, but the one we need.

Insecticons

Many an ordinary writer has associated the changing seasons of life with a butterfly's metamorphosis. But is no ordinary writer. Why stick with butterflies when there are so many other insect metamorphoses to choose from?

A millimetre’s worth of humanity

I always find it a thrill when attempting to comprehend the incomprehensibly vast universe. But such a daunting task requires a good analogy. If we think hard enough, shows we can hold the entirety of humanity in the palm of our hand.

See-through scientists

So many scientific communicators hide behind the opaque authority of Truth. But once an audience starts seeing “Truth” wrapped in the self-comforting invisibility cloak of air quotes, this authority becomes very transparent indeed. shares a story about Bruno Latour and his realisation that there may be a better place to direct an audience’s gaze.

Pull cord, break glass, grab the peanut butter

Only a few can climb the highest mountains. Only a minority can blaze down a running track. Only a handful can swim across seas. But what about the rest of us? How can the everyperson reach human greatness? , master of enjoying the spiciest of peppers, provides a guide for all of us to reach chilli Everest – and an escape route if things get too hot to handle.

Punching above a fish’s weight

Humans and sheepdogs form a healthy bond to herd sheep. Surprisingly, as excitedly points out, octopi and fish form an unhealthy bond to herd crabs.

A googol’s worth of defiance

I am guilty of spending far too much time looking up the “right” word, worried about how others may judge the limits of my vocabulary. , with courage abound, makes it clear that some descriptions are just fine the way they are.

An atomic heist

Unrelatable splodges at the microscopic scale have always been difficult for me to communicate. How do you describe the otherworldly weirdness at the quantum level? Well, has an ingenious solution. Writing in , he shrinks the reader down and gives them a toolkit filled with the laws of physics. He says that an enemy has locked your precious electrons in a vault. It is now your job to get them out.

I hope you enjoyed this footnote adventure – I sure did enjoy writing it.

Are there any footnotes you have written or spotted (whether Substack, article, book or otherwise) that you think deserve to see the light of day? Please do get in touch! Would love to hear from you.

I find the whole discussion surrounding psychiatric diagnosis dull and uninteresting. This is not because the subject is fundamentally about a manual – I love a good deep dive into procedural instructions. It also isn’t because I think the subject of diagnosis is unimportant – it is, and there are very clever people making very clever points on all sides. Neither is my lack of interest in diagnosis because I believe the subject is somehow uncontroversial. Indeed, they say that if you whisper “DSM” three times the ghost of improper diagnosis past haunts you by constantly exclaiming “GET RID OF THE DSM!!!” without providing any viable alternative.

I find diagnosis discourse dull and uninteresting because it is mostly serious discussion about ideas that vary by one or two shades on the absurdity chromatic scale. Yes, HiTOP appears to be a clever alternative way of diagnosing conditions, and network models push past the conventional monochrome. But why hasn’t anyone written an article about what we could learn from the categorisation of tropical storms to diagnose mental ones, for example?

At face value, this appears absurd. What do swirling masses of air and water vapour have to do with mental illness? But to my physics brain, this is the most obvious place to explore. A brain in the throes of mental illness is a complex dynamical system in an extreme state that we currently classify through qualitative methods. A tropical storm is a complex dynamical system in an extreme state that we currently classify through qualitative and quantitative methods. An article about the lessons that psychiatry could learn from how meteorologists combine quantitative and qualitative information for accurate classification would be incredibly interesting, to me at least.1

The weird and wonderful world of physics

In contrast to the stern, emotive nature of my experience within psychiatry, my time in physics contained many goofy and odd occurrences. Whether academics using strange analogies,2 the odd hobbies of students, or enthusiastic members of the public with off-the-wall personalities, absurdity is the norm. So much so, that when I decided to meditate under my PhD office desk by bringing in a pillow and lying on the floor, not one person questioned it. It was just another physicist doing a weird thing.

Many famous physicists are known to be quirky characters. There was Schrodinger with his slicked back hair and small round glasses,3 Feynman with his reputation for wacky adventures,4 Einstein and his “mad-scientist” hairstyle,5 to name but a few. Let us not forget famous physics educators such as Walter Lewin6 and Tatiana Erukhimova,7 who are known for their energetically odd styles.

One could argue that the subject of physics attracts absurd characters because the universe itself is absurd.8 But this would be missing the point. It matters not why physicists tend to have absurd characteristics, but what the embrace of absurdity allows a physicist to do.

Exploration through absurdity

I think it is probably safe to say that no psychiatrist has ever considered how moth-human hybrids could evolve, or how a horse could be launched into space. Of course they haven’t. With so much suffering and death associated with mental illness, surely there are more important things to think about?

Perhaps. The thing is though, we don’t need every psychiatrist thinking about the same important things. If they are all looking straight across the same epistemic chasm, every psychiatrist misses the bridges to their left and right.

What I think physicists have figured out is that slightly absurd premises are one of the best ways to explore our complex, connected universe. Take launching a horse into space. To figure out how and why a horse would be launched into space, I covered: public policy, the history of art, photography & optical principles, psychiatric medication effects, kangaroo physiology, the Mongolian empire, types and characteristics of horse breeds, horse movement mechanics, horse digestion, astrobotany, microbiology, biochemistry, physiological/behavioural changes in microgravity, spacecraft science, the Mongolian space agency, Mongolian population density research and, most importantly, crystal growth in space.

While trying to figure out how microgravity affected horse digestion, I stumbled upon protein crystallisation in space, which subsequently led to drug development in space. New psychiatric medications are few and far between – it is a significant problem. Who knows? Perhaps space psychiatric drug development is a future avenue to explore.9

If I had never asked the question, "How do you get a horse into space?" I would never have realised that space drug development was a thing. How many psychiatrists are aware of it, I wonder?

A spoonful of ridiculousness

I use absurd premises to facilitate the discovery of niche, disparate links between subject areas. Links that no reasonable person would ever think about, even if they had 200,000 chimps constantly typing on 200,000 typewriters until the end of the universe.

I do not, however, use absurdities completely removed from reality. The premises are breaking tools. They break my current mental model of reality just enough for me to be able to reconstruct a new model through the discovery of new links. I chose 1% moth, not 50% moth and 40% elephant. I chose a horse launched into orbit, not to the centre of the galaxy in a dessert spoon. Stray too far into randomness, and the connections lose contact with reality.

The method is perhaps best thought of as an exploratory thought experiment – where the primary aim is to force contact between areas that wouldn’t normally meet, without descending into chaos.10 While there don’t seem to be any studies looking directly at absurd premises for the discovery of disparate idea connections, indirect research on curiosity and knowledge exploration suggests there may be method to my constrained madness.11

Breaking through the absurd barrier

It is not easy to embrace tractable absurdness. I remember as a physics undergrad how challenging it was to let go of the mental models that I had relied upon my entire life, so that I could understand how the fundamental gears of the universe turn. I think every physicist finds it difficult to deal with the uncomfortable feeling of the ground shifting beneath one’s feet. But if you do, if you let the foundations of your mind rearrange, there is an entire fascinating universe out there to discover. I don’t think I’ve known a better feeling than when weaving disparate threads into a new idea.

Whenever I dive into the world of psychiatry, it feels stagnant, like I am breathing in thick, humid air. It is a subject stuck between the present and the past, unable to find a future. Maybe a small dose of absurdity is just the tincture that could release psychiatry from its stubborn ills.

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You would think that the subjects of neuroscience and psychotherapy would be closely linked – both are heavily related to the brain, of course. But at the moment, the fields stand quite far apart.

One person trying to change that is Ana Lund, a psychotherapist in private practice in Northwest England. She specialises in neuroscience and psychotherapy integration, often focusing on the neuroscience of attachment. She is currently writing two books: one as a neuroscience guide for therapists, the other on the neuroscience of attachment.

I first encountered Ana through her Substack, Neuroscience and Psychotherapy. I loved her bold way of addressing neuroscience topics for a psychotherapy audience, so I wanted to have a chat about her experience of becoming a therapist, the neuroscience of therapy itself, and her new idea for a “Therapyverse”.

(Ana’s 3 [+2] Substack recommendations are: Michael Halassa, The Maternal Stress Project, Other Interests, Therapy for a New Generation and Unscripted.)

This conversation has been edited for length and clarity.

Alex Mendelsohn: Ana Lund, thank you very much for joining me.

Ana: Hello, Alex. Thank you for having me. I’m glad to be here.

Alex Mendelsohn: So I remember when I first started therapy. And I remember initially being quite shocked at just how quite demanding it can be. It’s really quite hard work a lot of the time. You have expressions of emotional pain, you have a lot of introspection, and after the hour was done, I would go away and I’d leave and then I’d wait a week come back do the whole thing again.

But I was always in awe that the therapist I was seeing often had the next person come straight in. They were spending the whole day in this quite intense profession. So I was wondering, what was it about this dedicated work that first attracted you to therapy?

Ana: What attracted me is that I spent most of my adult life in therapy. So before becoming a therapist, I was in therapy on and off from the age of 17, until now. I’m still in therapy. Therapy is something that I really feel I know inside out, I’m very comfortable with it. So that’s kind of one side of it.

The real kind of spark of an idea came to me in my previous work – which had nothing to do with therapy, I was working in science as you know. I worked there for 10 years. And there was obviously in 10 years in a workplace, you know, the same people you see day in, day out. There were conflicts, there were people who ended up not talking to each other. There are all sorts of problems, right? And I would always end up talking to all sides in the conflict, and being able to understand different points of view.

And so my boss at the time was like “you should be a therapist” jokingly, but I actually then started thinking maybe I should. So that’s how I started looking into it and decided to enroll in therapy training. That is kind of the origin story of it. It was basically my boss’s idea, without him knowing it.

Alex Mendelsohn: So I guess the question that comes to mind, was it an interest that rose up while your career as a scientist stayed level? Or did you lose interest in what you were doing as a scientist?

Ana: At that time in science, I was in a place where I knew that I wouldn’t stay in science anymore. But I stayed because I had a great boss. I always didn’t want to leave because I wanted still to work with him. But I knew that I didn’t really want to do science anymore because I was missing the human communication and contact. The science, as far as I’m concerned, did not fulfil those needs for me.

I always loved and keep the love for science and scientific methods, but I think the reality of science as a day-to-day profession, that was not something that was suitable for my personality, I think.

Alex Mendelsohn: You mentioned earlier that your boss sort of said you should be a therapist. I’m wondering did that, talking to people in your old job almost like a therapist, did that come from your early experiences in therapy? Did your experience as a client translate?

Ana: Well, a million-dollar question, I have no idea. Probably that could contribute. Because as I say, I was in therapy on and off through my whole life and undergoing different kinds of therapy. And so asking important questions and not feeling that that’s stupid or inappropriate, asking “how do you really feel” or things like that – that was always normal for me because I’ve been in therapy. It was part of my life.

And to your first question about the difficulty of therapy as a profession, I think… Yeah, there is certainly vicarious trauma in therapy. That’s why it’s important not to have too many clients. And I think when you don’t work for yourself, maybe you don’t have that much choice about that.

But I think therapists choose this profession, because I think it’s mostly a labour of love, you know, it’s a calling. These are people who genuinely really want to know what’s going on. And so, because it comes from a place of real interest for the other person, it’s almost kind of that mitigates somewhat the difficulty, I think.

Alex Mendelsohn: You’ve still carried the scientific mind over to therapy because you started the Substack Neuroscience and Psychotherapy. When I first came across it I found it quite rare to have someone from the therapy world involve so many aspects of neuroscience. Is that, I’m just curious, is it something you noticed when you first started therapy that this was needed? Is it an idea that built up, or is it something that came to you all of a sudden?

Ana: I wish it was as engineered as that, but no. No, I kind of started thinking about neuroscience psychotherapy prior to writing Substack and it was through really trying to understand some of the established neuroscience topics, or tropes rather I would say, that exist in psychotherapy that all turned out to actually be nonsense but initially I didn’t know: polyvagal theory, left brain, right brain, the triune brain theory. These are kind of the three pillars of neuroscience in psychotherapy.

You hear those tropes being thrown around as explanations for all sorts. It really kind of permeated the psychotherapy discourse. And I was very curious about those things. So I wanted to understand. And the more I was trying to understand, the more I was realising this actually has nothing, has no support whatsoever.

Another thing that happened, this was all prior to Substack, is that I was really interested in attachment. I was interested in attachment when it comes to my own life. I was using attachment in my work, which was not part of my core training, but I learned about it, and then I realised that there is this emerging neuroscience of attachment, which was not Neurobollocks.

Neurobollocks, for your readers, is when neuroscience myths are used as facts in therapy.

And so I realised, okay, for attachment, there is this real neuroscience. And I started being interested in that. And then I started creating workshops around that that were successful.

And then that led to some invitations. And so one thing led to another.

By the time I started the Substack, I already had a blog and already had a readership and things like that. So really, there was no initial motivation other than to understand better neuroscience that already existed in psychotherapy.

Alex Mendelsohn: You’re describing the, you said the three pillars, what were they again, sorry?

Ana: The three pillars, I would say, are neuroscience tropes in psychotherapy that are thrown around.

Alex Mendelsohn: Sorry, is this Neurobollocks?

Ana: Neurobollocks, yeah. So the three ones are: polyvagal theory, the left brain, right brain… the lateralisation – I’m not saying that there is no lateralisation of the brain at all, but the right brain, left brain explaining everything that we can imagine – and the third one would be triune brain theory – essentially the lizard brain.

So yeah, these are the three main big ideas of neuroscience myths in therapy that are thriving, despite all my hard work, you see!

Alex Mendelsohn: We’ll get to your hard work in just a minute!

But the thing that came to mind, they’re all, they take something which is complicated, the brain, and make it, all three of them, come down to a very simple idea – you can do this very simple thing and your life will change significantly.

Perhaps this is an unfair question, but is that something which you think is unique to therapy and therapy culture? The attractiveness of these simple ideas. Is it something you think therapy culture is specifically susceptible to? Or do you think it’s something that’s widespread throughout everyone’s life?

Ana: I’m going to give a controversial answer here. I don’t think it’s specific to therapy at all.

Actually, I think I have good faith in therapy community. I think we’re very good in embracing complexity. That is our job.

And we’ve been mostly trained, whatever the modality, to embrace the complexity. And I think these new kind of neuroscience spin-offs that are not really neuroscience, Neurobollocks spin-offs, are kind of giving us the wrong message. It’s going against what therapy as a culture is.

I think as humans, we always want simplicity. I mean, if you think about it, science or scientific laws are a way to distil simplicity from the complex world. So all we ever do in science is trying to find simpler ways, trying to find order in the chaos, if you think about it, right?

I think… and this is only my intuition, I have no data on this… My intuition is that therapists feel: I don’t want to miss out, I don’t want to not provide the best possible information available out there to my client. And look, there’s this science! And so it must be true because the therapists don’t know it’s Neurobollocks. It took me a long time to realise that all those theories are just, you know, bollocks. And so, you can’t expect every therapist to spend as much time as myself researching that. And so therapists just kind of think, oh, well, it’s science. This training program says it’s science. Maybe it’s my duty of care to have this available knowledge to provide to my client.

I think therapists are maybe as susceptible to embracing simple rules, or maybe even a little bit less than the general population, because I think we do want to embrace the complexity of human nature. And we can hold black and white together. We can understand why somebody can be a good person yet do a bad thing.

Alex Mendelsohn: So if I’m if I’m understanding correctly, what you’re saying is that therapists, because of wanting to help their clients, are willing to go out and search for new theories. But if you haven’t been trained as a scientist – and training as a scientist I’ve known to be a very long, very difficult process – I remember how easy it is to look at something, and think “oh, that’s how things are”. And I remember how long it took me to get to the point where I would go “Maybe not.”

So, I think it’s very interesting that what you’re saying is not that, hey, look at these silly therapists in their Neurobollocks. You’re saying this is the process of how therapists learn and help their clients.

Ana: And I think that it’s only human to have this tendency to want simplified explanations, only so it happens that therapists work with people and then those myths are then used and perpetuated through working with people.

So I don’t think it’s specific to therapists as such. And yeah, you’re right. I think therapists don’t have the tools to understand whether it’s science or it’s not science. Having said that, many have good intuitions. I get emails and messages all the time of people saying “oh, I always knew there was something wrong. It just, it never felt right.” Many people felt that something was off and felt uncomfortable with the fact that they’re being taught that Neurobollocks is a hard science and those are the rules. And they just kind of thought, well, I’m not sure. So it’s not like everybody was falling for it.

Alex Mendelsohn: I remember earlier you said you were particularly interested in attachment and that was something that has really interested you. What is it about attachment that, being punny, attached you to the idea of attachment?

Ana: Well, attachment is one of those things that even prior to writing about anything, it’s one of the things that when I learned about it, I just thought, wow.

Attachment simplifies the world, but it’s supported by empirical research. It does give you a map. That map is quite complex, but it does give you ways to understand things in a simplified way. That’s why it’s a successful theory.

When I heard about attachment, first, it was something that I could see my life through that lens and explained things in my life, and people around me. And then I realised how powerful it is in therapy. Because it explains patterns of how we relate. I will give a layman’s explanation of attachment theory because I’ve been thinking in terms of neuroscience of attachment for a long time. I now tend to see everything through that lens, but that didn’t used to be the case when I initially heard about attachment theory.

And so, do you know about attachment theory?

Alex Mendelsohn: A little bit, when I’ve sort of looked into it, for this interview.

Ana: But did you know prior to us talking about this?

Alex Mendelsohn: No, in terms of before I came on Substack, before I came across your work, I didn’t know anything about attachment at all.

Ana: So interesting. I live in such a limited world. I thought that everybody knew about attachment. Everybody should know! I’m joking. I’m joking. As I say, I also only found out about attachment theory when I was training really.

So attachment theory is a theory that is about human relating and it poses that we all have an innate set of instincts to seek the care of reliable others. Now, there is attachment theory that applies to children and development. And there is attachment theory that’s about relationships in adult life. But shall we just move to the relationships later in life? Because I think maybe that’s what people know more about, and also because I work on that.

Attachment theory is mostly known because of the three attachment styles, the secure, the anxious, the avoidant. There is a fourth attachment style, which is Fearful Avoidance, but I’m not going to talk about it right now. So these three attachment styles, they can explain some of the behaviours that people have in their relationships. And why certain people act in certain ways in relationships and why that is not something they do on purpose.

To kind of boil this down, secure attachment style is the attachment style where we are relaxed in the relationship. We’re not clingy, we’re not trying to push everybody away. We’re okay being intimate and close, sharing our emotions, asking for help, or we’re also okay being on our own and kind of leaving a little bit of room to the partner.

Then there is avoidance attachment style, which is usually considered as the villain of all attachment styles. And it’s the attachment style where people are really afraid or they really avoid becoming close emotionally. They will engage in all sorts of strategies to implement a defence, which is I can’t be close with somebody because I can’t really rely on other people. Therefore, what’s the point? And so in dating, let’s say, this will be typically people who, you know, oh, please don’t get attached to me or this is kind of going too fast. They’re never ready, they never want commitment. They’re not emotionally available for the other person. Whenever there is any kind of emotional drama, they just detach and they can’t deal with it.

The mirror image of the avoidant attachment style is the anxious attachment style, which would be kind of more clingy, lots of demonstration of love, affection, needing the presence of the other person all the time, becoming maybe jealous, becoming maybe overbearing, wanting contact all the time. And then in a very Greek tragedy kind of way, enact its worst nightmare, which is pushing the person away.

So anxious avoidance style is insecure, right? Once more, all the time, the demonstration of love because they don’t feel the person will stay with them or love them. But because they become so intense, they just, they basically make their worst nightmare happen because everybody in the end goes, oh, I can’t be dealing with this, you know?

Alex Mendelsohn: So my next question is, how does this relate to therapy, when you have attachment styles in therapy? Say I suppose a client is not getting what they want to in life and they are a certain attachment style. First of all, can you change an attachment style? Then is the aim in therapy to change the attachment style? And if it’s not, what is the aim in the therapeutic process?

Ana: So the aim absolutely can be to change attachment style. And if I work with attachment, my ultimate aim will be to change attachment style. Attachment styles do change. They are not permanent fixtures. They also don’t change easily, right? They are lasting patterns of feeling behaviour and even biology. So they make an imprint in the biological sense. They’re very, very powerful. I was giving the light, kind of maybe a bit of like a funny version when I talked about dating, but they are not conscious strategies. They really shape our biology in some ways you know. And certainly neurobiology. And so as a result, they are difficult to change, but they are amenable to change, which is a great news. And clients sometimes come already knowing that, because it’s quite popular now. Sometimes people come to me because they know I work with attachment and they’ll come for that specifically. But not always. Sometimes they know something is wrong in their life and they didn’t know about attachment but once they realise it’s like a revelation really you know.

Alex Mendelsohn: So you mentioned there’s attachment in terms of the layman, but there’s also the neuroscience of attachment. What is the neuroscience of attachment?

Ana: The neuroscience of attachment in a nutshell, is neuroscience that studies the neural correlates of different attachment styles.

Alex Mendelsohn: What are neural correlates?

Ana: If you use a metaphor of a computer, or hardware. The Brain is a hardware of sorts… It’s what part of that hardware and what kind of relations, what kind of connections in that hardware make, which enacts that system of behaviour. Basically, if one person has an anxious attachment style and the other person has an avoidant attachment style, in which ways are the patterns of their brains and physiologies different, in order for their styles to be different? And, actually, is there a difference in neural patterns? Is there a difference in physiology? These are the neural correlates.

Alex Mendelsohn: Moving on a little bit, you’re also interested in the predictive brain. What is the predictive brain?

Ana: We think of our mind, what we perceive and see, and how we make conclusions in real time, as something that’s based on perceived reality. But the idea of the predictive brain is that the brain operates as a predictive machine or mechanism. When you think about it, the brain is not seeing. It is in the darkness of the skull, and has to reconstruct reality. The best way to do that, to construct reality, is based on what already we think we know.

One example from therapy and really linked to attachment is… Say I have an anxious client in therapy, if I ask them: How did the last session feel? How is this therapy working for you overall? They will see that as a bid for connection, and they will see that as me being attuned and caring about them. And they’ll like that, right?

If I’m sitting in therapy room with an avoidant client, they’ll go: “Why are you being so insecure? Why are you being so clingy? What do you want from me? Do you want me to validate you?“ This actually has happened to me in therapy. This was a breakthrough moment where a client with avoidant attachment, when I was asking how was the last session for you, they saw me as insecure, as wanting validation.

Do you see how both people see the same thing? But their brain doesn’t see the reality. Their brain sees what they are used to seeing. A person with an avoidant attachment sees the world as wanting too much from them and being too clingy. So even the therapist is insecure and clingy.

I’m just doing my job. I’m just asking how it was because the feedback helps me improve my work. And I don’t have a way of reading their mind. So I’m in kind of this very neutral position, but the observer, which is in one case avoidant, the other anxious, they see the same situation very differently based on what they expect from others and how others are. And so you see this is a prediction.

But predictions happen on so many levels. It’s not only about relationships. For example, I have motion sickness. I don’t know if you’ve experienced this ever, but for people who have and who are reading, they might be able to relate to this.

If I know I’m traveling, especially if I know I’m going to have to sit in the back of the car, I will, so Alex, I will an hour before start feeling sick and sometimes wanting to throw up… I’m not in the car. But I’m starting to get that interoceptive feeling. So, I mean, what is going on there?

You could have all sorts of weird explanations why that happens. But my brain knows I’m traveling in an hour so is already kind of putting the body in that state. Really, sometimes it’s so weird. I relish it because sometimes I’m like, wow, am I going to actually now kind of start feeling I want to throw up even if I’m not in the car yet?

Alex Mendelsohn: Predicting the prediction.

Ana: To me, it is about embracing the idea of the predictive brain without having to say that it explains everything. Sometimes people think when we do neuroscience in psychotherapy, we need to know the nitty-gritty of the brain. It’s not about that. It’s about adopting an idea from neuroscience that’s empirically supported and seeing how far we can go with that in changing how we work in therapy. That is for me how I think about it.

Alex Mendelsohn: So for your Therapyverse, a different reality upon which if something changed there would be some benefit to therapy, what would be your proposed alternate reality? If with a click of the fingers therapy is suddenly better through a change, what is that change?

Ana: For me if I could just click my fingers, I would really put the focus on finding out with the client, what is the predictive model they’re using? This would apply to other things as well, but let’s focus on attachment.

So, in the same way I earlier used that example of a client who reacts in certain ways to a question that’s very neutral, you can then…once you map out that model with the client… you can then work on more easily changing the model. Once the client realises they don’t perceive the “true” reality, that other people have their own models, they can think “how can I on purpose pull and stretch the model.”

I do want to say that while putting a full focus on it would be new, attachment theory has had the intuition to see that we operate within, it’s called, internal working models of attachment. It’s part of attachment theory because very early on they have realised that it’s almost like we are operating from a model and not from reality. And so that idea is not new. It’s not like me introducing the idea of models into attachment.

Alex Mendelsohn: So if I understand correctly, it’s not so much about introducing something completely new, it’s about introducing a framework, making the predictive models a central framework.

Ana: Yes. That’s what I’m trying to do when it comes to attachment, really kind of finding ways how to really put that in the centre of the conversation.

Alex Mendelsohn: So how is the predictive brain not in the centre at the minute with attachment? Is it in terms of just simply not thinking about attachment that much in a predictive model type way, or is it something else?

Ana: Yeah, I think in therapy, mostly when it comes to attachment, typically people will focus on feelings and why we feel this way and how that reminds us of our childhood and things like that. But I think it’s not seen as really an object, as a model. Let’s kind of stretch the model, let’s change it, let’s really work with that. I think it’s currently a side thing in attachment work in therapy. Sometimes it would be accommodating the world to our attachment style rather than changing our attachment style, changing the model.

Alex Mendelsohn: The word that came to my mind when imagining what changing the model would look like was “roleplay”. But I don’t think that is exactly what you mean! In the therapy room, what would the process look like instead?

Ana: It wouldn’t be in a therapy room. So I think attachment therapy currently is very much focused on the work in the room. But I think attachment style has to be changed through work outside it. So it would be more in life rather than with a therapist. A therapist is the guide, as in we will then talk about things that have happened and plan how to put in place new experiences.

Let’s imagine somebody who is the avoidance attachment style. And so that person typically will think that whoever they meet, they will want straight away to be an exclusive relationship. They will want to move in with me. They will want something from me and they will already be checking out before they even start seriously dating somebody, let’s say. Because they are pre-emptively trying to kind of distance themselves. And we might work on the fact that they give an opportunity to this new person to show who they are without that kind of avoidance and see whether they might not be the person they think they are. That they are more capable to be on their own than what they think, you know? And so through that, rather than their usual reaction, just give the benefit of the doubt to the person to show who they are and therefore adjust the model, right?

Because acting in their usual way, it’s almost a self-fulfilling prophecy. If you don’t let anybody come near ever, well, you’ll never be able to update your prediction about others because nobody’s close enough to show who they are.

Alex Mendelsohn: I think that’s a good place to end. My final question, which is going to be a regular final question for this interview series. Do you have three Substacks or publications or individual articles that you’d recommend to readers?

Ana: I was trying to reduce it to three, but can I give you five?

Alex Mendelsohn: Yes, of course you can have five.

Ana: Are you sure?

Alex Mendelsohn: Yeah, Let’s go for it.

Ana: The first one is the Substack of . Mike is a neuroscientist who is very open-minded and very down to earth and doesn’t feel that as a scientist, a neuroscientist, he’s above everybody else. And, you know, I can ask him any question and he won’t think it’s stupid or anything like that. So I learned a lot from him. He writes amazingly well on very complicated things in neuroscience and he has a really good overview of the frontier of neuroscience today. And so for me, it’s very, very interesting.

And another person is , she writes The Maternal Stress Project and she is a stress physiologist. It’s really interesting for me on many levels and so I follow her Substack on neuroscience and physiology of stress.

The third one is who writes Other Interests on Substack and she writes many things, but she has done some amazingly brave debunking of some of the guru figures in psychotherapy and trauma world, such as Bessel van der Kolk or Gabo Mate and Peter Levine. So she’s really my go-to to find what’s what and some really in-depth debunking about these important topics.

And then I want to also mention . She writes Therapy for a New Generation and she is a therapist that is thoughtfully writing about working with young people. I don’t work with young people, so I don’t know much about it. She’s my go-to if I want to find out a little bit about that. She also writes interesting things about how to improve the standards of training for therapists.

Last but not least, . He writes Unscripted. And again, he’s somebody who writes with lots of knowledge about evidence support in psychotherapy. At the same time, he’s somebody who is very down to earth and very accepting of difference.

Alex Mendelsohn: Ana Lund, thank you very much for helping me create a Therapyverse.

Ana: Thank you so much for having me.

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I know what it feels like to be trapped. If I am honest, before I found treatments for my condition, I was pretty sure there was no escape. My time was up.

You might think that getting another shot at psychopathological freedom would be a liberating experience. That is what the movies show you, right? Find a treatment and it’s all plain sailing to the promised land of euthymia.1

In real life, it is work all the way up. It turns out that you cannot just disappear from the world for half a decade and expect to land right back on your feet. During these years of frustratingly small steps, writing this Substack has given me a sense of purpose. It has provided me with an escape – a way to reach out into the world.

I also hope that The Psychiatric Multiverse has been (and will be) valuable to you. I strongly believe that problems in one occupational discipline will have solutions in another. And this Substack is all about exploring and finding solutions from a wide array of areas.

It has now reached a point where I’m well enough to start thinking about returning to the working world. And I am a realist at heart. While meaningful work, and I plan to continue writing this Substack for the foreseeable future, I have no ambitions to be a full-time Substack writer.2 But I would love for it to become one small, rewarding strand of my working life.

So, while I’m turning on paid for this Substack, I’m doing so in a way faithful to the style of the Psychiatric Multiverse: convoluted with a side of absurdity.

Inspired by Tommy Blanchard,3 I’m introducing a flexible supporter model. You can choose a standard paid subscription, a discounted subscription, a one-off contribution, or choose to pay nothing at all. It truly doesn’t matter to me the reason why you might want to pay less or nothing at all for a paid-tier subscription. Maybe times are tough and a Substack subscription feels a bit too much right now. Maybe you are a millionaire and, well, you simply don’t want to pay money towards this Substack, but nevertheless like what I am trying to build. All good reasons.

If in any doubt, please go down the free paid-tier subscription route. The act of going out of your way to show you find this Substack valuable is a meaningful and supportive gesture to me.

If you decide to support me, please choose whichever option you would prefer:

• 0% off (£40 per year or £4 per month)

• 10% off (£36 per year or £3.60 per month)

• 20% off (£32 per year or £3.20 per month)

• 30% off (£28 per year or £2.80 per month)

• 40% off (£24 per year or £2.40 per month)

• 50% off (£20 per year or £2 per month)

• 60% off (£16 per year or £1.60 per month)

• 70% off (£12 per year or £1.20 per month)

• 80% off (£8 per year or £0.80 per month)

• 90% off (£4 per year or £0.40 per month)

• 95% off (£2.00 per year)

• 99% off (£0.40 per year)

• 100% off (£0.00 per year)4

If a one-time payment is more your thing, a herbal tea would be much appreciated!

Buy me a herbal tea

Subscriptions can be cancelled at any point, and your paid-tier access will continue until the end of the period you’ve paid for. The price you choose will remain the same for as long as you keep that subscription. Also, you can switch to a free (100% off) paid-tier subscription at any time (This will be applied at the end of the current billing cycle, but happy to offer pro-rated refunds).

Wait, what? Why are you offering a 100% off paid-tier subscription?

Firstly, what is useful often isn’t popular. A month writing about planes didn’t exactly produce engaging material, but I would strongly argue that if every therapist and psychiatrist had a distinct interest in aviation, we would have built a much safer mental health system. Monetary exclusivity comes with an internal pressure to write what an audience wants, rather than what an audience needs.

Secondly, when someone has previously subscribed to this Substack, it is difficult to tell whether they are a casual reader (who might have just subscribed because of, say, the cool logo) or a reader who is generally more invested. A free paid-tier subscription provides the most inclusive blunt tool to help me learn this.5

Finally, living with a mental illness makes one inherently unreliable. There will be times when output is low. Having a free paid-tier option helps keep the burnout pressure off.

Will there be (optionally free) paywalls?

For the most part, no. The types of articles free now will stay free in the future. Optionally free paywalls will be for new types of articles and content.6

If I decide to pay for a subscription, what will the money go towards?

Your subscription would go to helping me spend more of my time trying to help prevent what happened to me, from happening to other people. One consequence of experiencing long-term illness is a burning desire to help improve the healthcare system. Whether writing research papers, giving talks or working with academics, professionals and policy makers.

I want to do the unsexy work. I want to discuss problems, agonise over repercussions of actions, spend hours upon hours reading, rereading, then rereading again until I understand all the complexities required to improve systems, and ultimately improve people’s lives. I want to help build, not debate.

The Psychiatric Multiverse is the scaffolding which helps me build. There is a point to all this absurdity you know! By exploring new areas, gaps in knowledge and understanding appear. I’ll give you one example: LFPSE7

Other than a terrible acronym, it is also a terrible name for an incident reporting system (Learning From Patient Safety Events), and most pertinently, terribly difficult for patients to use.

Incident reporting systems are mostly set up as a way for healthcare professionals to report mistakes, so that the system can “learn”. But few reporting systems accommodate patients, who make up the other half of the healthcare system. Of the systems that do allow patients to report mistakes, like LFPSE, there are significant usability problems. LFPSE isn’t promoted to patients, the forms are long and confusing, and you are forced to remain anonymous – you never know whether your report led to any system change.

I discovered the problems of LFPSE through my Psyverse series on incident reporting systems. I subsequently proposed potential solutions in the final article. I want to find, and hopefully work with, people who could help improve the LFPSE form. I believe that even though the change would be small, it would have a significant impact on patient safety.8

A subscription would also, of course, go towards the time needed to write this Substack. Ironically, we are just entering the “break” phase of the season model, where my output will be lower while I work on the next Psyverse (I told you I was a terrible marketer!). Nevertheless, I will still be publishing essays, interviews, Footnotes from the Margins and Scientific Paperverse articles. And, I am always experimenting with new ideas!

During the PhD, I used almost every strategy that I could discover, and a few I invented. I dug as deep as it was possible to go. I thought I was besting my disease. In reality, I was only ever holding it at bay. My disease required medication, not talking. I don’t know how it took me so long to see something so obvious.

My condition declined so slowly, I never realised it was happening. After I completed my viva, I collapsed from exhaustion. My illness finally had me. It engulfed the shredded remains of my defiance with a ruthlessness I had never experienced before, and pray never happens again. I learned that when God wants you, he takes it all. Every. Last. Drop.

I understood with harrowing clarity what I had just done. I finished a PhD while severely mentally ill. It would not have been possible without an extremely high dose of delusion. By pretending to be wise, I missed what was right in front of me. My mum was the only person who kept telling me throughout the PhD that she thought psychotherapy was not the answer for my illness. Everyone else, including my therapists, thought otherwise. My story directly contradicts the narrative that all mental illnesses can be solved through talking. It is simply not true. I should have listened to my mum. The extreme suffering to come might have been averted.

I lost nearly all functioning. So much so, that my mum became my carer. Social interactions became overwhelmingly painful. In order to survive, I purposefully cut myself off from the world and became a recluse. This might be hard for many of you to understand. All I can tell you is that it was necessary. For the last three years, the only people I have had lengthy conversations with have been my mum and my brother. For all intents and purposes, I have been forgotten.1

My initial psychiatric treatment was beyond woeful. Every decision the psychiatrists made seemed to either do nothing or lead me closer to death. I felt that if I let things continue as they were, I was going to die. So, I made a decision that I should never have had to make. I began to guide the treatment of my own mental illness.

For almost two years, trialling treatment after treatment, I experienced pain and states of consciousness I did not think it was possible to experience. It felt like I was walking along a tightrope wire, one small misstep from annihilation. To a degree, I am still walking it. In early 2021, I was fortunate to find two medications that started to reduce symptoms that have been plaguing my mind for nearly a decade. Progress is frustratingly slow, but I am hesitantly confident that one day I will reach remission.

I will accept nothing less. This is because in order for the mentally ill to reap any of the benefits I have written about, we must be helped back to remission. The mentally healthy must care about the mentally ill. Otherwise, we spend all of our energy simply trying to survive in a society that does not understand us. Or worse, we slowly become sicker and sicker, falling into death.

When thinking about what it means to live a full life, many of us likely picture falling in love, starting a family or working in a fulfilling job. We picture visiting new places or experiencing new things. But this is only half a life. Without spending time with the many people in the world who are suffering, we never know the meaning of strength or courage. We never feel fully comfortable in our own skin. We never understand what is important in life and what is not. It becomes impossible to fulfil the potential each and every one of us holds.

What I find difficult to understand at best, and soul-crushing at worst, is why I am not seen as valuable. Most people see the horrors of my story but not the person who got through it. I think at the very least I am worth knowing. I hope I am worth helping. I will need a lot of support just to feel safe again, I’ll need a community to get back to full remission. With help, I hope to write articles that punch through the complex web of misconceptions and lies surrounding mental illness. I hope to educate and teach in podcasts. I hope to stand on a stage and weave the intellectual and emotional together with such skill that for the briefest periods of time everything will feel so simple. Before the complexities of life slowly seep back in, leaving the audience to wonder what exactly just happened. I hope I can help those more fortunate than me to see the value in helping people with less. With help, I hope I can live a full life.

Perhaps, then, we can show the world the benefits of mental illness.

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It felt fantastic to get back to the university and my PhD. This feeling proved short-lived when it dawned on me that I was back at the university and had to do a PhD. Many mentally healthy people leave the experience with a mental health problem. I was going into it with one. Reducing external sources of stress was a molehill to the mountain of stress emanating from inside my brain. Akin to learning how to walk again, I needed to learn how to think again. Fortunately, my therapist helped me learn a skillset so powerful that it was possible for me to cobble together what remained of my inner shattered existence to take on the highest level of educational degree there is. I guess I would call it: the intrapersonal skillset.

The first skill in the set I learned is emotional observation. It is the act of, for lack of a better phrase, “checking in” with yourself. Essentially, I was training myself to think during states of extreme emotion. Since my general emotional state was pretty much always extreme anxiety, most of the time I would be checking in on my anxiety. For example, I would often ask myself “How anxious am I right now?” If the level felt manageable, I would continue what I was doing. If I thought the level of anxiety was high, I would readjust my plans and try to put in measures to lessen it.

The reality was a lot more complicated than I am making out. If my anxiety was rising, I would try to determine if it was caused by something I was doing, or an altercation, or bad sleep, etc. I would be looking into the future, too. I would try to predict my dips and rises in anxiety, planning to do more intensive work after exercise, for instance, or keeping work light after an important and/or long meeting. I was constantly trying to circumnavigate existential thoughts about death and suffering that my brain was throwing up all the time. I would “lead” those thoughts to a more positive emotion. One of the most difficult parts of emotional observation was making decisions on how long I could stay for a social event without it impinging on my sleep or mood. I left a lot of events early. Sometimes, when I lost functionality, I would even pull out of them to recuperate at home.

I was doing all of this stuff (though one at a time) in my head persistently. The person next to me would be none the wiser. If you think this all sounds incredibly exhausting, you would be right. In order to keep up this ridiculous amount of internal computation, I needed to recover energy as quickly as possible and be as efficient as possible with my time.

Fortunately, the next skill I learned provided me with the ultimate break from activity: meditation. Up until The Event I was pretty sceptical of it. As a scientist, it always seemed too mystical. Nevertheless, I was intrigued by its relaxation claims.

My therapist was able to teach it to me through guided meditation sessions. I would close my eyes, and my therapist would instruct me in a very soft voice what to do. We started with body scanning meditation, that is, sequentially focusing attention on specific areas of the body. “Erm, I can’t close my eyes…” I say, 5 minutes into our first session. The severity of my physical anxiety symptoms was causing my eyelids to shake too much. Not hearing a response, I turned to see my therapist’s face in a semi-blank, utterly confused state. I don’t think they had heard that complaint before. It became apparent that meditation was not going to be a straightforward skill for someone like me to learn.

For a while, I tried different types of meditation and different positions without much success. I actually found it quite difficult to stay in meditation. It took energy and effort. I was so used to the fast-paced nature of modern life I found it difficult to do nothing at all. Which is why I find week-long silent meditation retreats strange. I suppose those attending might feel fantastic after leaving those retreats, but I also think it would feel fantastic after being released from a week in prison. There is a difference between feeling relaxed and feeling relieved.

In the end, I decided I would just try to keep my eyes closed for ten minutes each day and see what happened. While taking this advice with a pinch of salt, I would actually propose this strategy for anyone starting out. During the first few weeks of meditation, listen to music, surround yourself with pillows (the comfortable type), have a conversation with someone, have a conversation with yourself, whatever it reasonably takes to keep those eyes shut for ten minutes each day. Then perhaps move on to body scanning or guided meditations, etc.

It took six months of daily ten-minute meditations for something to finally happen. As a side note, when others tell me how meditation is “not for them” after trying it twice, I find it only a tad difficult to maintain composure – ironically, meditation helps with this. It was during a hypnotherapy session (which for me didn’t really hypnotise nor provide any therapy) when I first felt the isolation meditation provides. It felt like something had clicked into place, as if the last cog had just been put into a mechanical watch so it could finally tick. It was an extraordinary experience. And a wholly unexpected one.

Meditation wasn’t really what I wanted it to be. I would eventually feel more relaxed (well, my weird version of relaxed) towards the end of meditations. At the beginning, I would actually feel more anxious with sprinklings of depression, sadness or anger. When most of us think of relaxation, we usually imagine still doing something, just less intensely. Maybe reading a book, going for a walk, or watching a program on television. During these activities, your brain still has to process the information your senses automatically send to it. In my opinion, the initial act of meditation is the attempt to close off the senses and therefore this processing. With nothing masking my emotions, I felt them in their totality. The opposite of what I thought meditation did.

During the occasional extreme emotional episodes I suffered from, which extended over several days, meditation actually made things worse. The last thing I wanted was to feel more of the pain these states provided. During acute episodes, and the rest of the time, meditation was immensely useful. It made emotional observation a lot easier, allowing difficult emotions to eventually subside, revealing the relaxed state I was after.

When I returned to the PhD, I quickly learned that I could only work for twenty-five minutes before my stress levels started to rise exponentially. Therefore, I started to use meditations as a break in between these work sessions. They acted like a reset button. It seemed to help my brain revert almost back to the state I was in at the start of the session. It was kind of like a very quick clearing of mental clutter. The constant refresh process would eventually stop working around the six-hour mark, when my fragile mind would finally succumb to the stress of PhD work. In fact, my brain was so fragile I could only work around three to four days per week. In all likelihood, I was ranked bottom in terms of the number of hours worked per week by academics at the university. Meditation isn’t a miracle worker.

It is, on the other hand, extremely useful at improving work efficiency. Meditation resets seemed to allow parts of my brain to work on problems in the background. Anyone who has done a PhD will know that it is frequently spent in a perpetual state of being stuck. I used to toil over problems, spending hours desperately trying to find a solution. After I learned meditation, I can’t think of a time when I have been completely stuck any longer than twenty-five minutes. The meditation breaks, while rarely leading me directly to the solution, would almost always help me decide which direction to go in next. It would just literally pop into my head. The effect felt extremely similar to the times I would go to sleep, unsure of what to do about something, and wake up with the answer suddenly in my head.

The quality of my work improved immensely because of meditation. Before it, around 70% of the work I produced could be thrown straight in the bin. I would spend a lot of time going down the wrong “path”. I would seek comfort in tasks I was accomplished at or liked doing, not necessarily tasks that needed to be done. It would take me a long time to notice mistakes, or to realise that the work I was doing was leading to a “dead end”.

The eventual relaxed state provided through meditation allowed me to see from a more objective standpoint. For example, when electronic calendars and task managers did not work for me, I came up with a way to produce a flexible schedule using a whiteboard and some magnetic dry-erase strips. Pretty much every idea, analysis, even large chunks of this very article, has in a significant part, come through meditation. After I learned this skill, around 10-15% of my work was not useful.

Only one problem remained once I moved into my new office away from my old research group and ex-friends. I didn’t have any place to meditate. The postgraduate physics administrator, who was lovely and very keen to help, suggested the chaplaincy. Unfortunately, it was about a ten-minute walk away, meaning half my day would be spent simply walking to and from it. So, we went looking for a quiet room within the department that no one ever used, or a series of rooms that were vacant at specific times. The only suitable room we could find had to remain locked, and I wasn’t allowed the key.

The fact that there was no room in the department where people could meditate was a little strange to me given the growing mental health awareness in society. Stranger still, there wasn’t even a wellbeing position in the department’s student-staff liaison committee. When I pointed this out to the committee, there was an enthusiastic consensus to create a position. They asked if I wanted to do it, and I naively said yes. I decided to quit the position I had proposed only three months later. As well as proving overwhelmingly stressful, I realised the role didn’t allow me to change the existing system. Fortunately, someone took over and did a much better job.

Unfortunately, I still did not have a place to meditate. After doing some exploring of my own, I came across the very quiet fourth floor of the materials science department building. The common area had eight rows of long and comfortable benches forming four small cubicles. If the area was empty or nearly empty, I used these benches to meditate on. Things were going rather swimmingly until one lunchtime, mid-meditation, I heard someone repeatedly say “excuse me” with growing ferocity. I took off my noise cancelling headphones and sat up. There was a professor from the chemistry department standing a fair distance away with a disgruntled look on their face. I politely asked what the problem was. In a stern voice, they said “What you are doing is incredibly unprofessional and highly inappropriate. This is a research area. My colleague and I are about to eat lunch, and you are taking up an entire cubicle. Can you please leave”. I looked around to see two empty cubicles and a lone PhD student happily eating lunch in the third. “I’m sorry” I hesitantly replied “I am meditating”. Without a hint of a pause, the academic retorted “Well if that is the case, you should go somewhere quiet to do so”. I paused for a moment, distracted by the sound of a pin dropping, before apologising again and slinking out, tail between my legs.

Halfway to my office, I somehow concluded that this was a person I could reason with. I walked back and knocked on the professor’s door. A moment later, I was met with a face that evoked a feeling of coldness I had not experienced before in my life. With it being too late to back out, I apologised again then tried to explain that I was meditating to cope with my anxiety. The professor simply repeated that what I was doing was incredibly unprofessional, highly inappropriate and I should go and meditate somewhere else that was quieter.

In the office next door to the chemistry professors’, there was a physics academic I knew quite well. I travelled the enormous distance of about four feet in tears and told them what had happened. The academic explained to me that the space I was meditating in was part of that chemistry professor’s “territory”. “This again?!?” I thought in quiet exasperation. The physics academic continued, saying that while they would try to talk to them, the political power of the professor within the university meant that I had likely lost my new meditation spot. Before giving me a hug, the academic vowed they would help me find a new one.

Which is exactly what the physics academic did. I pointed out a space in the common area on the third floor of the department. My supervisor’s office was nearby, meaning I could lay claim to the unused territory. Using their sway with the manager in purchasing, the physics academic bought a new bench and placed it in the spot I previously indicated. The academic told me that while this technically was a bench in a public area, I had priority use of it. So, if anyone happened to be sitting there, I could ask them to move. If there was a problem, I was to refer them to the physics academic. For the remainder of my PhD, I used that spot to meditate in the times I needed it most. It turned out I never had to ask anyone to move. That spot was just too dang quiet.

The final skill I learned, perspective shifting, helped me to move on from my conflict with the chemistry professor. Knowing I would still see them around the department, I used perspective shifting to imagine our confrontation from their side instead of mine. The goal was to achieve some kind of empathetic view, regardless of whether it was true. I came to the conclusion that a person who goes out of their way to pick on a random PhD student lying on a bench is not exhibiting normal behaviour. I questioned the emotional security of the professor. Why were my actions and my medical condition such an affront to their way of being? I started to pity them. I found it likely that they struggled to understand why other people did not act in the same way they did. I tried imagining myself in the position of someone with a serious lack of empathy. I could easily see myself chastising most people around me. After coming to these conclusions, I hardly thought about the professor again. My anger subsided. I moved on with my life.

Perspective shifting is the act of reserving judgement on an observation until a conclusive view from the opposite side of the judgement is found. I suppose it can be summed up as “how could the person do what they did and still think themselves as the ‘good guy’”. A more advanced version of putting yourself in someone else’s shoes. Although, it can be on anything really: TV shows, fashion, or, dare I say, even Marmite. As a basic example, it would be very easy for me to categorise the contestants on the show “Love Island” as completely superficial human beings. However, despite being two broken strands of elastic from fully nude, I realised they were treating each other as if they were fully clothed and dating for the first time. They were forming complex relationships. It was odd, to say the least.

My ability to shift my perspective kind of emerged after a lot of counselling sessions. My therapist would often offer an alternative perspective when we were discussing past emotional conflicts. After a while, I started to learn how to do this of my own accord as emotional conflicts arose in my life.

To clarify, when I write “emotional conflict” I rarely mean an argument or shouting match. In my view, an emotional conflict is any situation where at least one person feels emotionally hurt, misunderstood or confused in an interaction between two or more people. Both parties might feel contrasting emotions/views on a topic, or one person might deliberately be acting maliciously towards another, etc.

In an emotional conflict, the first thing I do is try to calm the heck down. It is a lot harder than it seems. In the age of TikTok and Twitter X, most of us seem to act immediately after any given emotional stimulus. This, I find, usually inflames emotional conflicts instead of resolving them. Sometimes I use meditation to help calm me down, but it can also make things worse as the anger/frustration/exasperation is then free to roam around my mind. The only reliable and effective solution I’ve found is physical distance from the conflict, and time (usually minutes, sometimes days).

Once I have calmed down, I try to get clear in my head what my actual views are. I find it useful to try and remember how and when the emotion came up. Was there a specific thing a person said, or just a general haze of emotion for the entire conflict? I have found the true reason I am feeling the emotion is rarely the first one that pops into my head. Here, the point is not necessarily to be correct, just to have some specific viewpoint that can be challenged instead of simply “I hate them” or “what they said was [input accusatory adjective or expletive here], they are wrong”.

Next, I start thinking about what the other person’s views might be, which again, is initially not obvious. I usually think of anything they went through recently or whether their interaction with me seemed out of character. The purpose of this exercise is to come up with an opening question that would likely lead to a non-threatening conversation. For instance, “when you said ‘x’ to me, were you trying to say ‘y’?” In our conversation, rather than give my view, I would listen and ask leading questions until I thought I understood their side of the story. Then, as a general rule, I would ask at least three more questions until I actually understood their view. Most of the time, I didn’t even have to give my side of the story; all the stress just melted away.

With more complex problems, I give my view so both of us can understand each other’s viewpoints. Most of the time, the conflict remains unresolved, but as long as both parties understand each other’s emotional state, there usually isn’t anything left to be stressed about. If I manage to communicate well enough, the other person may not even realise we were in a conflict.

I used to have the opinion that the aim in any emotional conflict with another person was to feel good. I wanted the other person to understand only my side of the story so that I could feel happy. Now, I believe that resolution for both parties is the ultimate goal, regardless of how it might make me feel. After The Event I rarely ever felt good after resolving an emotional conflict. In fact, I would mostly feel terrible, sometimes making the other person feel terrible too (e.g. break-ups). I would persistently put myself into vulnerable situations in order try to understand the other person’s perspective. It meant I could find resolution quickly, allowing me to move on with my life.

In the years leading up to The Event, small stressors I was oblivious to would add up over time. If I was annoyed with my supervisor or a colleague, I would hold on to that emotion for days, sometimes weeks. I was storing up righteous anger, as though it would make me feel better. The emotion related to the occurrence that originally annoyed me would keep popping up again and again, actually making me feel worse. Given the same situations after The Event, I still felt annoyed with the colleague or my supervisor, but by using perspective shifting, I was able to process it quickly and by the time I saw them next, it was gone.

Towards the end of my PhD, I began to notice in others the same little stressors adding up throughout the day. Some of my colleagues were stressed even before they arrived at the office. I noticed others venting regularly and repeatedly along similar themes. They would sometimes bring up specific events months, sometimes years after it happened. For instance, when I first talked to a new housemate about his ex-girlfriend, his manner and intensity gave me the impression that they had broken up the day before. In fact, they had broken up three years earlier.

When I started to tire while writing my thesis, shifting my perspective helped to utilise all the energy I had available. One bitterly cold day in winter, perhaps the coldest of the year, sticks in my memory. The combination of the UK’s lack of cold weather infrastructure and my lack of cold weather footwear meant my early morning trek to the health food shop was unusually treacherous.

I arrived gratefully into the warmth of the store. I got what I needed and walked to the counter. There was no one there. In fact, there was no one else in the store at all. “crud” I thought “how am I going to pay for this stuff?” The rapid deterioration of my IQ was interrupted by a warmly dressed clerk walking through the front doors of the self-opening store. They seemed to adopt the “Frankenstein Russian doll” strategy to counteract the freezing weather. Chucking on anything that had the quality of warmth. During the laborious process of stripping off the apparel, the cashier began to tell me about their day. In a strangely animated tone, the cashier listed the morning’s trials: the heating came on very late, the kettle broke, meaning the regular morning brew was off the table, and the freezing walk into work was miserable. The clerk told me they felt sorry for themselves and just wanted to go back to bed and skip work. This feeling lasted right up until they passed a homeless person bundled up in multiple sleeping bags at the side of the road. The cashier told me in that moment they thought “Gosh, some people have it so much worse than me, at least I am not in that position”. The clerk finished by telling me that seeing the homeless person put things in perspective and helped them to feel a lot better.

In that moment, my first thought was “No! That isn’t a useful perspective!” What if the clerk had got up that day and the little things they had experienced didn’t bring them down? What if the clerk didn’t get up feeling low and sorry for themselves? They would have had more energy. Perhaps they would see the homeless person and instead of thinking “I guess my life is not so bad” they would be thinking “I want to help that homeless person and others like them”. Without all the little things adding up and bringing the clerk down, there would have been the emotional space to be empathetic. In my experience, once the small emotional conflicts have been dealt with, the natural emotion that comes forward is empathy. Even when mentally ill.

Emotions have the greatest influence on the way we live our lives and yet most of us spend absolutely no time thinking about them. Instead, there are an endless number of motivational articles proposing specific mindsets or quick fixes that drastically oversimplify and overgeneralise the unique complexity of individuals. Without awareness of how your emotions affect the way you think and behave, it is unlikely any plan of self-improvement will ever work. I actually loathe anything mentioning “self-help”. We became the dominant species on this planet through social cooperation; why do we think doing things in isolation will ever work? Without the help of my therapists, family, friends, colleagues and acquaintances, I would not have been able to even resume the PhD. Never mind complete it.

And yet there I was, finished PhD thesis in hand. I remember standing in front of a display along the main hallway of the physics department. It showed the pictures of all the physics PhD students sorted by the year of intake. My face was in amongst the fourth-year students. “I shouldn’t be here” I remember thinking, “I should be in a mental hospital… or dead… how am I here?” It didn’t seem real to me. It didn’t seem possible, despite the fact I had just done it.

It would not be long before I fully understood the extent of my achievements.

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During the eight months away from my PhD, I went from someone who couldn’t leave the couch, to someone walking around society looking pretty much normal. I brought a whole new meaning to the “couch to 5K” movement. I was confident, exercising regularly, eating healthily, teetotal, extremely sociable and a complete mess on the inside. My goodness, if there existed a brain-wellness measuring device and you pointed it at my head, the meter would explode in a cartoon-like fashion.

I was only barely below the threshold of functioning to non-functioning. Any small amount of stress would plunge me into a world full of internal pain. Add to this the decision of my then psychiatrist to mistakenly prescribe a weaker version of the drug that caused The Event, and I should have had no right to do a wordsearch, never mind a PhD.

I moved out of my mum’s place and back to my rental accommodation I was sharing with a couple of friends, who were also PhD students from the research group I was in. Given my fragile state, I asked if they could help by asking me every now and then if I wanted to talk, check on me, among other things. They agreed.

Two weeks later, they sat me down saying I was “too much” and they were moving out in a fortnight. They then left it up to me and my mum to clean the entire house so that we did not lose our deposit, demanded money for bills during the eight months I was not in the house, finally deciding to, behind my back, tell the research group academics that the reason they left was because I was screaming all of the time and generally off my rocker like some Hollywood movie description of mental illness.

Unsurprisingly, they are no longer my friends. The intellectual side of me thinks they were probably scared, had their own problems and didn’t want to be near someone worse off, yadda yadda yadda. The emotional side of me feels they’re, in their own way, quite dreadful.

The first thing I wanted to do was move to another office. The further away from my ex-friends, the better. Given I knew there were plenty of free desks in other physics research groups, I asked my supervisor to help me move, hopeful the process would be swift and efficient.

Of course, it wasn’t. While empathetic, my supervisor explained that most of the academics in the department used desk space like territory. The more desks each academic had, the higher the status of their research group. Like some sort of weird conglomerate of empires. Giving up a seat meant losing “territory”. My supervisor, despite thinking this was pretty dumb, had to negotiate a PhD student “swap” with another group. We were literal pawns on a chessboard. It was pathetic. Many of these generally highly regarded and respected academics seemed to have the emotional maturity of a five-year-old.

While the unnecessary game of musical chairs was going on, my mum was helping me find a new place to live. I initially went Airbnb hopping, staying for as long as the host had available. I did this for about a month before we found a suitable rental property. We were lucky, the place was near perfect for what I needed at the time. It was right in the centre of the town, adjacent to the town where I previously lived. This town was much bigger and had a lot more opportunities to socialise. When I finally moved in, my new desk space had been organised. My new officemates were very friendly. I could now figure out how to manage the plethora of external stressors I faced on a daily basis.

My anxiety, while utterly debilitating, was not completely useless. I was incredibly sensitive to stress-inducing things. Minimally stressful things that the vast majority of others wouldn’t even notice were like an air horn blaring directly into my ear. You would think that this would be the opposite of useful. Well, yeah, you would be right, mostly.

In experimental science, the more sensitive the instrument, generally, the more brittle it becomes. I saw my anxiety as like a sensitive scientific instrument – I could pick up on every small stressor. I planned my life to be as stress-free as possible using this sensitivity, but, unlike my experiments at work, failure didn’t mean disappointment. It meant pain. And failure was necessary. It allowed me to see the ways to not go about avoiding stress so that I could figure out methods that did avoid it. I applied my stress sensitivity to all aspects of my life. Food, socialising, work and sleep. Especially sleep.

Before The Event, I thought of sleep as an annoyance. There were many occasions where I tried to get away with less of it to fit more stuff in the day. Yes, I did manage to fit more things in, but I never realised that the quality of experience was dramatically lower than if I’d had a good night’s sleep.

Sleep is a nearly magical process. I could go to bed groggy, frustrated and stressed after a long day and the next day “poof”, all of it was gone simply by closing my eyes and waiting. Do you understand how incredible that is? When neuroscientists finally unlock all the secrets sleep possesses, I think they will encounter a picture so astoundingly beautiful they cannot help but be overwhelmed by it.

In my extreme mental state after The Event, the importance of good sleep became patently obvious. One bad night’s sleep and the next day was a write-off. It would then take two or three further sleeps to get back to the same functional level as before.

An optimal sleeping environment, in my opinion, requires three basic considerations: light, heat and comfort. To keep myself cool, I opened the window and attached a clip-on fan to the headboard of my bed. I would run it all night, pointed at my head. To regulate the amount of light, I would put on blue light-blocking glasses about an hour before bed (the science is pretty sketchy, but I thought there was nothing to lose). I bought blackout blinds and a smart colour bulb that would turn to red in the evenings, turn off during the night and would slowly light up at 6 am to simulate a sunrise. I made sure to go to bed and wake up at the same time each day (9 pm and 6.30 am). For comfort, I bought a smart plug and an electric fragrance emitter that would periodically let off nice scents during the night. Years later, I updated my bedroom routine further by buying comfy bamboo sheets, an active cooling pillow and a smart blackout blind.

Next, I used my stress response to optimise my journey to work. I printed out the bus timetable and stuck it right next to my bedroom door. It was quick, easy and caused barely any stress - unlike my constantly crashing phone app. I found the quietest route to the bus stop, utilising one hidden pedestrian path only findable using satellite mode in Google Maps. I chose a bus stop early enough in the route so that a seat was always available, but not too far of a walk. I made sure to get a bus before 7.45 am. Any later and a swarm of undergraduate students would progressively flood all the buses in a race to get to 9 am lectures or find a spot in the library. The quietest place to sit on the university double-decker bus was at the front on the top deck. The whole of the bottom deck was a no-go area because of the engine noise. Also, the rule of thumb of most university buses is that the further back you go, the louder the conversation tends to be. For extra peace and quiet, I got noise-cancelling headphones that played calming music, meaning I could meditate the entire forty-minute journey. It allowed me to not think about all the things I had to do once I arrived at work. The other passengers were none the wiser; they just thought I was just taking a nap.

Once I arrived on campus, I found that, ironically, the best route to the office was the pavement adjacent to the road leading to it. While longer, it was quiet owing to the few cars on the road. The undergraduates all chose the faster and more pedestrian-friendly route. Walking amongst a herd of rushing students is…stressful. When I arrived in the office in the morning, I felt refreshed. In the evening, I left my work behind at the door.

A few months into my PhD return and I had strategies to deal with most of the stressors I faced in the world around me. Things were looking up.

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I wish I could tell you that my trip to the grocery store cured me of my panic disorder. But that is not how it works. The trip did, however, help me come up with a method that would eventually cure me. I like to call it plane crash crosswords. The idea was to try and treat the emergence of a panic attack as if I was trying to finish a crossword while on a plane about to crash. The panic made me feel like my life was about to end, so when one started, I would attempt to focus intensely on continuing whatever I happened to be doing at the time. In the case of the grocery store, this was getting to the till and paying for the sub roll.

Plane crash crosswords required quite a blasé attitude towards death. My panic would say “You are about to die!!!” and I would respond “Well, can you do it already? I’m trying to pay for groceries”. Suffice to say, it is much easier said than done. But, on the odd occasion, it seemed to work. After about eight months or so, I stopped having panic attacks altogether. It was the only anxiety condition I was able to cure through cognitive means.1

Towards the end of our work on panic, my therapist shifted the focus. We hadn’t even touched on my severe generalised anxiety yet. While not as incapacitating as when a panic attack arrived, it is the most painful of anything I have ever experienced. Every ten seconds I would find a new terrifying perspective on the fragility of my mortality. The worst part of my generalised anxiety was that a large aspect of it was rational. Death and sickness are going to happen to me. My generalised anxiety convinced me it was going to be soon. While the panic involuntarily forced me into incapacitation, the generalised anxiety persuaded me into it.

So, I found it a bit odd when my therapist started to ask about my self-esteem.

Indeed, before The Event my self-esteem was in the gutter. I had been suffering regular old depression since I was around eighteen. It slowly worsened through to my early twenties, prompting me to take the Sertraline that turned my life to bedlam. I didn’t think I belonged amongst the other physics doctoral students. I didn’t think I was particularly worthy of happiness and was terrified of failure. While not the cause of my depression, it did amplify it significantly.

I was, to put it lightly, bemused when my therapist started working on self-esteem rather than the anxious nightmare that was my existence, but I went along with it. I figured: what choice did I have? My bemusement changed to near incredulity after we started doing power poses.

To be specific, we started with the Superman pose. “How do you feel? More confident?” my therapist enquired while I stood there looking like a man particularly impressed with their current wee. “Erm, Yea, I think so” I responded, lying through my teeth.

Power poses were a fad at the time, instigated by the famous TED talk by Amy Cuddy. She said that the research she and her colleagues did showed that consciously changing your pose to broader shapes will make you feel and actually be more confident.

At the time, I thought the theories were credible. Now I don’t think it’s wrong, just nowhere near right. I think the research question is far too vague. What exactly is confidence? What is a body pose? When you conduct scientific studies with vague definitions, all you are going to get are vague results. Vague in, vague out.

Even if it was true that broader poses make a person feel more confident, that is most certainly not my impression looking at them from the outside. Take a look at this photo of the former British Chancellor George Osborne in a power pose.

Is this the epitome of confidence, or a man trying desperately to keep their balance on a new pair of roller skates? You decide.

My therapist and I tried power poses for a while, but I never really felt any different while doing them. Perhaps they work for some people, but it just felt odd to me. When my therapist started to move on to affirmations, I was seriously starting to doubt their methodology. But I continued. I trusted my therapist. I kind of had to. There weren’t any viable alternatives at the time.

My therapist gave me some homework. It was to say “I love you” to myself in the mirror at least once a day. For the first couple of weeks, saying the phrase made me want to vomit. I didn’t really understand the point. A month or so later something started to change.

On their own, affirmations do very little. The most you can accomplish is the successful portrayal of a narcissistic parrot. The real progress is made in the counselling room. My therapist would pick out the times I spoke negatively about myself and challenge them at almost every instance. My therapist was trying to provide an alternative picture. The reality my therapist was trying to paint was one where I wasn’t failing. Perhaps I was missing my small but significant displays of character. Maybe other people weren’t perfect. My therapist pointed out that, ultimately, we are all in the same boat. She showed me the damage others can and persistently do to themselves, hamstrung by a personality they do not yet understand.

I began to realise that I was valuable, but not in the corny “everyone is beautiful” kind of way, like I was some sort of imperfect diamond. I became aware that others cared about me and that I was worthy of it. I started to believe the affirmations I was telling myself in the mirror. They became reinforced and ingrained in the back of my mind. At any wobble of self-esteem or vulnerability, the affirmations would play in my head like a broken record. The affirmations became a protection.

I think most other people misinterpret what high self-esteem actually means. I think others believe that the transition from low to high self-esteem involves a complete change of thought pattern. From a negative set of thoughts to a positive set. This has not been my experience.

While a lot fewer in number now, I do still think the same thoughts compared to the time I had low self-esteem. The change has been how I feel about those thoughts. There are occasions where I think I’m useless, or stupid, etc. The difference is that after the “low” feeling happens, a certain “comfortable” like one emerges. I feel, I guess, “authentic”. There is an acceptance that I, as a person, will always lie between flawed and perfect. By giving me alternative perspectives, my therapist helped me to understand that there is never only one narrative. It is impossible to be completely terrible, with the general trend towards learning and evolving. My focus changed from performance to improvement.

It was only later that I understood why my therapist started with self-esteem. There seems to be a common perception that in the throes of mental illness, low self-esteem is a given. I learned it is possible to have high self-esteem and be hideously depressed. I will grant you it was a bit bizarre to experience. I had long periods of time where it felt like the world was a horrible place to be, I held little hope for the future, and nothing gave me any pleasure. However, had you asked me “Is life worth living?” my answer would be “Of course silly. Look at what I was surviving through and doing despite the illness. How could I not think of myself as an impressive person?”

When I was trying to get back to my PhD, high self-esteem meant I had the confidence to do all the work that was ahead. Only someone with high self-esteem could utilise the courage I had learned. My perseverance through my mental illness reinforced my self-esteem. The more trials I got through, the greater my self-esteem became.

Of the many things I learned on my journey from low to high self-esteem, perhaps the most ironic was to discover that I was hurt by others more when I had high self-esteem. Curiously, it was my friends with low self-esteem who were usually the ones who unintentionally hurt me. They wouldn’t trust me when I told them they were capable of doing something they were doubtful about. I didn’t ever get the impression that they understood I helped them in the times they needed it because I liked them as a person. They always seemed to attribute my actions to some other motive. I suppose if you don’t think very much of yourself, surely everyone else must have come to the same conclusion?

I couldn’t really tell my friends with low self-esteem that they were hurting me. If I told them, then that in itself would’ve made them feel worse, which would have lowered their self-esteem, which would’ve made them feel worse, etc. They would have been caught in an infinite loop!

I would rarely ever be seen as someone who was in a crisis, sometimes even if I let the other person know directly. I was confident, self-assured and open about taboo issues. How could I be in a crisis?

I am someone who has a crippled mind. It took an inordinate amount of energy to get through each and every day. Yet if someone (on rare occasions, a stranger) told me about a problem they were having, as long as I felt good enough, I would ask them how I could help. If they responded with something I was unable to help with, I felt able to say no.

It is now seven years since The Event,2 and I can only remember a handful of times when someone asked how they could help me. I don’t help others for reciprocation; the feeling of helping is good enough. But it doesn’t half make me feel exhausted.

I believe the dangers of low self-esteem occur when an individual begins to experience a mental health problem. The low self-esteem makes it extremely difficult to get out of the downward spiral these problems can produce. My last safety net is high self-esteem. In my lowest moments I would think “Why would I kill myself? Despite all the pain, I am a person that other people would want to know”. It not only kept me alive, it allowed me to dare to believe that I could return to my PhD.

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The cause of my mental illness was rather unusual: a severe but extremely rare reaction to the antidepressant Sertraline, most likely serotonin syndrome. From now on, I will refer to the reaction as "The Event."

For some reason, The Event semi-permanently changed the functioning of my brain. Overnight, I went from someone who had never experienced a clinical anxiety symptom before, to someone who was now experiencing almost all of them in their most severe form. It was anxiety Christmas. Ho ho aaaaargh!

Readjusting to severe anxiety overnight, as it turns out, is not easy. In fact, I would not hesitate to say that it was extremely bloody difficult. Most accounts of anxiety I have read describe only something that “arrives”. Indeed, when my anxiety “arrived”, the metaphorical volume knob that controlled the level of fear in my brain was turned up to around 30 times what I thought was my maximum.

What was most noticeable, however, was something that had left.

It became apparent that my brain used to have a set of filters that I never knew existed. They were always working in the background, only allowing through stimuli deemed scary enough to be worthy of my attention. These filters would stop potential anxiety stimuli as small as a random twitch, and as high as high-speed metal boxes whizzing past only a few feet next to me while I sauntered down a sidewalk. In the “before” times, I thought nothing of these occurrences. The possibility of something bad happening was just a philosophical afterthought.

Like most things in my life, I had realised the importance of something once it had completely buggered off. Twitches and twinges suddenly assumed the significance of life-threatening events like a stroke or a heart attack. The precious logic I had relied on for my entire life was suddenly useless. Any rationalisation would not make the fear, nor the thoughts accompanying the fear, go away. There was always a very small chance that this seemingly innocuous sensation could be serious. Without the internal filters in my brain removing these infinitesimally small chances from existence, the intense fear I was experiencing always had something to grab onto. It always had an uncertainty to leverage.

It felt like the universe had been flipped on its head. It was as if some of the internal circuits in my brain were cut and now flailing around chaotically.

Needless to say, the situation wasn’t exactly optimal for continuing my PhD. I moved back to my mum’s place to try and recover. Initially, the most prevailing problem was the ten or so panic attacks I was having per day. Their random nature was causing my brain to associate nearly everything I encountered in my house with intense fear. I eventually became restricted to the couch, where I dare not move.

I thought courage was the act of overcoming a fear; you know, like skydiving or something. But, in reality, I think all you’re really doing in these cases is overcoming common sense. Jumping out of a plane without the proper training is not exactly clever. These types of “facing your fear” experiences do not even approach the amount of learning that is required to be courageous.

I learned that bravery and courage mean different things. I believe that bravery is something inherent. Bravery requires automatic filters, the ones I lost, to work in the background to allow the individual to function. The filters allow us to go outside, drive cars, and get on aeroplanes, as if it were the easiest thing in the world. I think most of us don’t even realise we are being brave.

Courage, on the other hand, is learned. In situations where our automatic filters do not protect us, it requires learning to navigate the monumental emotions as they arrive. There was no overcoming my panic attacks. I could not face up to them as if it were some sort of cavalry charge. It wasn’t a fight for control. Instead, I had to learn how to exist in the torrent of fire that a panic attack causes.

In a panic attack, my brain seemed to trick itself into believing death was imminent in a situation where a paper cut wasn’t even possible. A panic attack designated every system within my brain as “out of order” so that I could survive the oncoming and perilous threat of absolutely nothing at all. As an overwhelming sensation of doom built, my brain would go into an erratic search pattern. Sensations and sounds that are normally filtered out, such as my heartbeat, would have their volumes turned up to full. My heart rate would quicken to get all the lovely oxygen in my blood to the muscles, ready to stay pretty much stationary. “Aha!” my panic attack would go, “the heartbeat is quick and loud, so we must be having a heart attack!” The cycle of ridiculousness would continue like this.

My mum helped me find a private therapist to help me recover. The therapist and I spent a long time talking and strategising on how to deal with the panic. I learned calming techniques (e.g. deep breathing) that helped, but they were only part of the solution.

The tables started to turn after a particularly severe panic attack in a grocery store. I remember a claustrophobic feeling as I was queuing for the till. A burst of what I can only describe as “doom energy” then filled my brain. There was a powerful sensation, like an invisible force (mental illness has a lot of these) pulling me towards the floor. It took almost all my resolve to keep myself standing upright. From the outside, it probably looked like I was daydreaming.

I was experiencing the forgotten sibling of fight and flight: freeze. I was rooted in place for what felt like minutes, but was probably only 10 seconds. The attack subsided as the queue moved slowly forward. When I finally reached the till, the attendant asked cheerily “Hello! How are you today?”

A deep association had now burned into my brain. I couldn’t even turn the corner of the road to the grocery store before my brain started to ramp up the feelings of panic.

It is here that I started to learn how to be courageous. In order to get back into the grocery store, I had to put myself in a situation where I knew a panic attack was likely to happen. My first realisation was that courage, like anxiety in general, is measured in inches. I wanted to get it over with and run mindlessly towards the grocery store. But that would only result in a panic attack more severe than the first one, making the problem even more difficult to solve.

I inched my way towards that grocery store, each time choosing a point to turn back from and travelling no further. It took weeks to walk around 100 metres down a road, but I had yet to have a panic attack.

Inspiration for the final 200 metres came from an unlikely source. I was watching coverage of the rocket launch taking the British astronaut Tim Peake to the International Space Station. I couldn’t help but notice the contrast of a man preparing to propel himself upwards using a prolonged explosion, and my inability to get to the grocery store. It felt overwhelmingly frustrating.

So, I completely abandoned my plan of slow progression down the seemingly never-ending road, and ran mindlessly towards the grocery store (well, more walked briskly like someone late for a bus).

I found myself getting further along than I thought before the panicky feelings started. They eventually arrived as the shop sign came into view. To my surprise, the feelings seemed to halt at the “potential crisis” level. As I entered the store, I braced myself for the full onslaught of a panic attack, but none came. I found myself pausing briefly just inside the store doors, perplexed at my current upright stature, before realising that the less time I was in the store, the higher the likelihood I could maintain my bipedalism.

I had but one item on my shopping list: sub rolls. I quickly made my way over to the shelf where I had always picked them up in the past. Croissants. Packets of croissants were sitting directly where the sub rolls should have been. The space-time continuum must have ruptured. “Frick” I thought, or something along those lines. I hurriedly scanned the entire bread section. Hot dog buns, baguettes and burger buns lined the shelf adjacent to me in abundance. Pitta bread was squished in right at the end. I hustled around to the other side to find to my disappointment brioche and ciabatta occupying my full gaze. There were bagels and focaccia in my peripherals. But nothing approaching sub rolls.

A person in a calm state of mind would come to the logical solution of simply getting the next closest type of bread. But I was neither calm nor thinking logically. The only thought that occupied my otherwise chaotic mind was “get the sub rolls and get out of there”. And I had yet to acquire sub rolls. So, a task that should have taken a minute was now pushing ten. My aimless wandering finally came to a conclusion at the drinks section when, finally, a rational thought fought its way to the front of my awareness “Why don’t you just get a baguette?”

Despite the disaster of the missing sub rolls, my brain had not eclipsed into panic. Nevertheless, I wanted to get the heck out of there. I found myself in a short, but still significant, queue. The panicky feeling ramped up ever so slightly. I kept my focus on the till, determined to get my disappointment of a baguette paid for.

This time the till clerk only uttered a rather disgruntled “hello” while I was beaming ear to ear. I walked outside and called my mum. “Tim Peake went into space and I went grocery shopping; those two achievements are about equal, right?” I rhetorically asked her.

I learned that there is no such thing as “fully ready” when taking on a challenge. Like a trampoline gymnast learning a new trick, no matter how long I prepared, at some point, I would need to jump. I also learned that jumping is not the courageous bit, it’s the stupid part. Regardless of how the jump goes, there will always be an end. Meaning there will be relief that the difficult bit is over.

No, the actual courageous part was during the weeks of inches. The benefit, being able to go into a grocery store again, was too far in the future to produce any meaningful motivation. I first needed to know the answers to questions like: what are the first feelings of panic? What thoughts run through my head? Which symptoms are manageable and which aren’t? Which strategies help and which ones make it worse? How quickly do the feelings of panic ramp up? These questions could only be answered by instigating the beginnings of panic and reflecting on them in a therapy session. It is this, tiptoeing into fear not knowing whether I would leave it in tears, where I think courage is learned.

Learning courage had benefits far past tackling my panic disorder. I learned how to step into everyday fearful situations like public speaking and important meetings. It meant I gave talks on therapy and meditation in an academic environment, right out in the open. In fact, I frequently talked openly, honestly and challenged people’s perceptions. I started to ask “dumb” questions (FYI, it turns out not many people care if you break minor social norms, and if they do, it usually only lasts a day or two).

Perhaps the most surprising revelation about learning courage was realising that not many other people had learned it. Most others around me seemed to be in a perpetual state of “staying safe”. I’m not sure my peers understood the cost of inaction. Taking almost zero risk, while safer in the short term, is almost entirely detrimental in the long term. Relationships and friendships between others were slow to develop. When they eventually did form, there were many occasions where those around me would either leave beneficial relationships in search of something better, or stay in damaging ones for fear of being alone. Job opportunities were often not taken, or not thought through, and bosses and supervisors were rarely ever challenged.

The vulnerability experienced during mental illness is, at the very least, a semi-permanent fixture in everyday life. It feels like everyone around you is attacking you, due to the preconceptions and expectations most of the population has of those around them. Any emotional conflict I have, for example a heated argument, has had an exponentially greater impact after The Event. It feels like my emotions are persistently on the edge of being over-activated, resulting in my brain collapsing in a heap.

Therefore, simply walking around in society with a brain in such a vulnerable state requires a remarkable amount of courage. If listened to, mentally ill people have the potential to teach what courage is and how to utilise it. We have the potential to help others learn to live with their vulnerabilities.

So, if you want to learn courage, don’t listen to an idiot who risked their life and terrified their loved ones by climbing a mountain for the benefit of only themselves; listen to someone with a mental illness or mental health problem, who is just trying to get through the day.

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Whoever came up with the phrase “life lessons” probably didn’t understand life very well. I’ve not so much learned anything from my life, rather, stood in bemusement while I’m pelted by stones made of pure absurdity.

For instance, I once went to a beginner’s mindful meditation session led by a very kind Buddhist monk. It was held in a dimly lit room with about thirty other people. The monk politely instructed that we find a space to sit on the hardwood floor, directing us to the pillows laid out with the intention of sparing our posteriors.

Unfortunately, it seemed like the designer of my pillow thought that a cushion’s primary function: cushioning, was merely an optional extra. The top face of its flat cylindrical shape could barely accommodate a baby’s bottom. Its filling somehow had the consistency of frozen peas; my weight easily parting the styrofoam sea. The pillow shell was adorned with endless stitching, sequins and beads. While stunningly beautiful, if I’d sat on that pillow a minute longer, a template for a mandala tattoo would have been permanently etched into my buttock. Therefore, I decided to hedge my bets with the hardwood floor.

As I was processing my near future of throbbing pain, the soft voice of the monk informed us that we would be meditating for around an hour. “An hour!” I thought, “God help me”. My internal cries for help useless in a deity-free religion. It turned out to be an hour and fifteen minutes as this particular monk’s internal clock was running a bit slow.

The pain was manageable. The boredom wasn’t. In my experience, there is rarely a reason to meditate for longer than twenty to thirty minutes. Similar to napping in the afternoon, meditating longer than half an hour actually makes me feel worse, not better.

At the end of the silent meditation session, I heard the monk’s voice once again whisper through the room. Finally, I was free. Or so I thought. He spent ten monk-minutes (15 actual minutes) speaking about the quirks of meditation and mind. His voice was so quietly confident that I became deeply attentive to his every word, despite the lack of feeling in the lower half of my body. He seemed so wise. I left with a feeling of awe. It lasted right up until I started to think about what he actually said. It was mostly vague generic poppycock.

The profound “life lesson” I learned that day? Always bring your own pillow to a meditation session. Also, just because someone dresses in an ornate meditation robe, doesn’t necessarily mean every word they say is gold dust.

When I tell people that I finished a PhD while suffering a severe mental illness, I hope for the same type of enthusiastic attentiveness and eagerness to learn that I gave the Buddhist monk. But it rarely ever happens. In its place is usually just a blank stare.

I sometimes get a question along the lines of “how on earth did you cope?”

I think others assume I gritted it out, that I fought a titanic battle against the disease. But anyone who has ever had a mental health problem will know that fighting against it will only make it worse. It is like trying to fix a slow computer, because it is overheating, by making the processor run faster. Which just produces more heat.

The obvious solution is to cool down the processor by reducing the workload. Which is sort of the basic principle of mindfulness. To give your brain a rest every once in a while. I believe that everyone can benefit from practicing mindfulness. But, like everything else in this world, it has its limitations. Something the monk didn’t seem to quite understand.

Mindfulness assumes quite a bit of the brain is still working a-okay. As a basic example, it assumes that when you breathe in and out slowly, the complex network of automated neurological systems that allow you to feel calm engage with significant effect. Or, in other words, doing calming things makes you feel calmer. While for most people slow breathing does alleviate stress, in my case, there was a long period of time where slow breathing didn’t do much at all.

To do a PhD with a severe mental illness required a great deal of skill. A lot more than simple mindfulness. I had to be able to resolve conflicts and stressors quickly and effectively so that they did not have a chance of incapacitating me. I had to utilise every possible drop of emotion that was still working in my mangled and mutilated mind. I had to use emotional techniques meant to temper a light breeze to subdue a hurricane.

Most of the stories I read about mental illness portray it as this hellish, horrendous thing that you must wait out. That there is nothing to gain during its murky depths. While in the darkest throes of mine, I have found it difficult to read these stories. I could not see any horizon of relief in front of me. If the experience I was in was entirely a waste, how could I find motivation to keep on going?

I have found that the prevalent feeling during my illness has indeed been of time wasted. However, I would hesitate to say that there is absolutely nothing to be gained. There are significant benefits if remission is found. I hope that highlighting them will help those out there going through mental illness.

The main purpose of this series, however, is for the mentally healthy. I want to show that many people with mental illness have the potential to be of immense value to society.

This is not to say that the experience of mental illness is worthwhile in the slightest. The drawbacks enormously outweigh any hint of benefit. What I mean is that those who go through mental illness have the greatest potential to improve society as a whole. But they must be brought back to remission first.

If we bring these people back, the first thing you will notice is…

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Wait a minute… where are the footnotes? Have I just written an article without footnotes?

In 2017, the president of the United States in Psyverse #2 was thinking of establishing a “Space Force”. It was to be a new military branch that dealt with national defence matters in space. The president ordered a draft proposal to be sent to the head of NASA for revision.

Unfortunately, the official put in charge of writing said proposal had just recently had a child with their partner. The previous night had been spent attending to their cute, but extraordinarily loud, baby. In the official’s slightly delirious state, they misheard the orders of the president. They wrote a proposal about a new project codenamed “Space Horse” - a mission to send the first horse into space.1

At the time, the United States was competing with the British to achieve various space-related firsts. The head of NASA started asking colleagues about the feasibility of equine astronauts for a space horse race with the British. They quickly suggested he should probably see a psychiatrist.

So, when a man entered a relatively inexperienced psychiatrist’s office talking about the advantages of designing a space suit for a Mongolian horse instead of a Shetland pony, while also claiming to be the head of NASA, eyebrows were immediately raised.

Through quite a remarkable feat of pure bad luck, both parties managed to completely misunderstand what the other was saying. For instance, when the psychiatrist asked about any past feelings of stress, being wide-eyed or perhaps times he felt exposed, the head of NASA described the first time he tried to take a photo of the stars on the International Space Station “All I could see in front of me was darkness - a vast emptiness that extended beyond my imagination”.

The psychiatrist thought this was a sign of depression. In reality, the head of NASA was trying to communicate his frustration at being unable to correctly set the exposure and aperture settings on his camera.2

The head of NASA was prescribed a Selective Serotonin Reuptake Inhibitor (SSRI).3 The response to SSRIs (and antidepressants in general) is assumed to be highly variable.4 For instance, some people may report complete remission of their depressive symptoms, while others report an “emotional blunting”. Some may receive no benefit at all. There is a great deal of uncertainty surrounding treatment response. What we can be certain of, however, is that a person without depression5 isn’t going to benefit from the antidepressant effects of an antidepressant.

This does not mean that for the undepressed,6 taking an antidepressant is risk-free. SSRIs, particularly when it comes to various bedroom activities,7 can produce noticeable side effects. The head of NASA and a firefighter, who also happened to be his wife, both noticed these noticeable side effects. After six weeks, due to not noticing any noticeable improvement in his actually notably fine brain, the head of NASA booked another psychiatric appointment to discuss the matter, then made a note of the date in his calendar.

As the appointment was during work hours, the head of NASA arrived in his official jacket.8 It did not take long for the psychiatrist to realise that yes, this was in fact the head of NASA and yes, NASA was indeed trying to send a horse into space. It was agreed that it would probably be best if the head of NASA weaned off the SSRIs.9

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With that mistake dealt with, all that was left was this silly old horse thing. The head of NASA booked a meeting with the commander-in-chief. Now, if the United States had a president who could admit mistakes, everything would have gone back to normal. But the U.S. didn’t. And thus, the USA became the first country on Earth #2 to announce it was going to put a horse into space.

The British, rather predictably with their storied history of drawing galloping horses incorrectly,10 couldn’t let this stand. They announced that the U.S. was sadly mistaken. It would be the Brits that would be the first to put a horse into space! Australia, who couldn’t let some Poms get away with any horsey business, entered the race too – but with a kangaroo. It didn’t go well. Kangaroos like to kick.11

As news spread around the world, more nations with proud associations with horses entered the space race.12 Even Mongolia, despite their less-than-ideal technological situation, sprang into action. Hey, if Genghis Khan could conquer a quarter of the world in a quarter of a century on the back of a Mongolian horse,13 surely the great country of Mongolia could send one into space.

It became clear to the countries involved that the task of sending a horse into space was not going to be easy. Starting in all places, with their complicated digestive system. Annoyingly, horses need to feed almost all the time. Other than leaving little room for the many administrative tasks required of a horsetronaut, a lot of hay, grass, grains and fruits would be needed. If the horse were to stay for any protracted period in space, produce would need to be grown.

Fortunately, there exists an entire field of Astrobotany14 you probably didn’t know about until this sentence. Despite the problems of growing plants in space15 plenty have already been grown on space stations like the ISS, and even a cotton plant briefly grew on the far side of the moon. So interestingly, growing the steroid-infused grasses for a horsetronaut was the least of the Psyverse #2 countries’ concerns. What happened when the space horse swallowed the grass was the bigger issue.

Horses may have a problem digesting food in space. They rely significantly on enzymatic digestion. The massive caecum in a horse – around 30 litres – acts as a kind of fermentation vat, where bacteria and enzymes break down food. The entry and exit to the caecum are at the “top” of the horse. Gravity is required to keep food in the caecum to ferment, and the caecum uses peristalsis to move food up and out into the large intestine. It might be the case that there would be a greater chance of impaction in microgravity.16 Which would not be good for the short-term health of the horse.

On the other hand, bacteria thrive in space.17 Some strains seem to grow much more quickly, though it is unclear why.18 This might offset the gravity problem in the caecum.19 Nevertheless, the horse digestive system is incredibly fragile. One of the most common causes of death for a horse is colic,20 which is a catch-all term for the symptoms caused by over 70 different types of intestinal problems.21

For our intrepid nations of Psyverse #2, digestion is not the end of the story. If a horse is to spend any reasonable length of time in space (months), their musculoskeletal22 system will likely weaken significantly. For humans in our universe, we have found that microgravity reduces bone mineral density, decreases muscle mass, and loosens tendons.23 A horse in space would have a greater susceptibility to bone fractures24 and would be significantly weaker on return to Earth.

One potential solution would be to breed “Mighty horses”. By inhibiting genes that produce proteins involved in muscle and bone loss – myostatin and activin A – researchers Emily Germain-Lee and Se-Jin Lee showed it was possible to breed jacked mice.

They then sent the mice adonises with their normal counterparts to the International Space Station (ISS). The swole mice were protected against both muscle and bone loss in microgravity.25

Perhaps the most important factor that would need to be considered is the behaviour of the horse in microgravity. Weightlessness could be very disorientating for the equine astronaut. Fortunately, there is a 1995 paper by a Japanese researcher called S. Mori26 which definitely helps illustrate the postures of various mammals in microgravity:

According to this figure, I have scientifically deduced the most likely posture a horse would have in microgravity:

Interesting. Looks like we have horse drawing history all wrong. Artists weren’t drawing horses galloping; they were drawing horses in microgravity!

Despite an initial panicked and disoriented behaviour, there is some reason to believe that a horse would become acclimatised to microgravity. Mice are frequently sent up to the ISS, and after hanging around for a couple of days, they eventually learn to whizz around their cage as if it is one giant stationary wheel.27

The choice of breed is crucial for any space-faring horse. Thoroughbreds would be far too agitated to deal with the stressors of space, increasing the risk of conditions like colic. Ironically, one of the calmest breeds, the Clydesdale, is also one of the largest. In rocketry, the larger and heavier the capsule, the bigger the rocket needs to be, the higher the cost.

We are just touching the surface of the potential problems that would need to be solved to send a horse into space. There is potential for retinal damage, or cardiovascular insufficiency. If it is a long-term mission, you would have to think about horse breeding28 and radiation effects. How would a horse use the controls?29 What would you do with horse waste? If you wanted to do a space-trot, how would you get the horse into the spacesuit?

It took until the end of the 2020s for the United States to be finally ready to send a horse into space. The head of NASA had settled on an American Quarter Horse due to their calm temperament and highly trainable nature. The rocket was on the launchpad, the Quarter Horsetronaut had a calm and determined look in her eyes.

Then the head of NASA turned on the television. A Mongolian flag was painted on a spaceship orbiting around Earth #2. Inspired by the wooden satellite “LingoSat” launched in late 2024, and the wooden heat shields on the Fang Shi Weixing satellites developed by China in the 1960s,30 the Mongolians had built a wooden spaceship.

The head of NASA tilted his head to the right. Right there, proudly floating in the cockpit, legs splayed out, was a Mongolian horse.

After more than a decade of effort, the United States had lost the space horse race to Mongolia.31 In a wooden spaceship no less! Dejected, the head of NASA wondered why on earth (#2) they started this godforsaken project in the first place. Oh, wait, that’s right. A mistake. This whole project snowballed from a single mistake. Otherwise, the whole thing went pretty smoothly.

Not like that incident with the psychiatrist, the head of NASA thought. He seemed to make plenty of mistakes. In need of a distraction, the head of NASA revisited the psychiatrist who mistakenly gave him medication for a condition he didn’t have.

“Where did you anonymously report the mistake to?” The head of NASA asked out of curiosity. The psychiatrist gave him a confused look “What do you mean ‘anonymously report the mistake’?”

“You know, you fill out a little form, send it off to an independent national organisation, they do an investigation. That sorta thing” the head of NASA replied.

The psychiatrist paused in thought for a few seconds “Hmm. There isn’t something like that here… but I do recall something like that in a country in Asia. Ahh, it is on the tip of my tongue! Like, had that guy that conquered a whole bunch of places… Gengu… Gungis…”

“Oh god. Please no…” the head of NASA interjected “…is the country Mongolia?”

The psychiatrist’s face lit up. “Mongolia! That’s it! The Mongolian patient safety reporting system. I’ve heard it’s been quite successful. Even helped send that horse into space. Crazy world we live in!”

The head of NASA made a quiet whimper as his head sank into his neck. Without saying a word, he turned on his heels and slumped his way out the door. He knew that if he wanted to build a national patient safety reporting system in the United States, he would need to learn from the best.32 In a tone resembling Eeyore from Winnie the Pooh, he muttered “Why is it always Mongolia?”

The next day, he booked a flight to the country that he now disliked with all his heart.

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10

Before videos, people could not figure out how the legs moved on a horse in full gallop. Horses’ legs moved far too quickly. Therefore, there are a whole host of paintings where horses are seemingly levitating with both sets of legs outstretched.

Eadwaerd Muybridge, photographer and part-time alleged murderer, designed the first-ever cameras that could take images quickly enough to film a horse in a gallop without being blurred.

On June 15, 1878, he invited the press to see his process. He showed how he captured the images using trip wires and 12 quick-exposure cameras. This was the first ever moving picture.

It was not a good day for horse artists.

Historical Note: Before perspective was figured out, some medieval artists had an especially bad time drawing horses…

13

The rate of expansion of the Mongolian empire is truly astonishing.

32

I didn’t include the Psyverse #2 Mongolia story as I felt this was a natural ending to the article. I was going to say that Mongolia, due to their inexperience in building rockets, had a lot of injuries. This would bring the aviation engineers, pilots, etc., into hospitals. Thus, there would naturally be a conversation about the lack of incident reporting systems in healthcare.

Given that much of the population of Mongolia is highly concentrated in small areas (the capital Ulaanbaatar contains almost half the population of the country), with large geographical separation between these areas, this makes the logistics of setting up a reporting system much easier, I would guess. i.e. testing of procedures in towns with the same population, which can then be applied to large hospitals in the few big cities.

Subsequently, I was going to say the incident reporting system helped to improve safety, as well as improve the medical system generally. Psychiatry was a huge beneficiary. The significant problems with mental health that Mongolia faces started to be tackled. Combined with the technological scarcity, innovation increased dramatically, leading to the wooden spaceship.

All of which is ridiculously flawed, wishful thinking, to the extreme. But you have now learned more about Mongolia, a country not often talked about.

This is the final article in the Psyverse #2 series. For previous posts, see the compendium.

I try as much as humanly possible to find the nuance in every field I explore. I try as much as possible to see the bigger picture. When it comes to psychiatry’s own engagement with human error, however, there is no bigger picture. There is barely even a drop of paint on the patient safety canvas.

Yes, there are important, emotionally vulnerable stories about iatrogenic harm. There are bold debates about coercion and autonomy. There are discussions about involuntary commitment from both patient and clinician.

But, put bluntly, none of this translates into meaningful structural change. Patients continue to be harmed; operational safety still isn’t central to the field.

If it were, we’d see sustained, mainstream engagement with human factors, human error, and learning systems across flagship psychiatric outlets. Psychiatry would be heavily involved and integrated within the safety science field. Structures such as safety management systems, incident reporting systems and investigation bodies would be prevalent. Just like it is in aviation and, to a lesser extent, other fields in medicine.

Be honest, when was the last time you read a flagship psychiatric editorial centred on human error? That this still feels marginal in 2026 — more than twenty-five years after the patient safety revolution — is a serious failure of imagination.

When the subject of iatrogenic harm is discussed, we quite rightfully highlight the pain, the injustice and discuss the philosophical implications to the ends of the earth. But in the final analysis, I cannot help but conclude that few are willing to roll up their sleeves and venture into the subject of human error.

I believe this is psychiatry’s crux. In physics, when we need tools from another discipline, we go and learn them. Psychiatry appears more inclined to stay in its lane. While I understand this is beneficial and often necessary for everyday clinical practice, the result is psychiatric discourse has all the epistemic variety of a greyscale Rubik’s cube.

Where are the psychiatric innovators? Who speaks for systemic safety change in psychiatry?

Looking back through the history of aviation reporting systems, I could not help but notice the social push for better safety. Through their associations, pilots, air traffic controllers, and other aviation staff relentlessly advocated for better aviation safety systems. I do not see this kind of advocacy in psychiatry.

I have been impressed by the insight of authors tackling the complexity of psychiatry. I have been engaged learning about the hope, or indeed false hope, of new treatments. I have been moved by deeply personal stories of patients and practitioners in their struggles navigating the psychiatric system. I have had my mind changed through the continuous dialogue about what diagnosis is and isn’t.

And none of it matters.

Even if you came up with miracle treatments or technologies tomorrow that cured every single mental illness, even if you proved it was effective, it would not matter. Because you wouldn’t be able to convince patients to take it.

Someone has to design the treatments. Someone has to diagnose the patients. Someone has to administer the interventions. And with people comes human error. Patients would continue to be harmed, some would die.

When new technologies are introduced, people do not demand “better than before”. They demand near perfection. Trust is not built on promise. It is built on reliability. Without a rock-solid foundation of patient safety systems in psychiatry, none of the mountains of quality mental health commentary matters. Still, I wouldn’t even say the foundation of patient safety systems in psychiatry is flimsy. It has to exist first.

Building these systems requires a culture that treats error as data, not disgrace. In 2005, Justin Waring interviewed 28 specialist physicians about their attitudes to human error. Many described mistakes as inevitable – “Human error is always going to occur,” one said. Error reporting was widely regarded as pointless. If error cannot be eliminated, why report it?

How much have attitudes changed since? Does psychiatry, and perhaps healthcare in general, still focus on individual performance, over system safety?

I can’t know. What I do know is that having been a patient in the medical system for over a decade, I almost expect error to occur. I have to fight complacency. My psychiatrist, whom I respect, asks at every appointment whether I am still receiving rTMS treatment. I stopped five years ago. At some point in almost every year since my sister was born, my mum has to phone healthcare professionals to ensure my sister’s tube feed arrives on time. The very food my sister needs to live is not exempt from human error.

It doesn’t have to continue like this. Change is possible. The knowledge already exists. We do not need a new philosophy. We need to engage with the safety science already built.1

Psychiatry does not lack intelligence. It does not lack compassion. It lacks operational imagination.

And until that changes, patients will continue to be harmed – not because we failed to debate, but because we failed to build.

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Welcome to the Psychiatric Multiverse – where we take an idea from an area of life, and postulate if it could be useful in the psychiatric system.

Today, we are postulating how an effective reporting system could be constructed in a hypothetical alternate reality. To explore previous articles in the series, visit the compendium.

To help with the split between our universe and Psyverse #2:

Explanations will be in normal formatting.

While the story of Psyverse #2 will be in italics.

Late one evening, I had an absurd idea.

While tucking into a good book, in the form of Don Norman’s The Design of Everyday Things, I read this paragraph about NASA’s role as the independent administrator of the Aviation Safety Reporting System (ASRS):

NASA is a neutral body, charged with enhancing aviation safety, but has no oversight authority, which helped gain the trust of pilots. There is no comparable institution in medicine (emphasis added by me)

I felt an excitement start to build – the kind that always accompanies me before a quest into the academic literature. “What if healthcare professionals just reported their mistakes to NASA?” I thought, as I leapt into my office chair and turned on my computer.

To my dismay, I was three decades late to the party. The U.S. Department of Veterans Affairs (VA) had the exact same idea while convening several expert advisory panels in 1997. After a talk by Linda Connell, the director of the ASRS, the VA enquired about the feasibility of applying an ASRS-like system to medicine. Both organisations worked together to set up what became known as the Patient Safety Reporting System (PSRS) in 2000.

The PSRS was run by NASA in a very similar way to the ASRS – it was an external, voluntary, confidential reporting system. There was, however, one major difference. It was run as a complementary system to the VA’s own internal one with the same coverage. PSRS was intended as a “safety valve” for reporters who wanted confidentiality. Unfortunately, unlike the ASRS, it was not successful. Over a 10-year period only 500 reports were submitted to the PSRS, while the internal VA system received approximately 700,000.

Due to cost-cutting measures, the partnership between NASA and the VA ultimately ended,1 leaving only an abandoned website as a window to the late 2000’s internet.

Ever the optimist, and lover of left-field ideas, I was not discouraged by this failure. I read more about incident reporting, going far deeper into the subject than I had anticipated.2 I think there is a genuine need for improved patient safety incident reporting systems. But how could it be done?

Fortunately, here at the Psychiatric Multiverse, we don’t have to worry about the frustrating roadblocks of societal and political forces. All we have to do is imagine our universe splitting in two at this very moment. One continues as our own universe, the other (Psyverse #2) builds a national patient safety incident reporting system in the United States.

Using what we have learned from the history of aviation reporting systems, and the current literature on patient safety reporting systems, let us try to figure out how an incident reporting system could be built.

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Patients, Patients, Patients!

Firstly, I believe a truly effective patient safety reporting system has patients reporting incidents. Patients are the ones with the most skin in the game. They are the ones harmed by mistakes. They are front and centre in the discussion about their care, and if they have the mental capacity, they have a veto over any treatment proposed.

In aviation reporting systems, both air traffic controllers (ATC) and pilots report incidents.3 Drawing an analogy to medicine, doctors are like air traffic controllers, and patients are passengers who are suddenly thrust into becoming pilots. While patients generally know little about their bodies, ultimately, they are the ones who have to “fly the plane”, so to speak. Therefore, patients see a very different picture compared to the “ATC” doctors, who can only advise and provide treatment.

Logically, it follows that a patient’s perspective is essential to fully understanding an incident. Information from patients can be useful in isolation, but the primary value comes from the added incident context through doctor-patient report comparison. But, with our current patient safety reporting systems, many don’t even allow for patients to report, while for the ones that do, they make up a tiny proportion of incidents. Which begs the question: how can we expect patient safety reporting systems to help indicate where system wide learning can take place, if we are missing information from half the system?

Including patients in an incident reporting system would not be as straightforward as simply allowing them to fill in forms. Factors like the design of the report form,4 legal protections,5 promotion of the reporting system to patients6 and feedback mechanisms7 would need to be addressed.

Starting our story of Psyverse #2:

Due to wildly improbable circumstances,8 a sudden social and political will to build a national patient safety incident reporting system within the United States #2 arises. Miraculously, the U.S. #2 government in this alternative world takes this public pressure as a sign they need to do something.

To figure out how to design an inclusive reporting system, they create the Never Again Unit (or NAU – pronounced “now”) to consult with patients and lived experience experts.9

They help design a form with plain English language, simplified to the digital equivalent of one side of A4 paper. The form has only very basic fixed-choice questions to ascertain where the event took place, with the free text portion dominating (prompts a simple question: what happened?). They find in testing that the “callback”, where patients are called back for clarifications, is essential with patient reporting. It not only ensures that the lived experience analyst correctly understands what occurred but also provides an excellent opportunity to indirectly promote the system.

Every stage of the reporting process has patient and public involvement. Working with their clinical counterparts, lived experience analysts help to decipher patient narratives, while lived experience investigators help to spot areas of improvement (that may otherwise be missed from a clinical perspective).10

The government drafts specific legislation to protect the patient incident reports from being used as evidence in legal proceedings (reports are privileged). Patients are asked to be involved in investigations through the confidential communications software. Later, promotion of the program is integrated into the wider strategy, when NAU teams up with the promotions team at the yet-to-be-announced independent third party.11

A trusted third party

In a previous article, we argued that there is a need for national patient safety reporting systems. This is especially relevant for the United States, which currently doesn’t have one - instead relying on a complex fragmented web of voluntary institutional reporting systems conglomerated into one national database. Briefly, health care providers can report to a Patient Safety Organisation (PSO), which can then send a standardised report to the Network of Patient Safety Databases (NPSD).12

While healthcare providers have found some benefit in reporting to PSOs, significant difficulties remain, including low participation, legal protection confusion, and poor patient involvement.13

It may be best, therefore, to start afresh. But given the importance of an independent third party, which one would be best? The architects of the ASRS emphasised that “not any third party” will do. From the NASA Reference Publication on the ASRS:

Any organization called upon to manage and direct a program as sensitive as ASRS has proved to be must meet several criteria, among which are the following: ( 1 ) credibility with users, the relevant community, and the bureaucracy; (2) unquestioned integrity; (3) experience in gathering and handling information; (4) technical proficiency; and (5) an understanding of the community, the operational context and an appreciation of the relevant political issues.

Currently, the Agency for Healthcare Research and Quality (AHRQ) runs the Network of Patient Safety Databases. Given the institution’s non-punitive function, combined with previous experience handling technical information and a deep understanding of healthcare, the AHRQ would seem like the perfect third-party.

There is, however, one major problem. Very few people outside of the U.S. healthcare professional community (i.e. patients) know about the AHRQ.14 Any third party must at least be known by patients, never mind have credibility with them, if we want patients to report. Ten years ago, the Centers for Disease Control and Prevention (CDC) may have been a better bet, given it is more widely known and has experience in dealing with large healthcare datasets. But the CDC doesn’t, erm, have the best reputation with the public at the moment.

Thinking about it, not many U.S. institutions seem to be seen in the greatest of lights right now – from both sides of the political spectrum. I think NASA is probably one of the few institutions that has the name recognition, is still widely thought of as credible, capable and independent, while also having the relevant technical proficiency.15 It has run the successful ASRS and must have learned lessons from the failed VA-PSRS project.

But, for any independent third party chosen to run a hypothetical United States national patient safety incident reporting system, the historical roadblock of healthcare staff not reporting to the old VA-PSRS system needs to be addressed. Perhaps there is an out of the box solution.

Continuing the Psyverse #2 story:

Popularised in the media as “The Decision”, the actual selection of an independent third party was relatively straightforward. Many stakeholders argued for over a month about why they were best placed to run a national reporting system, then it was awarded to NASA.16 Ultimately, there was no way of competing with the reputational capital that comes with successfully launching a horse into space.17

A Prototype in Psychiatry?

Both Charles Billings and Lucian Leape expressed concerns that the complexity of the medical system would forbid useful functioning of a national reporting system in the United States. However, Billings, in his 1998 talk to the National Patient Safety Foundation, proposed a possible way forward18:

I would offer you some hope that it may be possible to define areas within medicine in which there is a somewhat smaller constituency, a somewhat smaller group of stakeholders and within which, therefore, the problem may be slightly more tractable than it will be if you decide that your purview is all of medicine. I am not sure I would know at this point, even after 20-plus years of experience with this business, how to design a system for medicine. I think I could perhaps design a system for some subsegments of medicine, that are more tightly circumscribed, but I hasten to add that I am not even sure of that.

I would put forward that the psychiatric system is one of the better places to begin building a national reporting system.

Historically, psychiatry was somewhat separated from general medicine – both conceptually and geographically (in the form of asylums). While there has been a growing effort to integrate mental and physical healthcare systems, divisions remain.19 Oddly, while this separation likely hinders the current quality of care of patients, it arguably reduces the complexity of implementing a reporting system.

In an inpatient setting, the reduced interaction with general medicine means fewer types of health practitioners involved in incidents. Potential investigations may initially stay within the confines of a psychiatric ward (or within a separate hospital entirely). In an outpatient setting, most interactions between a psychiatrist and patient involve only a conversation.

The technological simplicity of psychiatry also lends itself to easier reporting system implementation. It is impossible to report an error with a complex diagnostic test if they don’t exist. In many cases, the most advanced diagnostic technology used in a psychiatric clinical setting is a piece of paper.20 Treatment of mental health conditions remains mostly confined to therapeutic methods or medication, though there is a growing use of brain stimulation methods.

The relational complexity of psychiatry, spanning issues like coercion, capacity, stigma and broader ethical issues, makes the narrative-rich free-text section of incident reports particularly valuable. A lot could be learned and improved upon using the narratives of psychiatric patients and staff.

While many types of patient safety factors are shared with general medicine,21 some are relatively unique. On the patient side of things, there is likely little that indicates a need for improved psychiatric patient safety (and care) more than an entire anti-psychiatry movement. Also, self-harm and suicide are increased risk factors. On the healthcare worker side of things, the potential for aggressive behaviour (in certain settings of some sub-groups of patients) means that not only are physical injuries more likely, but healthcare professionals can also often suffer mental harm through second victim syndrome.22 After investigation, some system wide changes may also be unique. For example, changing décor and introducing physical barriers may lead to safer environments.

Perhaps the best argument for implementing a national incident reporting system in psychiatry is that the field has the most to gain from a focus on patient safety. Up until now, the field has mostly been “in a world of its own”. Psychiatric patients were either excluded or not mentioned in landmark patient safety studies or reports, while the psychiatric patient safety literature generally runs in parallel, rather than with, general patient safety literature. Psychiatric safety remains an under-researched field.23

A team at NASA #2 assembled to plan and implement the new national reporting system. They chose psychiatry as the field to test a prototype: the Psychiatric Safety Reporting System. The NASA team batted away suggestions that the subsequent acronym, PSRS, would be “confusing” compared to the previous PSRS,24 since that PSRS was too old to be of relevance to this PSRS. The name stuck regardless.

Rather than relitigate a very complex US #2 incident reporting landscape, NASA #2 sets up a new Patient Safety Organisation that covers all of the psychiatric system. They have their own database and run their own analysis. Over the 5-year testing period, they iterate the design of the report form, developing their own standardised taxonomy of incidents. However, throughout this period, the analysts still convert a copy of the incident submissions to common formats and send it to AHRQ and the Network of Patient Safety Databases.

The NASA #2 team finally sets up a national investigation unit called INSIGHT (Independent National Safety Investigation Group for Healthcare Transformation). It is modelled after HSSIB in the UK.25

If successful, the PSRS program will be slowly applied to other medical fields, replacing the AHRQ program. It is proposed the name would then be changed to the Patient Safety Reporting System, or PSRS for short.

Open databases

Right now, you can go to the Aviation Safety Reporting System website and look through any report that has ever been submitted to the ASRS. It is completely open to the public. No need to sign up. No special clearance required.

The open ASRS reports include both the fixed choice and narrative sections, with a very short synopsis at the end. There are report sets grouping reports together by type of incident. They contain synopses and narratives. There is not a statistic in sight.

Compare this with the UK’s Learning From Patient Safety Events database, and you get a very different story. Only health and social care staff have access to the patient safety incident reports,26 seemingly restricted to reports from their own local organisation. The only public data available consists of purely summary statistics.

It is a similar story in the United States. For instance, the FDA Adverse Event Reporting System (FAERS) also doesn’t include the narrative portion of the report in the quarterly data files or public dashboard (which again shows only summary statistics).27 The AHRQ Network of Patient Safety Databases page has chart books, dashboards and spotlights – all showing summary statistics, with no hint of a narrative section or synopsis in sight.

The medical system’s obsession with statistics in patient safety reporting is confusing, to say the least. The predominant value of incident reports resides in the narrative (qualitative) data, not the fixed-choice quantitative part. Therefore, the patient safety database statistics are of little practical use.28 They also do not seem to change much from quarter to quarter, providing little to no new information.29

In order to have an open database, the incident data would need to be deidentified. It has always confused me why so little anonymised medical data is accessible in open databases. I would argue that the benefits of allowing access to anonymous medical data far outweigh the very small risk of reidentification.30

With narrative sections in patient safety reporting systems closed off from the public (and possibly other healthcare providers where the incidents didn’t occur), local healthcare providers who conduct their own root cause investigations lose opportunities to achieve a wider “window into the system”. Access to multiple perspectives of slightly different incident reports from other providers offers helpful context for investigation. An open database would also increase the likelihood of communication and collaboration between providers - duplication of root cause analysis investigations would become less likely.31

Access to incident reports across a country can help enormously in equalling the power imbalance between a patient and practitioner (and subsequent practitioner learning). For example, would the historically widespread dismissal of patients with Chronic Fatigue Syndrome (CFS) be so widespread if CFS patients could show their doctor incidents (or even better: root cause investigations) of similar adverse outcomes?

The PSRS team at NASA #2 sets up both a private and a public database. They add an “opt-in” tick-box asking the reporter if they would like to include their deanonymised report in the public open database. The private database contains all reports, and the public one has opt-in reports (including full narrative) with carefully worded synopses for opt-out reports.

A working group of patients, clinicians, data engineers, legal scholars and other experts is set up with the aim of determining the kinds of free-text data that should be modified or completely excluded when deidentifying report data. It is an ongoing process. Legislation is also written to protect patients and practitioners in any case of reidentification.

Promotion and Feedback

When my (then) psychiatrist produced a report with factual inaccuracies based on a 15-minute conversation about a simple dose increase of lithium, I contacted the Patient Advice and Liaison Service (PALS) asking for advice. During the two or three conversations I had with the PALS team, not once was it mentioned that it was possible for me to submit an incident report to the National Reporting and Learning System (NRLS), operational at the time (the NRLS was the predecessor to LFPSE).

In fact, the only reason I know about incident reporting systems at all is because I read about them in the aforementioned book by Don Norman. I would not be surprised if I were one of maybe five patients in the UK who know about the LFPSE incident reporting system.32 Gosh, by reading my series of articles on the subject, this may be the first time you, the reader, have even heard about the existence of patient safety reporting systems!

This is a huge publicity problem – especially because criticism of patient safety reporting systems is growing. As we discovered in the fourth Thin Line article about the ASRS, persistent promotion was critical for the program’s success. It is difficult to persuade diverse groups of stakeholders that a reporting program is useful if too few of them know about it, never mind report to it.33

When Charles Billings and Rex Hardy (of the ASRS team) introduced the first edition of CALLBACK magazine back in the 1970s, some of their NASA colleagues thought it was “shockingly casual for what was unquestionably a government publication”. But it was a successful strategy for reaching a wider, more diverse aviation audience.

In comparison, the UK’s LFPSE promotional material seems to consist of a webpage with a YouTube video and five unconnected podcast episodes, which makes for, erm, not exactly thrilling listening. The situation seems to be similar for the U.S. and the Network of Patient Safety Databases, with only a webpage (which includes a sign-up for email updates).34

Perhaps future promotion of patient safety reporting systems can learn from the casualness of CALLBACK. In the modern media age, the public and medical professional community are more accessible than ever. Why not produce short TikTok explainers, YouTube interviews or a Substack case study publication?35

This kind of promotion also acts as a feedback mechanism – a general audience is learning about the system. Reciprocally, feedback in the form of reporter follow ups (i.e. callbacks) helps to breed a sense of familiarity and trust with the people running the reporting system.36 Given many reporters in medicine currently feel like their reports disappear “into the ether”, the introduction of more rigorous feedback mechanisms appears greatly needed.37

The Psychiatric Safety Reporting System team at NASA #2 begins a targeted promotion strategy. Posters (both paper & digital) are sent to be put up where psychiatrist and mental health patient congregation is highest: Community mental health centres, psychiatric clinics, inpatient hospitals, pharmacies, etc. Automated messages are recorded for telephone queues. An “opt-in” tick box is added to patient complaints report forms all over the country, asking if they would like to include their complaint in the new learning system (an analyst converts the various complaint formats into the standardised form).

A publication and podcast titled “The Near Miss Clinic” launches for a general audience (including healthcare staff). Every month, a case study of a near miss, the subsequent report, investigation and improvement is followed. This is made possible through the open database. A YouTube and TikTok educational channel called “Psychiatry Safety Lab” is created. Every week, a different concept about patient safety in psychiatry is explained. There is an emphasis on an engaging, storytelling style to ground the message in everyday experience.

To engage a clinical audience, guest posts are regularly written on psychiatric-centred publications (like Psychiatry at the Margins, Psychiatric Times, RC Psych Insight, etc.), and interviews on podcasts and YouTube channels are booked. In the Psychiatric Times, a column about learnings from incident reporting in psychiatry is introduced.

After submission of a report, regular feedback on the course of the investigative process was facilitated through the confidential communication platform.38

The vital provision of transactional immunity

In the summer of 2020, I had to wait 42 days for lithium to be prescribed. There was nothing wrong with any of my blood or ECG tests. The psychiatrist who suggested lithium was experienced, a professor, even.

With every other medication I trialled, the time between agreement with my psychiatrist and prescription only took a few days (at most). So why, in the case of lithium, was there such a long delay?

Well, my psychiatrist professor was in charge of an rTMS centre, and I was receiving private treatment specifically for rTMS. He wasn’t allowed to prescribe me lithium, so I had to go to my local NHS centre. Long story short, the whole matter was eventually settled around day 40 of the 42 days, through communication between my local NHS psychiatrist and my private rTMS psychiatrist.

The first 40 days were filled with an unnecessary assessment, countless clinician group meetings, administrative mishaps and a fruitless communication with an in-house rTMS psychiatrist (not the professor). This, it could be argued, was an example of “active defensive medicine” – where more procedures were undertaken than needed for my care.39

The practice of defensive medicine, both passive and active, is highly prevalent throughout the world.40 While there are many good reasons to define defensive medicine broadly, the term is usually defined as physicians deviating from sound medical practice due to liability claims and lawsuits.

Within this culture of defensive medicine, it may be surprising to learn that the vast majority of patient safety incident reporting systems do not utilise limited transactional immunity (protection of the reporter from disciplinary action)41 – the vital provision that gave aviation professionals the confidence to report to the ASRS. Even the Department of Veterans Affairs PSRS, based on the ASRS, didn’t have transactional immunity.

Instead, the focus has been on providing privilege (protection of reports from being used as evidence in legal or disciplinary proceedings) and anonymity. Yet, one of the most significant barriers to reporting in medicine remains fear of reprisal. Why haven’t the privilege and anonymity protections removed this fear? And why hasn’t transactional immunity been introduced?

A potential explanation for the first question is provided by Huynh et al. (2017). The authors point out that healthcare professionals have a duty of candour – an ethical duty to be open and honest when an error occurs – codified by professional regulatory bodies.42 Given the privilege and anonymity protections usually only apply to the incident report they submit, a healthcare professional cannot remain truly anonymous. In fact, these types of protections incentivise not telling the patient about errors, then submitting a report - thus promoting unethical practice, an unjust culture and a continued fear of reprisal.

As for the answer to why transactional immunity is so rare in patient safety reporting systems, it appears partly due to the complexity of the healthcare regulatory system, and, at least in my opinion, partly due to a lack of will.

Unlike aviation, which typically has one national regulator, in medicine, there are multiple bodies for collections of professions within the healthcare system. In the United States, regulatory power is split even further into individual state regulators.43 Trying to produce legislation for immunity that all regulators will agree on is a tough task, to say the least. However, there is evidence to suggest the task isn’t impossible. Many states have enacted laws that provide immunity from civil malpractice claims for reports by physicians to the Department of Motor Vehicles (DMV) about patients who decide to drive despite being impaired by a medical condition. A similar kind of malpractice protection was advocated for at the beginning of the COVID-19 pandemic, when healthcare services were stretched thin.44

In terms of incident reporting systems, there have been a very small number of academic papers that have advocated for transactional immunity.45 But discourse remains thin on the ground. I find this lack of will confusing.

I can appreciate that the medical system is much more complicated than the aviation system;46 nevertheless, I am struggling to understand why transactional immunity cannot be offered for incidents which clearly do not cause harm to a patient.47 Malpractice claims cannot be filed for these incidents, and potential disciplinary measures would most likely be on the milder side.

With the backing of all state boards, U.S. Government #2 introduces legislation that provides transactional immunity for psychiatrists in possession of a receipt related to a no-harm incident submitted to the PSRS (within 10 days of said incident). Transactional immunity is limited to non-criminal, unintentional, and/or inadvertent actions. Immunity is also limited to one “usage” per type of no-harm incident, up to a total of ten types of incidents over a five-year period. Investigations can still be carried out. The immunity only waives sanctions. Funding is allocated to each state board to set up committees to settle any disputes.

A wider transactional immunity that includes harmed patients is planned if the PSRS is successful. It is recognised that implementation requires an overhaul of federal & state regulations as well as tort law.48

Harnessing technology

It is often mentioned that a major limitation of anonymous reporting systems is that two-way communication with the reporter is not possible.49 But this is no longer true. Two-way anonymous communication technologies exist and have existed for at least a couple of decades.

While there are different methods used to anonymise communication, generally, anonymity is preserved through the generation of a unique “key” (instead of any personal information) after the initial message by a reporter. This key can then be used to log in to a secure online platform.50

Most two-way anonymous systems have been used for whistleblowing or behaviour-related reporting (like bullying and harassment). Examples include: The Guardian newspaper’s SecureDrop whistleblowing service (launched in 2014), tip411 for anonymous tipping, and Whispli.

Anonymous communication is not restricted to text. There are ways to protect the identity of an individual in audio and video communication too. Both the metadata and speech data (i.e. voice) of calls can be anonymised.51 Currently, there is a wide range of use cases.

Despite anonymisation technology’s clear use case for follow-up and feedback in anonymous patient safety reporting systems, I could only find one paper mentioning two-way anonymous communication. A single sentence in a 2025 paper by Beecham et al.52 So far, all the anonymous patient safety reporting systems I have come across have been one-way.

Oddly, two-way anonymous communication systems are used within the UK healthcare system, just not for patient safety incident reporting. Perhaps the example closest to a patient safety reporting system is the anonymous two-way system set up by Moorfields eye hospital as a response to the Lucy Letby case. The system appears to be primarily focused on whistleblowing, but patient safety incident reporting is mentioned in the response.53

Anonymous communication is not the only software from other fields which could be used to improve the functioning of incident reporting systems.

Sometimes, when I’m looking through a forum trying to find out how to fix an open-source software problem (otherwise known as a “bug”), I will see a “duplicate” tag (e.g. see this thread on GitHub). This tag will link to a thread posted at an earlier date where essentially the same problem is discussed, and a solution found (Note: by “duplicate” I don’t mean identical. I am referring to a similar report by another person about the same bug).

In the open-source community, duplication detection is usually carried out manually (by the owner of the software). But in the commercial software industry, with large userbases and mammoth numbers of issues, automatic (or semi-automatic) triage and deduplication are often used.54

Duplicate detection algorithms automatically analyse the narratives and structured fields of bug reports, and flag ones which seem to describe the same bug.55

In incident reporting systems, duplications – reports about very similar incidents – have been shown to exist.56 Yet research on deduplication techniques for reporting systems seems to have only focused on one: the FDA’s Adverse Event Reporting System (FAERS).57

In both the bug and FAERS deduplication discourse, duplication is generally viewed as a problem – duplications are something to remove. However, there is evidence to suggest that duplication could actually be helpful. A survey conducted by Bettenberg et al. (2008) found that bug duplicates provided software developers with extra contextual information, helping to fix bugs more quickly. They advocate for merging bugs. There are parallels with the change of ASRS transactional immunity policy in the battle for immunity of the late 1970s. The extra context provided by each aviation professional submitting their own report to gain immunity for the same incident helped with investigations.58

Instead of seeing overreporting as a problem, deduplication software could add rich contextual information about very similar patient safety incidents, while at the same time reducing the workload of analysts.

Any deduplication software would need to utilise Natural Language Processing (NLP) of the free text portion of the reports. Here (and with machine learning in general), the literature on incident reporting is much denser, focusing primarily on automatic incident classification and event detection.59

By harnessing technology, the PSRS distinguishes itself from all previous predecessor reporting systems. Because reporters are given transactional immunity for non-harm incidents only, the team decides to build an anonymous communication feedback system called TRUST (Two-way Reporting for Understanding Systems & Trends). Reporters can anonymously submit reports via text or through an interactive voice response system.60

At the same time, NASA #2 partners with a large software company to build an incident report clustering system that will recognise very similar incident reports through free text NLP. Once finished and tested, it is integrated into TRUST.

The process of reporting goes as follows:

Upon submission of an incident report to TRUST, a psychiatric healthcare worker or patient is provided with a unique anonymous login key and confirmation that the report has been received. Before an analyst at PSRS #2 receives the submission, the clustering software searches for a similar case file in the database.61 Depending on what the clustering software finds, the process splits into three potential courses of action, described in this footnote.62

In all three courses of action, the original reporter is part of the process.

Integrated into a wider safety structure (both nationally and globally)

In the 2004 paper, When will healthcare pass the orange-wire test, Sir Liam Donaldson wrote:

Imagine that an airline engineer doing a preflight inspection [of a Boeing 757] spotted [an orange wire] frayed in a way that suggested a systematic fault rather than routine wear and tear. Imagine what would happen next. It is likely that most 757 engines in the world would be inspected—probably within days—and the orange wire, if faulty, renewed.

Like airlines, hospitals take charge of people’s lives many times a day. Yet, health care has lagged behind other industries in putting safety first in dealing with its consumers. A systematic fault that put patients’ lives at risk discovered in one country would not surely be rapidly and simultaneously corrected by health services across the world.

Over 20 years later, I think it would be fair to say we are no nearer to passing the orange wire test in healthcare. Why? Why has there been so little progress?

Part of the answer is explained by Carl Macrae, the researcher whose work I was most influenced by when writing this series of articles. In his 2025 paper Systematizing Safety, he writes:

One of the most striking features of the past few decades of effort to improve patient safety is the isolated and individuated character of much of this work: the field has blossomed with separate interventions, stand-alone programmes, discrete processes, individual roles, and distinct policies. This blooming of a thousand flowers across the field is indicative of the creativity and experimentalism that has been brought to bear on the problem of patient safety. But it is also indicative of something much more troublesome: fragmentation […].

At best, the management and organization of patient safety tends to consist of loose coalitions of projects and activities brought together under broad thematic priorities coordinated by a handful of highly-motivated (but often under-resourced) enthusiasts. At worst, it is a tragic mess.

Aviation incident reporting systems had the benefit of growing out of an already developed safety system, strongly connected throughout the entire world. This is simply not the case in medicine.

How do you build an effective national incident reporting system? The answer is you can’t. Not on its own. You need to build the entire worldwide patient safety infrastructure along with it.

Perhaps a start would be the setting up of an organisation like the International Confidential Aviation Safety Systems (ICASS) Group, which provides advice, facilitates the exchange of safety information and identifies solutions to common problems between different countries. Given the World Health Organisation is an independent worldwide body, I think it would be one of the prime candidates to advise countries on how to develop safety management systems, and then helping to connect these systems.63

Forget landing on the moon, or sending a horse into space, the greatest human achievement of our age may very well be building a worldwide patient safety infrastructure that passes the orange wire test.

After a decade-long development within the US #2 psychiatric system, Congress agreed that the PSRS should be expanded to every field in medicine, as part of a broader plan to implement a national patient safety management system. Sitting around the desk of the main meeting room, clothes untucked, bags under eyes and hair slightly dishevelled, the staff at NASA #2 took stock of what they had achieved, and what was to come. “This is only just the beginning, isn’t it…” one member groaned. “Yes. Unfortunately, yes” another half-heartedly responded.

The head of NASA #2, twiddling his thumbs, commented through half a grin “To think… all this happened because every country in the world decided to send a horse into space.”

Epilogue: the invisible boundaries between worlds

In 1989, Lucian Leape, fresh from learning that there were potentially 120,000 preventable patient deaths in the United States, decided he was going to learn as much as he could about error management in medicine. He strode into the Countway Library at Harvard Medical School and searched the archive for medical literature on mistakes. He found nothing.

Confused and slightly downbeat, he asked the librarian for help in his search. She thought the search strategy was fine, but recommended looking in the social sciences or engineering literature. When they searched this archive, hundreds of references came up. Many people in these disciplines already knew a lot about mistakes and how to prevent them. Lucian suddenly had a lot of reading to do.64

You and I live in a world of invisible boundaries. Problems that have plagued an industry for decades will have solutions sitting in an adjacent one. We frequently pass people from these parallel fields on the street, we chat to some of them, and a few will even be friends. But the gaps between subcultures mean that some of these people exist in industries with solutions lightyears ahead of others, in one very specific area. And no one notices.

What would happen if we merged these adjacent fields? What if human factors culture became embedded throughout the medical system? What if all the lessons from aviation reporting systems were successfully adapted to the psychiatric system?

What if psychiatrists reported all their mistakes to NASA?

And Breathe. Congratulations gang, we’ve made it to the end! Gosh, that was a long article, even by my standards… Thank you ever so much for reading this series - whether you stuck around for the whole shebang, or just popped by, I am grateful you’ve decided to read my work.

As ever, if you Alex is go for launch enjoyed the… T minus 10 seconds and counting …wait a minute… 9 did she just say I was “go for launch?” 8 Am I in a rocket launch? 7 that would explain why my desk is facing directly upward… 6 …and my desk is actually a control panel… 5 …and I’m in a space suit… 4, main engine start Main engine unstart! Main engine unstart! 3 Can someone please blow on the exhaust flames? 2 Ah well, might as well accept my fate. 1 Where am I going anyway? And we have liftoff! For Alex on his one-way mission to Mars! Mars? Awesome! Ha ha suck it Elon! … … … Did she say “one-way mission”?

If you enjoyed this article, please do drop a heart❤️, restack 🔄 or share 🔗. It helps others find my work!

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40

Passive defensive medicine describes avoidance behaviours (e.g. avoiding high risk surgeries).

A 2023 systematic review by Zheng et al. (2023) put the worldwide average percentage of physicians who engaged in defensive behaviours (both passive and active) at 75.8%.

For an introduction to defensive medicine, personally, I found the 2017 paper by Leonard Berlin very readable.

The reasons physicians practice defensive medicine are summarised in Kakemam et al. (2017, while psychiatry-specific reasons are explored in Scognamiglio and Morena (2025).

This is article 9 in the Psyverse #2 series (and article 5 in the Thin line series). For previous articles, see the compendium.

Paradoxically, perhaps the most thrilling aspect of literature review is also the most infuriating. I had to re-write this post twice after discovering articles and books that retold the history of patient safety incident reporting systems. The frustration of rewriting an article, however, pales in comparison to the joy of being able to tell a story that is not often told.

So, I hope you will enjoy this story about trailblazing nurses, an accidental anaesthesiologist, the malpractice insurance crisis and a Leape into the unknown.

A genesis in medication errors

Nurses are the unsung heroes of patient safety history, with significant contributions extending back to at least the early 1900s. The history of incident reporting systems is no different. As early as 1939, a professor of medical nursing named Margene Faddis proposed the recording of medication errors to prevent future mistakes from occurring:

[A] record, written by the nurse, is desirable. This is not a means of punishment but assures the appreciation of the importance of mistakes and also serves as future reference; it should include a statement of the notification of the doctor and full details concerning the error. Finally, let us remember that the ordinarily careful and conscientious nurse who makes the mistake has had, in the realization of her act, all the punishment and discipline and suffering which are desirable. What is done beyond that must be of a constructive nature or it had better be left undone.1

In 1953, Anne Byrne2 conducted a study that used a form to catalogue medication errors by nursing students. Through analysis of the data, Byrne found “wrong medication given” was the most frequent error and determined:

…that the nurse in charge was at fault in approximately 50% (11 in 20) of the instances, either because she did not transcribe the doctor’s orders correctly or did not make out the medication card properly.

The data was reviewed by a curriculum committee, and recommendations were made.3 A second study was then carried out shortly after, which found that the number of errors had been cut in half.

Two years after Anne Byrne’s paper, Catherine Corcoran published a master’s thesis with one of the first examples of an incident report for medicine: the “Unusual Occurrence Report”. The very simple open-ended form was used to collect evidence of medication errors by nursing students over the course of two years.4

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OOPSie-daisy

Possibly because of the early work on medication error incident reporting by nurses, the Board of Trustees at the American Hospital Association pushed for the establishment of full incident reporting systems back in 1958.5 It may have been one of the first report forms focused on incidents beyond medication errors. Quite what the result of this attempt was, I’m not sure. I could not find a record of what happened next.6

In 1962, Kenneth Barker and Warren McConnell published a paper looking at the problem of detecting medication errors. Previous publications had established factors which prevented reporting of errors, such as fear of recompense.7 But the best method to overcome these detection inhibiting factors had not yet been established.8

Barker and McConnell tested three methods of collecting information: disguised observation, self-report and the study of existing records. They showed through comparison between the hospital’s records and observation that there was a severe underreporting problem.9 It seemed like the authors were hoping that the anonymous self-report “OOPS” form (One Object – Patient Safety) would be a way of addressing this problem.

The OOPS report was the earliest anonymous reporting form I was able to find in medicine. The form was very simple, providing only a section to write a story. Unfortunately, the authors received just six OOPS reports in seven months. In Barker and McConnell’s opinion, this was because of several methodological flaws.10 Despite the issues, research into the detection of medication errors pivoted away from voluntary incident reporting to observation.11 The story of healthcare incident reporting subsequently took a sideways leap into anaesthesiology, and a man dressed as a birthday present.

Making Sleep Safer

Just like in physics, the early years of anaesthesiology had a problem with infinities. In that the aim was to put patients to sleep for a finite amount of time, but on the rare occasion, this would inadvertently extend to infinity. Before 1954, quite how often deaths occurred from anaesthesia is difficult to say as mortality reporting was anecdotal.12 The first large observational study on anaesthesia deaths was conducted by Beecher and Todd, who looked at 599,548 surgical patients, putting the death rate due to anaesthesia as 1 in 1561.13

Today, general anaesthesia is almost as safe as commercial airline travel (mortality rate is approximately 1 in 250,000 for healthy patients and 1 in 10,000-15,000 for unhealthy patients14). So, what happened? How did anaesthesiology become so safe?

Believe it or not, a researcher named Jeffrey Cooper (and the research team he was part of) accidentally made anaesthesiology safer. In 1972, Cooper thought he had been recruited to the bioengineering unit of the department of anaesthesiology at Massachusetts General Hospital to be an engineer. In an interview with the Center for Medical Simulation,15 he said the recruiter had a different idea in mind:

The person who brought me here, brought me here actually to work privately for his company on the side (which I hadn’t appreciated) because I had been doing this work on biogalvanic pacemakers. So, I was in this group not knowing exactly what I was supposed to do.

Fortunately for Cooper, Randy Meyer - an anaesthesiologist at the group - frequently took him to the operating room. Meyer helped Cooper see the issues with anaesthesiology, particularly with how people made mistakes while working with technology. To prevent these kinds of mistakes from occurring, the group decided to design and build a computer-driven anaesthesia machine.16

While working on the machine, Cooper was invited as a plus-one to a Halloween party.17 Dressed as a birthday present, he just so happened to sit next to Ron Pickett while carving pumpkins.18 Pickett was organising a NATO sponsored conference on human factors in healthcare. After realising Cooper was working on trying to prevent errors using anaesthesia machines, he invited him to present at the conference.

While Cooper was giving his talk, a man called Mel Rudolf was sitting in the audience. Rudolf worked for the American Institutes for Research, a company which used the critical incident technique to study human factors. From Jeffrey Cooper’s interview again:

Mel came up to me after the talk and said: “boy you have a great laboratory to study [anaesthesia mistakes]. Did you ever hear of the critical incident technique?” I said “no”. And one thing led to another and… we started to study errors in anaesthesia. We thought it was about errors with technology and equipment, but when [people told us their stories]… they weren’t mostly about equipment. They were about everything.

Between January 1975 and April 1977, Cooper and his research colleagues interviewed anaesthesiologists, staff members and residents at Massachusetts General Hospital.19 Using the critical incident technique, they managed to codify the types of preventable incidents involving anaesthesia and published their findings in a 1978 paper.

The critical incident technique was developed by John Flanagan (and collaborators) to select and classify aircrews during World War II as part of the Aviation Psychology Program within the U.S. Army Air Forces. It was a five-step generalised qualitative research procedure for “gathering certain important facts concerning behavior in defined situations”.20 While it had a broad application, it was particularly useful in studying mistakes.

Within medicine, Dentistry was the first to use the technique in 195321 to evaluate student performance.22 In 1970, it was used to classify whether actions of physicians during a critical incident had beneficial or detrimental effects on a patient. Before the paper authored by Cooper and his group in 1978, the only time the critical incident technique was specifically used to study errors was a very brief 1960 study of errors in drug administration by nursing staff.

Through the broad nature of the critical incident technique, Jeffrey Cooper uncovered a wide range of human factor mistakes within anaesthesiology. Most importantly, the study by Cooper and colleagues showed the importance of recording and analysing incidents that didn’t end in mortality.

While the work of Cooper and colleagues provided a template for the development of incident reporting systems and their analysis in anaesthesiology,23 the study on its own wasn’t enough to spark a wider patient safety movement. If the procedure for incident reporting came from aviation, the motivation to implement it came from another familiar source of medical change: a health insurance crisis.

The Malpractice problem

While a plane crashed into a mountain, resulting in a revolution in aviation reporting systems in the mid-1970s, Doctors in the United States were struggling to find insurance coverage. The number of malpractice insurance claims, as well as the amounts awarded, were increasing rapidly.24 The crisis was particularly pronounced in California. As a result of multi-million-dollar settlements, malpractice insurance premiums were rising by up to 400%. More problematic, however, was the exodus of many insurance firms from the market due to the losses incurred from the increased number of claims.

The need to explore alternative malpractice insurance systems resulted in the California Medical Insurance Feasibility Study. From the 1978 paper by Mills:

What is needed, in contrast to the existing malpractice trials under tort law,25 is a system that will cost less to administer, and will stabilize compensation through scheduled, standardized benefits. In this way, patients who have disabilities as a result of health care management could be fairly compensated automatically, without having to prove fault. However, reasonable cost estimates for such alternative plans cannot be made without valid information concerning the type, frequency and severity of those disabilities for which compensation might be paid.

In other words, there was no data on how big a problem malpractice was. The California Study looked at a random sample of 20,864 inpatient charts from 23 California hospitals. They found that approximately four percent of patients who were admitted to hospital suffered a potential compensable event, with 17% of these events due to negligence.

While several solutions were implemented to reduce the number of malpractice claims (and monetary amounts claimed for each) by the Californian Government, the underlying factors remained unchanged. Claims as well as monetary damages continued to rise at a constant rate. This subsequently led to another mini-crisis in the mid-1980s.

The now decade old California study remained the only source of information on the incidence of iatrogenic harm and malpractice. Howard Hiatt, dean of the Harvard School of Public Health and James Vorenberg, dean of the Harvard Law School, wanted to rectify the situation.26

They, along with other colleagues, conceived of a study like the California one, but larger and, importantly, sampling patients that represented the population. All they needed was funding - a task easier said than done. Various institutions in Massachusetts thought the study was a terrible idea.27 Fortunately, or unfortunately, depending on one’s viewpoint, New York State was struggling with spending on medical liability claims. The Governor, Mario Cuomo, was happy to fund the project.

The Harvard Medical Practice Study (HMPS) was carried out in the late 1980s.28 A random sample of 30,121 hospital records from 51 hospitals (within New York state) over the 1984 calendar year was reviewed. The researchers estimated that 98,609 adverse events occurred, with 13,451 (13.6%) leading to death.

If these rates were representative of the population, the study implied that 1.3 million patients were injured by medical care, with 180,000 dying from these injuries. This was much higher than the researchers had anticipated.

An uncomfortable truth

Lucian Leape was encouraged to interview as a researcher for the Harvard Medical Practice Study six months after it began and immediately did not want anything to do with it.29 He had spent the previous year studying epidemiology and statistics in the hope of making a career change from academic paediatric surgery to health policy, and Leape didn’t want to waste time on malpractice, an issue that he saw no reasonable prospect for change.

Fortunately, Howard Hiatt managed to convince Leape of the underlying aims of the project: to expose the frequency of medical errors. The Harvard study ended up revealing something much more striking than the 98,609 adverse events. Two thirds of the events were caused by system errors that were detectable in the medical records. In other words, they were preventable.

This fact spurred Leape’s interest in patient safety. After studying the human factors literature from fields outside medicine, he wrote a paper titled Error in medicine where he laid out how the healthcare system could be changed to prevent errors.

The Harvard Study and the Error in medicine paper helped to inspire further research into medical errors.30 In combination with high profile medical mistakes covered in the media, a patient safety movement started to build through the 1990s.

Patient safety reporting systems started to be set up. In the United States, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) initiated a sentinel event reporting system for hospitals in 1996. The introduction of the MedMARx program, an internet-based anonymous system for hospital medication errors, occurred in 1997. Many states introduced or improved their mandatory reporting systems. Australia introduced the Australian Incident Monitoring System (AIMS), and the University of Basle in Switzerland set up a Critical Incident Reporting System (CIRS) for anaesthetists.31

Generally, however, patient safety reporting systems tended to be very specific or very local.32 It would take a patient safety revolution for the proliferation of reporting systems to truly ramp up.

The Patient Safety Revolution

Towards the end of the 1990s, the patient safety movement was slowly growing in the form of committees, conferences and reports. This culminated in the Institute of Medicine’s (IOM’s)33 Quality of Care Committee. Throughout 1999, they met with various experts and discussed ways to improve patient safety and quality of care. Two reports would be written. The first, titled To Err is Human: Building a Safer Health System, focused on patient safety.34

Amongst the many recommendations, the IOM report made two specifically about reporting systems. For accountability of medical professionals, the Quality of Care Committee recommended that a national mandatory reporting system be established for adverse events that resulted in death or serious harm. For learning and improvement, the committee encouraged the development of voluntary reporting systems.

The response to the report was beyond what any of the committee members imagined.35 Quite why the report cut through the noise to influence government officials and medical professionals, while also increasing public awareness, has been debated. Whatever the reason(s), there is no doubt that it did.36

The U.S. federal government sprang into action (which might be a surprise to many). The Quality Interagency Coordination task force (QuIC) responded to the report with extensive recommendations on actions to be taken. This included a detailed pathway to a national mandatory reporting system and a thorough plan on review and implementation of voluntary systems.37

It is difficult to express how significant To Err is Human was.38 I could tell you it has been cited over 27,000 times in a quarter of a century. I could show you a graph of how the research literature on patient safety tripled shortly after the report was published. Or I could note that the rate of biomedical US federally funded patient safety research awards increased by over 2800%. But it still wouldn’t convey how the conversation about patient safety changed at the turn of the century.

Starting in the early 2000s, high income countries started to create patient safety organisations and national reporting systems. Some countries started with sentinel events (e.g. Sweden & Norway) or focused on specific clinical domains (e.g. France – nosocomial infections), others were developed independent of government (e.g. Australia). The UK, Denmark and Ireland developed comprehensive wide-scale reporting systems.39

After the World Health Organisation (WHO) wrote draft guidelines for the development of adverse event reporting and learning systems in 2005, middle to lower income countries began the process of developing their own systems. The WHO, collaborating with many countries, subsequently developed the Minimum Information Model in 2016, with the intention of standardising incident reporting forms worldwide.40

Where are we today?

Despite the early explosion in the early 2000s, progress has generally been slow worldwide. While 94% of the 108 surveyed countries in WHO’s 2024 Global patient safety report have adverse medical reaction reporting systems, only a third of them have specific national patient safety programmes.

This is perhaps an indicator of where reporting systems in the world stand today. Trying to write about what happened after the year 2000 has given me a headache. Not because the fundamental logic of modern patient safety incident reporting systems is hard to understand, but rather due to the sheer number and diversity of systems. There are so many, of so many different types, in different configurations, either interacting with each other, or kept separate. Trying to map it in my head has been a terribly frustrating experience.

So instead, let’s try to build our own. In the next article, we will imagine an alternate universe where we have free rein to plan and develop a national patient safety incident reporting system.

What could possibly go wrong?

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5

This may have been a development from an earlier accident report form.

Writing in a 1953 edition of the “Hospitals” journal (Vol 27, Issue 3, pg 90-92), Kent Francis exclaims that:

The American Hospital Association and the National Safety Council have achieved a reasonable facsimile of the impossible—an accident report form on which can be reported injuries to patients, staff and the visiting public.

Francis also attaches the form:

This is article 8 in the Psyverse #2 series (and article 4 in the Thin line series). Find previous articles in the compendium.

James Dow didn’t have time. The tragedy of Flight 514, alongside other crashes and safety failures publicised in late 1974, resulted in rapidly decreasing confidence in the FAA’s ability to function.1 This perceived lethargy had likely cost the then-current FAA Administrator, Alexander Butterfield, his job.2 When James Dow took over as Acting Administrator in April 1975, he understood his term would likely be a matter of months, not years. But he also knew his authority would be limited if FAA staff saw him merely as a transitory figure. So, he acted, and made decisions, as if he were a permanent appointee.

Dow had over 30 years of experience within the FAA, working on some of the most significant development projects.3 This deep understanding of the bureaucratic machinery helped him to push through a whole heap of initiatives in a matter of months. One of these initiatives was the Aviation Safety Reporting Program (ASRP), a non-punitive incident reporting system, announced in May 1975.

Dow’s inspiration for the ASRP came from the FAA’s Near Midair Collision reporting program (NMAC), which ran from 1968 – 1972. The NMAC was essentially the same as all the other near miss reporting systems mentioned in this series, apart from one crucial difference. Reporters had extensive transactional immunity.4 Even if the reporter had been reckless, or evidence had been found from other sources outside of the report of a misdemeanour, the FAA could not apply punitive action.5 By submitting a report, the reporter received immunity in return from the FAA – hence “transactional”.

Just like a previous FAA near miss program under FAA administrator Quesada, this immunity provision was dropped with little warning in 1971, before the entire program was ultimately cancelled in 1972 due to the subsequent dramatic drop off in reporting.6

Dow wanted to both reignite and extend the cancelled NMAC through the ASRP. Reignite by reintroducing transactional immunity (with one caveat7) and extend through full incident reporting. Essentially, the Aviation Safety Reporting Program was almost identical to the incident reporting program Oscar Bakke proposed two decades earlier – but with enhanced immunity provisions.

And, in similar fashion to all the previous reporting systems devised by the FAA, the ASRP ultimately failed – in record time. The number of reports that came in were so low, Dow changed course after just 3 months. Reporting to the same organisation that gave out punitive measures and had previously taken away the immunity without any notice likely deterred reporters.

With an air of familiarity to the events that led up to Project SCAN 15 years prior, Dow turned to a third party to ensure anonymity from the FAA. But this time it wasn’t a non-profit organisation. It was a governmental one – NASA.

Building the ASRS

For an agency that had just put men on the moon, you might think overseeing an aviation reporting system for ordinary mortal folk wouldn’t be the type of small step NASA liked to take. But this would be forgetting the first “A” in the National Aeronautics and Space Agency. A deep knowledge of aeronautical principles,8 combined with a sky-high reputation and lack of regulatory function, made NASA one of the most viable, trustworthy and impartial third parties. All the FAA needed to do was knock on the right door. Fortunately, they did.

Charles Billings had a curious career path. He trained as a medical doctor, then served in the US Air Force as a squadron flight surgeon. After his military service, he worked as an aviation medicine researcher at Ohio State University before joining the human factors group at NASA Ames Laboratory. A couple of years into his role as a medical research officer, he received a knock on his door.

Billings was tasked by the FAA to lead the construction and implementation of a new incident reporting system – the Aviation Safety Reporting System (ASRS). The FAA would fund the program, but it would be run entirely by NASA. With the help of aviation psychologist George Cooper and research pilot John Lauber, Billings developed a rough protocol for the ASRS. After three weeks of refinement through NASA management, the protocol was presented to the FAA and quickly accepted.9

A Memorandum of Agreement was signed on the 15^th of August 1975. The ASRS would be designed to perform four primary functions:

(1) receipt de-identification and initial processing; (2) analysis and interpretation; (3) dissemination of reports and other data; and (4) system evaluation and review.10

with NASA developing procedures for receiving, de-identifying and processing ASRS reports, ready for operation on April 15^th, 1976. This meant Billings and the NASA Ames team had just six months to build an incident reporting system to accommodate the entire United States.11

Within two months, a procedure for day-to-day operation of the system had been written. A formal request for a proposal was made to find a contractor to help process the ASRS reports. Which was awarded to Batelle a week before the deadline. On April 15^th, Advisory Circular 00-46A announcing the ASRS came into effect, and reports soon came flooding in. Initially 250 per week, before eventually settling to 150. This was more than expected.

I’m not sure what it would’ve been like to have had piles of reports turn up every day, procedures being updated on the fly, without a working data entry computer system. The word “stressful” comes to mind.12 In this situation, the team followed a “first-thing-first” policy, with a focus on establishing satisfactory procedures, administrative control over the growing number of reports, and the first stages of the ASRS reporting process. Which went as follows13:

After an incident, an air traffic controller or pilot would fill out a report form, the entirety of which fit on a double-sided piece of paper.14 Once the form reached NASA, it was reviewed for appropriateness and whether it contained time critical information.15 The report would then be sent off to an analyst – an aviation expert (such as an ex-pilot, etc.) – to identify and categorise potential causal factors, among other actions.16 Sometimes, the analyst would determine that more information from the reporter was required. In this case, the reporter would be called up for clarifications – termed a “callback”.17

After analysis, the slip containing the contact information of the reports was cut off and returned to the reporter as proof it had been received and analysed. The report had therefore been preliminarily “deidentified” and was subsequently sent off to be encoded.

In the initial absence of a database, this involved transcribing pertinent information and analysis on to a separate record sheet (to varying degrees of completion) which was subsequently filed away until the ASRS processing procedure had been fully developed. The original reports were then destroyed after an arbitrary waiting period.

By the 6th of July 1976, Batelle had demonstrated they were ready to process, analyse and store individual reports and began the next day. Nevertheless, by Christmas 1976, the “ingestion of data had so far exceeded digestive capacity that strong measures were required”.

A team of Batelle researchers started tackling the fixed-field and free text analysis, as well as the encoding procedure18. Then, they introduced a new step: diagnostics. Each encoded analysis would have an additional diagnostics sheet where standardised keywords were applied to classify the types of causal factors in each incident. Useful for future research and trend analysis. Quite incredibly, in the early stages of the prototype ASRS, a single person developed the diagnostic lexicon and applied it. Each and every one of the hundreds of reports per week had to go through a single diagnostician.19

The ASRS project was overseen by an advisory subcommittee.20 Over the next few years, they helped to direct the further development and refinement of the ASRS as it went from prototype to fully functioning system. Eventually, the backlog of paper encoded records became fully digitised on Batelle’s database, realising Bobby Allen’s vision of computer utilisation. There was, however, one significant problem with the rapid change and development of the ASRS procedures. While the ASRS team understood how the system worked, almost no one else did.

Within the first couple of years, Advisory Circulars, brochures and posters publicising the ASRS were widely distributed to facilities by NASA and the FAA. But this wasn’t enough. In surveys, it was evident that “a large proportion of the flying population lacked knowledge of the ASRS and its immunity features.”21 The Advisory subcommittee therefore recommended that NASA develop an accessible way to communicate with the wide range of professionals that worked in the aviation industry.

The task fell onto the shoulders of Rex Hardy, a decorated WWII aviator and corporate test pilot,22 who, along with Billings, created CALLBACK. A monthly, short, easy to read newsletter that addresses a serious subject in aviation safety. Rex, however, had a “distaste for well-intentioned but dull exhortations on safety”, so he endeavoured to make the publication interesting, instructive, entertaining, and god forbid, funny. It seemed to work. CALLBACK is still in production today.

Promotion was crucial to the success of the ASRS. The program existed in a political environment. Having the aviation community not only onside, but actively advocating for the system helps provide political pressure to keep the program funded and running, as the writers of the NASA ASRS history put it:

Even if all the other motivators are present in the reporter community, a lack of appreciation for the purpose and scope of the program or difficulty in obtaining the means to communicate will eventually result in the termination of an effective and valuable safety system.

One of the greatest strengths of the ASRS, that promoters could point to, was the immunity policy. The transactional immunity policy – a submission of a report led to a waiver of disciplinary action from the FAA for everyone involved in an incident – was strengthened from the FAA’s failed Aviation Safety Reporting Program that the ASRS replaced. Reckless operation was partially protected. With the addition of NASA as a third party, reporters also had use immunity – NASA could not share any info from the reports which might reveal the identity of the reporter to the FAA. Given the lack of trust between the Aviation community and the FAA, immunity became a vital provision to incentivise incident reporting.23

As the 1970s drew to a close, the value of the ASRS was felt by both the developers of the ASRS and the reporters using it.24 Everything was going swimmingly, until the 31^st of January 1979, when John Winant,25 who had recently compiled a report evaluating the ASRS, received a letter from the FAA:

The FAA letter… largely addressed the immunity issue, a topic which had not been mentioned in my report to him. [T]he text said, “We are definitely considering a program of modification” which would “allow enforcement proceedings against any person who has allegedly violated an [FAA regulation]….” This meant the limited immunity provision would be canceled…. The pertinent paragraph concluded with this sentence: “Before taking such action, further discussion with you and appropriate NASA officials is contemplated.” To me, and particularly in the context of prior concerns over the immunity issue, the word “discussion” had a distinct meaning. I believe, in reading that sentence, that a process of consultation would begin shortly, and that full opportunity to modify the FAA intention would exist. That belief was shattered within 24 hours.

On February 2^nd, the FAA told Winant that they were going to go through with the cancellation of the immunity provision.

The mistake that almost cost immunity

When Langhorne Bond, the newly appointed FAA administrator, sat before a House of Representatives subcommittee in November 1977, he only had good words to say about the ASRS. Bond classified “NASA analysis of the aviation safety reporting system as a very healthy, constructive and professional effort”, saying later on the FAA “found the reporting system to be a helpful mechanism for assimilating as much information as possible…”. In a March 1978 letter to NASA Administrator Robert Frosch, Bond said the ASRS was providing “needed and valuable insight” confirming the FAA “was not contemplating a change of the [immunity] provision”.26

Just one year later, Bond’s opinion appeared to have changed drastically. In a speech to the National Aviation Club on March 16^th 1979, he announced a U-turn on ASRS immunity, giving his main argument:

[O]ne part of the program causes me grave concern. This is the cloak of immunity that a violator can draw around himself simply by turning himself in to NASA […]. The guarantee of immunity, I’m afraid, can be too easily corrupted into a license to endanger hundreds of lives with no fear of punishment. I want to continue the immunity program - but I want it modified to end these abuses. Under these modifications, airmen will no longer be able to claim immunity for violations – witnessed by others – of safety regulations

So, what changed Bond’s mind?

This, as Charles Billings explained in a 1998 talk to the National Patient Safety Foundation, was due to a political oversight:

We (or, rather, I), in my naiveté made an assumption. I assumed that since the chief of the FAA was asking for [the ASRS], the FAA wanted it. This was a bad mistake.

Over the past 21 years, the NASA Aviation Safety Reporting System has had the support of virtually everybody in the United States aviation community to a greater or lesser extent with one notable exception. The exception is the people under the FAA Administrator—and there are roughly 22,000 of them—whom he did not consult before he came to NASA and asked for an incident reporting system. We do well to remember that a primary issue is who may be hurt by reporting. This is especially of concern where use of immunity (and, originally in the ASRS, transactional immunity as well) is a prominent feature.

What was the largest segment of the FAA aside from the air traffic control system? Divisions involving regulations and enforcement. Whose enmity did we earn the day this thing was announced? Those who had to make it work in the community. That is the worst mistake I made in 40 years.

Due to the pace at which James Dow set up the ASRP and subsequent ASRS in 1975, regional FAA officials were not consulted. After implementation of the program, the morale of regional FAA personnel was negatively affected by the waiver of disciplinary action because more of their efforts to conduct investigations ended up fruitless. Efforts to explain why the immunity provision was important were few and far between and largely ineffective. It seems as if discontent slowly built until the autumn of 1978, when regional FAA directors expressed to Bond that the “Aviation Safety Reporting Program had not provided any significant, useful data not already known to us through FAA programs”.27

Political regional pressure, as well as pressure to show the FAA had safety under control after the 1978 deregulation act, likely led to the reversal of the opinion of Langhorne Bond.

In Bond’s proposed modification, the anonymity provision provided to reporters would be strengthened, while the blanket transactional immunity – waiver of disciplinary action – was to be removed entirely. If the FAA found incriminating evidence of a disciplinary infraction from other sources other than an ASRS report, the fact that a report was submitted would not mean the investigation was cancelled – it would carry on.28

The response from the aviation community was overwhelmingly negative. In short, they had been burned by the FAA too many times before. The fact the ASRS could be abused was acknowledged by commentators, but the effect of the potential loss of reports would be far more detrimental to safety than any current abuse. Their view can be summed up by Frank Munley29:

Unlike Mr. Bond, I’m firmly convinced that the problem of human error is better tackled by a scientific investigation of the true causes of hazardous situations, as opposed to a punitive approach which ignores the intent of the violator.

Rather than a win or a loss for either the FAA or aviation community, the battle for immunity ended in a draw. Due to the arguably unimpressive performance at the April 1979 committee hearing by Bond,30 he decided against returning for a follow up hearing and worked with the ASRS subcommittee to come to a compromise. Instead of full loss of transactional immunity, some would be maintained, while the strengthened anonymity provisions remained.31

Ironically, the weaker transactional immunity provisions seemed to improve the quality of reporting. Before the reduced immunity, only one reporter needed to send in a report for everyone involved in an incident to have immunity. With the new provisions, every person had to send in a report to gain individual immunity. The ASRS therefore received different perspectives from the same incident, enhancing the potential for analysis.

Since the late 1970s, the procedure of the Aviation Safety Reporting System has pretty much remained the same. It has become a mainstay of safety prevention in US Aviation, with over 2 million reports submitted since its inception. In recent years, additional voluntary reporting programs have been introduced within the U.S. to cover more specific and nuanced areas of aviation.32

The success of the ASRS prompted other nations to set up their own voluntary reporting systems, such as the UK’s CHIRP in 1982, Brazil’s RCSV in 1997, and Korea’s KAIRS in 2000. The proliferation of reporting systems led to the International Confidential Aviation Safety Systems (ICASS) Group, which facilitates the sharing of information between nations, among other roles.33

Today, through voluntary reporting systems, the aviation industry has managed to reliably take advantage of the thin line between normality and catastrophe. In medicine, I don’t think we can make the same claim.

Though, the history of patient safety reporting systems goes back much further than you might believe. In the age of Hawker Hurricanes and Supermarine Spitfires, just before they defended the British Isles from the Luftwaffe, a member of medicine’s unsung heroes was already advocating for the use of reporting systems…

Come back next week for the final instalment of the thin line series: the surprising history of patient safety reporting systems.

If you have enjoyed the story of the, not so smooth, Mr. Bond and his unintentional mission to alienate the entire aviation community, please do drop a❤️, restack 🔄 or share 🔗. It would be much appreciated!

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13

NASA actually asked a contractor to handle the data processing, as allowed by the Memorandum. This flow chart was subsequently replaced by the following one, by Batelle incorporated. Given its complexity and the poor quality of the scan, I thought I would stick to the preliminary program definition.

14

The developers reviewed previous reporting form make-ups from predecessor programs and had psychologists help design the form. They opted for a simplistic approach so the form would be as easy as possible to fill in, while still getting across the required information for analysis.

Comparing the old ASRP form with the new ASRS one:

This is article 7 in the Psyverse #2 series (and article 3 in the Thin line series). For previous articles, see the compendium.

This piece will draw heavily from an excellent article, A Different Approach: The crash of TWA flight 514 by Admiral Cloudberg, and Chapter 7 of Delivering the Right Stuff by Andrew J. Dingee. I recommend reading both for more information.

On the 1st of December 1974, a plane crashed into a mountain. It was not the first one in history to do so, nor the last. In isolation, the crash of Trans World Airlines (TWA) flight 514, tragically killing all 92 people on board, holds no more significance than any other deadly plane crash. Why flight 514 is considered one of the most influential accidents in aviation safety history has little to do with the crash itself, but with a near miss six weeks earlier.

In October 1974,1 a plane nearly crashed into a mountain. 40 miles out, at an altitude of 7,000 feet, flight controllers cleared a United Airlines flight for an instrument approach to Washington Dulles Airport without a minimum altitude.2

On the plan view of the Dulles “approach plate” (see Fig 1 below) three official flight paths - each with associated distance (indicated above path) and minimum altitude (below path) - converged to the Round Hill beacon point, or “initial approach fix”, 11 nautical miles (NM) out from the “final approach fix”. From Round Hill, a single flight path led to this “final approach fix” 6 NM out from Runway 12.3

On the profile view of the approach plate, on the other hand, only the final approach fix and the final 6 NM are displayed with a minimum altitude of 1800 feet. The flight path from Round Hill, with accompanying minimum altitude,4 to the final approach fix is not displayed. This discrepancy is what likely led to the United Airlines flight near miss.

When Air Traffic Control (ATC) cleared the United Airlines flight for an approach to land without a minimum altitude clearance, the pilot assumed they could descend to the minimum altitude of 1800 ft, clearly displayed on the profile view approach plate.5

Fortunately for the United Crew, they were in good weather conditions and could see that they were about to fly dangerously close to the peak of Mount Weather, so they adjusted accordingly.6 After landing, the pilots filled out an incident report and sent it to the United Airlines Event Review Committee (ERC). This was part of a new procedure as part of a program put in place by United in January 1974 called the Flight Safety Awareness Program. Once the report was reviewed by the ERC, a safety alert was sent out to all United Pilots about the Dulles Runway 12 approach discrepancy. But only United Pilots. Pilots employed by other airlines never saw this incident report – no federal system was in place to facilitate distribution.

The crash of Flight 514

One hour before Flight 514 crashed into a mountain, the pilots of an American Airlines flight made the same mistake that United’s pilots had made six weeks earlier. Seven miles out from Mount Weather, at 1800 ft, the American Airlines plane was heading straight towards the mountain. This time, the weather conditions were poor. The pilot decided to radio ATC at Dulles to ask what altitude they should be at. ATC told them to climb to 3,400 feet immediately. A crash was averted, for an hour.7

TWA Flight 514 took off from Port Columbus International Airport8 at 10:24 am, heading for Washington National Airport. But twelve minutes after take-off, the pilots were ordered to divert to Dulles airport - severe weather (high winds, snow and rain) had resulted in the closure of Washington National.9

Due to the diversion, the plane did not initially follow the official published flight path - instead intercepting the 300 degree (120 degree on the approach plate) radial 13km earlier than the plate’s initial approach fix at Round Hill.

At 11:04, 44 NM from Dulles Airport, ATC cleared flight 514 to approach runway 12, again without a minimum altitude. Just like the United and American Airlines flights, the pilot descended to 1800 ft, thinking the ATC had implicitly given him clearance and would point out if he was at the wrong altitude.10

While they were descending, the pilot had another look at the approach plate and noticed that “this dumb sheet says it’s thirty-four hundred [feet] to Round Hill — is our minimum altitude”. Due to confirmation bias, a discussion on this discrepancy was cut short before it could even begin.11 All the crew managed to miss the Mount Weather peak heights of 1764 and 1930 feet, which they were directly flying over.12

Once they reached 1,800 feet, they encountered significant turbulence and downdrafts, causing frequent altitude oscillations. They received only two altitude warnings: the first, seven seconds before impact, and the second, two seconds before impact. It was too late for the pilots to take any corrective action, and the plane crashed into Mount Weather, killing everyone on board.13

After the NTSB released their report of the Flight 514 crash, the FAA sprang into action and introduced what would become the Aviation Safety Reporting System or ASRS. The story of Flight 514 is often told as the turning point in the development of the ASRS, with the unique set of circumstances surrounding the crash being the key motivator. It is therefore interesting to note the nearly identical crash that occurred six years earlier.

Groundhog day

On the 25^th of October 1968, a plane crashed into a mountain. It was not the first one in history to do so, nor the last. In isolation, the crash of Northeast Airlines Flight 946, tragically killing 32 out of 42 occupants, holds no more significance than any other deadly plane crash. Out of isolation, this remains the case. Why flight 946 is considered just another accident in aviation safety history, has little to do with the crash itself (or the previous near miss), but the continuing inaction of the FAA.

The runway 25 approach plate of Lebanon Municipal Airport, North Hampshire, from 1968 looks confusing, to say the least. Since only one radar station existed without distance measuring equipment (i.e. just VOR, no DME),14 and the airport was nestled in amongst a very hilly region, the entirety of the approach plate flight paths were restricted to one single radial.

A flight at cruising altitude coming in from any direction was supposed to first head to the VOR (radar) station location, then head northeast (radial 066 degrees) for around 10 Nautical Miles. During this phase, flights could not descend below 4200 ft. This point – 10 NM from the VOR – can be thought of as the start of the final approach (see Fig 6, indicated by purple circle), but is not an official “fix”.

Flying north, a pilot was supposed to circle around in a clockwise direction – ensuring a minimum altitude of 4200 feet throughout - eventually ending up inbounds, travelling towards the VOR radar station and Lebanon runway 25 (the 246 degree radial). The flight was then supposed to descend to a minimum altitude of 2800 feet. Only once the pilot had passed the VOR station, could they descend no lower than 1800 feet until they could fly under Visual Flight Rules or “the time to fly to the airport had been flown”.15

The problem with this approach centres on the radar system. A VOR station can only provide a pilot with information about which radial it is on in relation to the station, and whether flying along that radial would take you towards (TO) or away from (FROM) the radar station. So, when coming into land at runway 25, the indicator on a pilot’s Course Deviation Indicator (CDI) would have a radial of 246 degrees selected, with “TO” on the display. As the plane passed over the VOR radar station, this “TO” would switch to “FROM”. There is a nice explanation on how this works from Clearflight.

At some point before Flight 946 crashed, a Northeast Airlines flight was coming in to land at runway 25. It was overcast, with occasional breaks in cloud. The pilots saw the needle on their display jump and the CDI switch from “TO” to “FROM”. Thinking they had just passed the VOR station, they started to descend. Once they reached 2000 feet, the pilots noticed the CDI had switched back to “TO”. The captain then saw how close they were to the ground through one of the breaks in the cloud and immediately climbed back up to a safe altitude.

Once they had safely landed, they reported this incident to the local FAA maintenance technician, who checked the VOR radar station and found no irregularities. The pilot “did not, nor was he required to by [the FAA’s] current procedures … [to] report this occurrence to any central unit within [the FAA].”16

Flight 946 took off 47 minutes late from Boston. It was late in the evening, sunlight was fading, and the conditions were overcast with occasional breaks in cloud. Arriving into the vicinity of Lebanon, the crew communicated to ATC that they were going to perform a “standard instrument approach”. For some reason, the crew decided not to perform the published instrument approach procedure.17

Flying due north-west, flight 946 attempted to take a shortcut, avoiding the initial VOR station approach starting point entirely. They tried to tack on to the very end of the approach procedure, turning anticlockwise onto the final approach path.

The flight then continuously descended, not stopping at the minimum altitude of 2800 feet, until they eventually crashed into the top of a rocky, heavily wooded mountain, 2237 feet above sea level.

In the subsequent investigation, the NTSB tested for possible interference that could affect a pilot’s CDI display. They found areas along the approach where “course roughness manifested itself on the Course Deviation Indicator” but could not recreate the switch from “TO” to “FROM”. The NTSB concluded that the probable cause of the crash was the premature descent based on navigational instrument indications that they were about to pass the VOR station.

Due to the potential for an incident report from the previous near miss preventing the deadly crash of Flight 946, the NTSB believed that “the FAA should provide the leadership in developing and implementing an industrywide operational incident reporting system”. The FAA responded with:

In regard to the suggested industrywide operational incident reporting system, this is now being accomplished by our system of issuing telegraphic alerts and operations bulletins […]. We will conduct a complete review of current incident reporting procedures.18

On the 1^st of December 1974, TWA Flight 514 crashed into a mountain. So the FAA quickly introduced an actual industrywide operational incident reporting system, at least six years too late.

The series within a series continues next week.

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This is article 6 in the Psyverse #2 series (and article 2 in the Thin line series). For previous articles, see the compendium.

On November 1st 1958,1 General Elwood Richard Quesada became the first Federal Aviation Agency (FAA) administrator at a time when air traffic control was “a dangerous hodgepodge of uncoordinated civil and military operations”.2 Quesada introduced a new program of cooperative military-civilian control of airspace, and instigated a “no nonsense” approach for civil aviation pilots, bringing them up to “military standards”:

[Quesada] sent his inspectors through a demanding Air Force checkout course in the KC-135 (the military version of the Boeing 707), and took the course himself… ‘Now,’ [Quesada] says, ‘the FAA inspectors can fly these jets better than the man they’re checking out.’3

The inspectors picked up on everything, with the FAA jumping on infractions with heavy fines. Quesada justified his actions by saying:

When you go to the ticket counter and buy a ticket…you don’t know who’s going to fly you, or anything about his training, or the airline’s equipment – nothing. The public acts in faith, faith in this system, and we’ll see to backing up that faith. I’m here to represent the public, and dammit, the public will be protected.4

Administrators and pilots reluctantly agreed that this cleanup campaign by Quesada was a good thing, but it came at a cost.

Animosity grew between pilots and the FAA. Pilots felt that the inspectors were overreaching, picking up on questionable minor indiscretions resulting in fines, instead of improving systemic problems.

For example, Quesada seemed to believe greater pilot discipline was the main answer to the near miss problem. On March 3^rd, 1959, he sent a letter to Clarence Sayen, the President of the Air Line Pilots Association (ALPA), noting as a passenger, “all too often the pilot is in the cabin talking to passengers or engaging in endeavours not essential to his duties”. He drew attention to a regulation stating that all flight crew members should “remain at their respective stations when the aeroplane is taking off or landing, and while on route except when the absence of one such flight crew member is necessary in connection with his regular duties.”

Sayen, in response, pointed out the impracticalities of Quesada’s request. Under the regulations in force at the time, only the pilot was required to be qualified to operate the specific controls of the aircraft being flown.5 Further, it was the pilot’s responsibility to ensure the passenger cabin was safe,6 and considering some flights were 12 hours long “the sensible pilot gets out of his seat occasionally for exercise… to retain his alertness”. He noted that ALPA had been pushing for a requirement of specific aircraft copilot training for years.7

Sayen noted that FAA inspectors were now timing the pilot’s visits to the passenger cabin, filing violations that were not consistent – the absence times ranged from 7 to 23 minutes. He accused the inspectors of turning Quesada’s letter into a rigid rule through a “childish Gestapo program”.8

The animosity had a particular impact on near miss reporting. According to Joseph Hartranft, president of the Aircraft Owners and Pilots Association (AOPA), when the transfer of safety regulation from the Civil Aeronautics Board (CAB) to the FAA began on 1 January 1959,9 near miss reports previously sent to the CAB were now heading to the FAA – without pilots knowing this had happened.10 When the pilots were eventually informed on March 9 1959, through a press release, it did not mention that pilots no longer had immunity, as that provision only rested with the CAB.

In the six-month period between January and July 1959, pilots were being charged by the FAA with violations based on their own voluntary reports. The pilots, understandably, were not very happy about this, and near miss report submissions dropped off dramatically.

When the CAB near miss program was shut down in July 1959, the FAA took on the responsibility of collecting and analysing near miss reports. Except almost none were now being submitted.11 Senator Engle, in the Review of the Federal Aviation Act Senate hearing in 1960, illustrated the situation:

The FAA invited pilots to report near misses. And so a lot of dumb country pilots like me – and I wasn’t one of them who made the report – reported a near miss; and found himself cited because he was at the wrong altitude or something… I noticed this magazine, the Pilot’s magazine, published by AOPA, just said quit sending in the reports; don’t report or you will get clobbered […]. This is the kind of an attitude that doesn’t contribute to air safety.12

Clarence Sayen asserted that the non-immunity “policy of the FAA is fallacious and should be reversed immediately.”13 It was not reversed.14 It took a new administrator of the FAA, Najeeb Halaby, to reignite a near miss reporting program when he took office on March 3^rd, 1961.

Due to the damage in trust caused by the previous administration, Halaby found that pilots were unwilling to report to the FAA, even with the promise of immunity.15 Therefore, he asked a third party, the nonprofit non-governmental organisation called the Flight Safety Foundation (FSF), to run a near miss reporting program. It was called Project SCAN (System for Collection and Analysis of Near mid-air collision reports) and initially ran for six months starting on July 1^st 1961, before being extended to a year, finally concluding on June 30^th 1962.16

If a pilot had a near miss, they would send a form to the FSF.17 It was anonymous – even if the pilot signed their name, the form would be destroyed once relevant information had been taken from it. Given the Flight Safety Foundation did not have the power to issue punitive action and did not pass on identifying information of the pilot to the FAA, pilots had immunity. However, similar to the previous Civil Aviation Board program, if the information of the incident came through other means, the voluntary form submission did not grant immunity.

The main difference between Project SCAN and previous programs was, according to a 1961 article in Aerospace Safety Magazine:

Where the analyzed information suggests the need for changes of any kind – changes in procedures, traffic patterns, even aircraft cockpit or instrument design – specific recommendations will be formulated and submitted to the FAA for action.… [T]his is where Project SCAN differs.… [Previous] programs have dealt solely with statistics, the ‘how manys’ instead of the ‘how comes.’ Project SCAN deals with the ‘how comes’ or the ‘whys’ as well as the ‘how manys’

Project SCAN received 2,577 reports during its year in operation and seemed to be popular. Some pilots even returned forms without a near miss, simply to state their approval of the program. Interestingly, the FAA also kept its own near miss reporting program, and pilots only turned in 549 reports over the same period – the anonymity and immunity provisions resulted in 2.5 times more reports.18

At the same time as Project SCAN, a small group of the International Air Transport Association (IATA) airline operators decided to form an information exchange “experiment”.19 Information related to safety reported by pilots under one airline operator would be shared with all the others around the world. Arguably, this was the first International civil aviation incident reporting system.20

During most of the 1960s, however, a U.S. national voluntary near miss and/or incident reporting system seemed to once more become relegated to discussions in safety conferences.21

The main push for a national incident reporting system came from the CAB director of aviation safety, and later director of the National Transportation Safety Board (NTSB),22 Bobby R. Allen. He was particularly interested in the role of the computer in accident prevention. Instead of condensing incident reports down into simple, broadly defined categories (such as pilot error, mechanical deficiencies, inadequate maintenance, etc.), Allen argued for a “bulk look” at the data. He wanted to utilise the memory and data retrieval capabilities of the computer to do a detailed statistical analysis to unpick the complex causes of accidents. And to project potential future causes of accidents through analysis of past trends.23

First, however, Allen needed data to awaken the “sleeping giant” of computational analysis. He needed an incident reporting system. This was the subject of his 1966 talk at the 19^th Annual International Air Safety Seminar in Madrid.24

In the talk, Bobby Allen highlighted how the International Air Transport Association information exchange processed incidents, quoting Boyd Ferris, a secretariat at IATA:

[W]e lump incidents and accidents together because the thin line dividing an accident involving fatalities or major damage to the aircraft from an incident in which everyone got off scot free is often nothing more than luck.

Allen then points out that:

The alarming thing is that we do not take advantage of our good fortune. Here we have a brush with disaster; a live crew and virtually intact aircraft ready to tell a story, and yet we never open the book […]. What is it, then, which stands in the way of communicating this incident information to the appropriate governmental agency for processing? Repeatedly, when this question is asked, one hears the reply – FEAR: fear of litigation; fear of regulation; fear of punitive action.25

In the late 1960s, Allen communicated with officials from the airline industry, as well as associations, to work out how to combat these fears so that an “information exchange program” could be set up.26 He found that the most stubborn fear was litigation.

Several lawyers tried to tackle the fear of litigation.27 Probably the foremost pushing against the fear was a UK lawyer named Harold Caplan, who argued that when an accident occurred, lawsuits would almost certainly follow.28 Since incident reporting would reduce the number of accidents, the number of lawsuits would therefore decrease.29

But fear is not rational. The worry for a lot of airline companies was that the information produced by incident reporting would be used against them in litigation. Caplan therefore proposed example legislation that could be used internationally to protect the exchange of safety information.30 Further, Robert Reed Gray built on an idea by Charles McErlean of United Air Lines, suggesting that liability without fault be imposed on air carriers. Litigation would only be used to decide how much to pay to survivors of victims of accidents – no blame would be asserted.31

According to the archive of Bobby Allen’s letters, significant progress was made towards an information exchange system as the 1960s were coming to a close.32 But Allen found he could not get the project over the line from proposal to implementation. He concluded:

To the question of “Why hasn’t a program been established” everyone immediately trots out the “6 symptoms of the Fear Syndrome” […]. But in the final analysis, I personally believe that the Fear Syndrome is used as an excuse for our failure to overcome the major problem of information exchange. That problem is nothing more than sitting down and writing specifications for the program.33

Allen nearly helped accomplish it. In August 1968, the Air Transport Association of America (ATA)34 and Aeronautical Radio, Incorporated (ARINC) held initial discussions about the establishment of an airline safety data bank to be used for an information exchange program. The ATA then reached out to Allen to try to have the NTSB as the custodian of the data bank, to keep the information safe. By October 1969, potential specifications and requirements for an information exchange program had been written up by ARINC and submitted to the ATA.

On December 3^rd 1969, the ATA safety committee met to discuss the ARINC report. Allen’s invitation to the meeting was withdrawn due to fears that a representative of the government in attendance would not lead to a frank exchange of industry views. Subsequently, the ATA decided they:

would not be willing to participate at this time […]. However, the airlines recognize the desirability of a program of accident/incident data analysis and exchange in the airline industry.35

ARINC recommended the ATA continue with an alternative program where the ATA would “select a non-government organization to function as data custodian”. This never came to pass. Bobby Allen died on November 17^th 1972. Despite all his efforts, he never saw the creation of an incident reporting system.

For fear to be overcome, the thin line between incident and accident had to visit Washington DC, where legislators could see the consequences of their inaction with their own eyes.

The series within a series continues next Thursday.

If you enjoyed today’s article please👻 AHH! A ghost!! … … Okay, I think the coast is clear… If you 🧟 AHHHH, gosh darn it! … Right, I’m boarding up my house🏚️ .

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17

Here is what the form looked like:

Today, we are indulging in an Inception (or Psyception), a series within a series. This is article five in the Psyverse #2 series (for previous articles, see compendium), and article one in the Thin line series.

The Psychiatric Multiverse is centred around taking an idea from another field and applying it to psychiatry. For this Psyverse series on incident reporting systems, the “other field” is aviation.

Over the next few weeks, we will explore the history of aviation incident reporting systems. As well as providing crucial lessons in our aim to build an effective reporting system in psychiatry, I think it is a story that has yet to be told.

So, without further ado, let us go back to the 1950s and the beginning of the jet age…

The United States had a problem. Since the dawn of aviation, pilots had operated mostly on a “see and be seen”1 procedure to avoid air collisions – they would visually scan for other aircraft and ensure their own aircraft was as visible as possible.2

This was okay during the 1930s and 40s when there were sparse aircraft in the sky and speeds were usually slow enough for pilots to take evasive action if necessary. However, by the early 50s, the number of planes in the sky was increasing rapidly, and the development of turboprop engines meant cruising speeds of some aircraft were approaching 250 miles per hour.3

Faster planes require more “separation”4 between other aircraft to ensure the risk of mid-air collisions is kept at a minimum. But in a congested airspace, especially around airports, this was quickly becoming unrealistic.5

The Air Line Pilots Association (ALPA) were well aware of the growing mid-air collision problem. Up until this point, problems were found and solved after collisions and the deeply unfortunate loss of life. But, talking to the Air Safety Board in a 1950 House of Representatives hearing, David Behncke, president of ALPA, noted:

Actual accidents are not the only fruitful source from which to determine the need for improvement in air safety. There are those about which the public never hears; about which you honorable gentleman seldom hear; indeed, about which no one except those very, very closely connected with the industry ever hear. These are the near accidents, the narrow squeaks, the close calls of high disaster potential. The independent Air Safety Board would find fertile ground indeed for investigation in a carefully compiled “close call” or “near accident” file. ALPA has such a file but the present air safety set-up is such that we are at a loss at times to know who should receive our reports.

During the early 1950s, near-accident (or near-miss) reporting seems to have remained a disparate practice of individual organisations running their own projects without an overarching organisation to send their reports to.6

Perhaps the closest to a nationwide scheme during this period was the “Anymouse” program introduced by the US Naval Air Force starting around 1954.7 Naval Air Force pilots were encouraged to submit anonymous reports to Naval Command whenever they nearly collided with either another aircraft or terrain. According to a 1954 article8 in Flying Safety Magazine:

[T]he idea evolves around the theory that a close shave with the reaper will probably teach a guy something. If he can pass on a bit of knowledge to the next man, then both will benefit.

In general, the military led the way in researching how to implement a near miss reporting program. It seems as far back as the 1930s, it was observed that it was more important to find out from a pilot how and why an accident occurred, than to punish the pilot for any mistakes they had made leading up to the crash.9 A research paper by the United States Air Force in 195310 suggested that a near miss reporting system without identification of the pilot provides “considerably more information on personal behaviour” than one which has the potential for evaluation or disciplinary action. Hence, the emphasis on anonymity in the Anymouse program.

In civil aviation, wider attention was given to the near miss problem through several safety meetings starting in 1953. Special attention was given to how to establish a near miss reporting program in 1954 at the meeting of airline chief pilots in Dallas Texas. Meetings between disparate airline industry groups and the Civil Aviation Board (CAB) about setting up a reporting program continued through 1955, when, finally, on February 23^rd 1956, the CAB announced Special Regulation 416 – “Voluntary Pilot Report of Near Midair (Near-Miss) Collision” – a national near miss reporting program.

Pilots were assured that they could submit reports, choosing to be anonymous, without fear of disciplinary action. Pilots had immunity. Up to a point. If information about an incident was obtained from other sources outside the voluntary report, the pilot in question could still face remedial action.

Despite this caveat, reports flooded in.11 In one year, 971 near miss reports were sent in, an average of 2.5 per day.12 Around 85% of the reports concerned near misses that were below 1,000 feet (around the height of the Eiffel Tower). In 256 of the 971, planes had narrowly avoided collision by less than 100 feet. To give some context, a Boeing 737-700 is about 100 feet in length:

According to Oscar Bakke, the safety director of the Civil Aeronautics Board (CAB), the reports confirmed that in areas with higher traffic density, there were more near misses. Interestingly, 98% of the near-misses were reported with visibility in excess of three miles, and a growing ratio of near misses over time involved jet aeroplanes – suggesting that see and be seen was indeed becoming obsolete. A final observation was that approximately half of the near misses reported by civil pilots involved a military aircraft. The near miss reporting program gave evidence for greater use of “positive control” of aircraft.13

It was recognised in the program’s May 1958 report that the CAB’s objective in collecting near miss statistics had been achieved, and that continuing the program would provide no further benefit. Therefore, the CAB proposed a new incident reporting program, with the same anonymity and immunity provisions, that would extend well beyond the near miss reporting program. On August 7^th 1958, under draft release 58-14, Oscar Bakke wrote:

The excellent response of pilots to the present program and the desirability of collecting broader information bearing upon aviation safety, leads to the belief that the program should be extended to include more than just the reporting of “near misses.” … [A]ny airman aware of in-flight, ground or procedural hazards [would be encouraged] to report them to the Board […]. The program under consideration would place less emphasis on the statistical aspects of the reports and direct attention primarily to the particular circumstances involved in each report.

But it was too late. The program could not be set up before the Federal Aviation Act of 1958 transferred the CAB’s regulatory function to the Federal Aviation Agency. Subsequently, on July 15^th 1959, the voluntary near miss reporting program under special regulation SR-416A was shut down.

It took the United States 16 years before an almost identical incident reporting program to Oscar Bakke’s 58-14 proposal, was finally introduced. The reason? The usual culprit at the heart of any inaction: Fear.

The inception-like “Thin line” series within a series continues next week.

Thanks for indulging this foray into aviation history. If you know anyone with an interest in aviation, please do share 🔗 the article with them!

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8

Reading old magazines, one cannot ignore the rampant sexism. Now and then, random images of scantily clad women pop up. Weirdly, sometimes with little to no relevance to the information on the page (do not look at page 29 of the 1954 article linked to this footnote).

A photo in the August 1961 edition of Military Air Transport Service flyer, I think gives a hint at what women thought about the sexism: