Madness and human nature

Natasha Mitchell

Richard. P. Bentall Madness Explained: Psychosis and Human Nature in Medicine, Penguin, Allen Lane, 2003 (640pp). ISBN 0-71399-249-2 (hard cover) RRP $88.00.

Recent revelations about the activities of Australian psychiatrist Dr Robert Towndrow are a chilling reminder that ‘experts’ can abuse their privileged status, especially when they’re unwell themselves. Towndrow is alleged to have persuaded a number of vulnerable patients to have sex with him, claiming it to be part of their psychotherapy (Bradley 2004).

The social and political power of medical knowledge and its keepers and institutions has perhaps been most famously analysed by French philosopher Michel Foucault. Foucault’s recently published lectures at the College de France revisit his controversial arguments about what constitutes normality, and about how the insane are excluded from ‘civilized’ society by medical and legal authorities (Foucault 2003). In other works, too, Foucault has questioned the legitimacy of psychiatric experts to categorise and incarcerate those they have deemed incurable and abnormal, recalcitrant or deviant (1984; 1988).

Such critiques of psychiatric practice have typically been lumped under the banner of either postmodernism or the anti-psychiatry movement, the latter with its own famous pin-up psychiatrists R. D. Laing and Thomas Szasz. Like Foucault, they saw the line between sanity and insanity as problematic, and argued that mental illness was less a (biological) disease than a social construct (Szasz 1961) or an interpretable expression of real emotional distress (Laing 1960). These arguments have now been largely discredited by mainstream medicine, not the least because of their use by the Church of Scientology in waging their own aggressive campaign against psychiatry.

The deep polarisation between psychiatry and its critics often prevents a more considered and open discourse about what is an evolving profession and its limitations. Unfortunately, though understandably, many see debate about the philosophies underlying the diagnosis and treatment of mental illness as invalidating or dismissing both the suffering of people who experience mental illness and the role of medication in assisting them. It can, but not always, and such sensitivity certainly shouldn’t prohibit the conversation.

Richard P. Bentall’s Madness Explained: Psychosis and Human Nature in Medicine is not, in this reviewer’s mind at least, an anti-psychiatry tome (and in hardcover at over 600 pages it is indeed a weighty one). Nevertheless, I suspect many psychiatrists and mental health professionals will be discomfited by it, and brand it as such for its apparently radical thesis and rhetoric. Likewise, zealous anti-psychiatry campaigners are likely to seize its words to justify their arguments. And so the intellectual silos will remain intact, and the blinkers as applied to debates about the practice of biological psychiatry will stay in place.

Kraepelin’s work forms the basis for today’s diagnostic bible in psychiatry: the DSM-IV.

This is a shame, because Bentall’s wide ranging examination of the medical model of mental illness is interesting and worth reading. At the very least it could stimulate cross-disciplinary debate about the definition, treatment, and experience of psychiatric disorders. The book could also promote discussion about the need to listen more closely to the specific contents of the experience of schizophrenia and mania.

Bentall, Chair of Experimental Clinical Psychology at Manchester University, argues that psychiatry’s current understanding of serious mental illness is ‘fatally flawed’. Many of the contemporary approaches to the problem of madness, he provocatively suggests, ‘although cloaked with the appearance of scientific rigour, have more in common with astrology than rational science’ (p. 8). He proposes what he describes is a radically different way of thinking about the experience of psychotic illness—one that ‘abandons psychiatric diagnoses altogether and instead tries to explain and understand the actual experiences and behaviours of psychotic people’ (p. 141).

CATEGORISING DIFFERENCE: SYSTEMS OF DIAGNOSIS

Bentall begins by introducing us to arguably the most influential figure in modern psychiatry: German psychiatrist Emil Kraepelin (1856–1926), who developed the first scientific system of classification for mental illnesses. Searching for patterns in hundreds of patient case studies, Kraepelin proposed two broad categories of mental disorder: dementia praecox (schizophrenia) and manic depressive illness. In doing this, he shifted attention away from the chaotic contents of individual psychotic experience, to a more generalised approach to diagnosing symptoms, all of which he believed must be caused by brain disease. Kraepelin’s work forms the basis for today’s diagnostic bible in psychiatry, the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders), and the neo-Kraepelinian quest for biological explanations of madness—for the neural and genetic substrates of insanity.

There’s little doubt that the classification of mental disorders is now as much big business as it is a valuable clinical tool for health professionals. The first edition of the DSM, published in 1952, described just over 60 disorders. The current fourth edition (published in 1994 and revised in 2000), with its proliferating categories and sub-categories of illness and numerous appendices, lists around 400 discrete disorders. Bentall quotes American psychologist Roger Blashfield’s rather disturbing prediction that the DSM-V, scheduled for publication in 2010, is set to ‘contain 1800 diagnostic criteria and 11 appendices, and will generate $80 million in revenue’ for its publishers, the American Psychiatric Association (p. 63).

Bentall isn’t alone in his anxiety about the ‘industrialisation of psychiatry’ through the DSM.

Madness Explained questions the universality and reliability of the DSM-IV for diagnosing mental disorders, and presents interesting evidence of the fallibility of its application across different cultures and clinics. After all, is the experience of schizophrenia universal? Are the contents of the delusions and hallucinations of a person in suburban Sydney the same as those experienced by someone in a rural community in India? Not necessarily. Further, what we understand as psychotic symptoms can mean different things in different cultures. A villager in Jaisalmer or an elder on Thursday Island might interpret the (commonly religious) contents of a psychotic episode as valid expression of their status or beliefs rather than as pathological (All in the Mind 2003b). And worldwide, do different clinicians read the categories and symptoms identically or does culture and context play a role here too? Again, perhaps not. As in Kraepelin’s day, the attempt to collapse the multitude of experiences and interpretations of mental illness into the one diagnostic guidebook continues to present tremendous challenges (Mitchell 2003).

Another salient example of the continuing debate over what is worth including in the DSM is premenstrual dysphoric disorder (PMDD), an extreme condition experienced by some women in the lead up to and during menstruation. Pharmaceutical manufacturer Lilly, the maker of Prozac, has recently been pushed to remove PMDD from the list of disorders considered treatable by their popular antidepressant because ‘the condition was not a well-established disease entity’ according to the European drug regulator (Moynihan 2004). This is despite Lilly’s high profile television marketing campaign to promote awareness of PMDD and its treatment in the United States. We can be thankful at least that direct-to-consumer marketing of pharmaceuticals is still prohibited in Australia. One can only imagine what prime-time television would be like otherwise … reality TV meets Big Pharma.

Bentall isn’t alone in his anxiety about what he describes as the ‘industrialisation of psychiatry’ embodied by the DSM (p. 57). A growing number of reputable psychiatrists now openly criticise the manual’s limitations (Parker et al. 2002; Chodoff 2002) and the central role pharmaceutical giants play in funding psychiatric research and publication. The potential commercial interest in classifying an increasing number of disorders that can be treated with marketable psychotropic medications presents obvious problems the profession would do well to openly debate (Starcevic 2002).

Bentall claims that he is trying to construct a scientific alternative to the Kraepelinian system. In partial jest, he presents a ‘post-Kraepelinian manifesto’ (in response to an equivalent written by the neo-Kraepelinian movement (Klerman 1978)) which includes provocative statements like ‘There is no clear boundary between mental health and mental illness’; ‘There are no discrete mental illnesses’; and ‘There is no inseparable gulf between the psychological and biological’; amongst others (p. 59, 143).

WHO’S NORMAL? THE SANITY-INSANITY CONTINUUM

It’s increasingly understood that schizophrenia is triggered by a combination of genetic and environmental factors and is the result of ‘abnormalities in brain development and maturation’, that is, it is a disease that results in ‘misregulation of information processing in the brain’ (Andreasen 1999). Bentall, however, argues that psychotic symptoms like delusions (false beliefs) and hallucinations (for example, hearing voices in the head) are responsive to psychological analysis—that there is meaning in their contents that link back to the lives, traumas, tribulations, and individual psychology of those experiencing them. He believes that, in the therapeutic setting, environmental factors are too often dismissed in favour of wholly biological accounts of psychosis.

The ‘continuum’ model for madness collapses the distinction between ‘us’ and ‘them’.

Some will see parallels with psychiatrist R.D. Laing, who wrote that ‘the experience and behaviour that gets labelled schizophrenic is a special strategy that a person invents in order to live in an unlivable situation’ (Laing 1967). However, although Bentall believes Laing’s work ‘revealed an uncanny empathy with psychotic patients … and intriguing insights into the psychology of their experiences’, he argues that his own interpretations are more scientifically based than those of the ‘New Age’ Laing (p. 117), and indeed the psychoanalytic tradition (p. 505).

Bentall’s core claim is that the difference between sanity and insanity is more subtle and less defined than the neo-Kraepelinians would have us believe. I’m reminded of a conversation I had with an American expat in India last year. She lived in Chennai with her German diplomat husband, and recounted the moving story of the sudden death of their youngest child early in their posting in the dusty seaside town. Contemplating the state of mental turmoil she was catapulted into, and her hellish journey through grief, she remarked to me:

Who’s sane? It’s all on a continuum. And you slide up and down this continuum all the time. People just aren’t aware that they’re on that continuum, they think they’re in their isolated box, “I’m well” and “She’s not well”, whereas in fact we’re all on a sliding scale, and at any time we can be at one end or the other (All in the Mind 2003a).

Perhaps we should not compare the temporary mania of grief and the permanence of a biological mental illness. However, Bentall presents research suggesting that many more of us live with voices in our heads in daily life than we might expect. This ‘continuum’ model for madness is challenging because it collapses the distinction between ‘us’ and ‘them’, the mentally ill and well. His brief mention of the Hearing Voices Network is particularly interesting. This group claims to ‘assist those who hear voices to find their own ways of coming to terms with the phenomena as part of their life experience’ (Hearing Voices Network n.d.). In light of the suffering of those confronted with deeply persecutory hallucinations, the Network has a medically unorthodox but intriguing mission that radically questions the pathological nature of their experience.

Bentall dissects in detail the development of scientific theories about why people in a psychotic state hear and misattribute the (often persecutory and angry) voices in their heads, or maintain delusional beliefs about themselves (for example, that they are God, Mozart, Shiva, or the Virgin Mary). He offers his own, though speculative, psychological hypotheses for the origins of these hallucinations and delusions, and for how we might interpret them (pp. 464–493). He critically explores the possible influences of family and insecure attachment relationships, stressful social environments, trauma and other potentially adverse experiences as triggers for paranoid thinking, and unhealthy beliefs about ourselves and others (p. 475).

BIOLOGY AND PSYCHOLOGY: LOOKING FOR PARTNERSHIPS

But what of the billions of dollars of neurological, pharmacological, and genetic research undertaken around the world, including in Australia, on the basis that schizophrenia is a neuro-developmental disorder? Can Bentall so confidently dismiss this research and the hope it instils in so many? For people diagnosed as mentally ill, emerging biological evidence for their experiences has diminished the blame and stigma surrounding their illness.

The relationship between psychology and biological psychiatry is shifting.

Bentall doesn’t dismiss the incredible power of new imaging and genetic technologies to shed light on the causes of mental illness. Instead he argues that ‘an exclusive focus on biological determinants of psychological complaints is bad science and leads to treatments that fail the needs of psychiatric patients’ (p. 143). He points to recent evidence that ‘environmental influences literally shape the brain’. He continues:

As neuroscience progresses, it seems likely that many more of these kinds of relationships between behavioural and biological variables will be uncovered by researchers. Perhaps eventually the distinction between what is biological and what is psychological will cease to be important (p. 485).

There’s no doubt that the relationship between psychology and biological psychiatry is shifting. There is growing appreciation that evidence-based approaches to psychotherapy have a central role to play in the treatment of even the most intractable or ‘biological’ of mental illnesses. Recent research evidence, for example, suggests that cognitive behavioural therapy can assist people to better manage the apparently nonsensical delusions and hallucinations of the psychotic experience (Tarrier et al. 2004). Likewise psychotherapy is back on the research agenda for the manias of bipolar depressive disorder, which until recently were only seen to be responsive to lithium (All in the Mind 2004). Bentall supports this trend. He acknowledges, though perhaps not robustly enough, that some patients fail to respond to psychological treatment but his work calls for a greater focus on the development of effective psychological interventions for people with schizophrenia.

Without commenting on the empirical accuracy or the possibility of bias in his review of the vast body of research from psychology, psychiatry, and neuroscience to which he laboriously refers, Bentall appears to be well aware of his critics (one psychiatrist he quotes, amongst others, has called his work ‘dangerous’), and seems preoccupied with pre-empting and responding to dissenters throughout the book. However, we’ll have to wait and see whether his critics and compatriots alike will step out of their silos to rise to the challenge.

I, for one, would be interested to read a review of Madness Explained by one of the one in 100 Australians who have received a diagnosis of schizophrenia first hand—by someone who lives with the reality of hallucinations, delusions, and psychotropic medication every day. Personal narratives of illness and treatment are perhaps the most important voice in this debate, the complexity and subtlety of which is rarely heard (Jeffs 1993). And this seems to be precisely Bentall’s point. We should follow the debate his work provokes with interest. Blinkers off.

REFERENCES

Andreasen N. 1999, ‘Understanding the causes of schizophrenia’, New England Journal of Medicine, vol. 340, no. 8, pp. 645–647.

All in the Mind 2004, Bipolar Disorder – Treating the Rollercoaster, Transcript, ABC Radio National, 14 February [Online], Available: http://www.abc.net.au/rn/science/mind/stories/s1042977.htm [2004, April 9].

All in the Mind 2003a, A Mental Health Odyssey in India Episode 3 – Kendra’s Story: A Foreigner in India, Transcript, ABC Radio National, 16 March [Online], Available: http://www.abc.net.au/rn/science/mind/s806422.htm [2004, April 9].

All in the Mind 2003b, A Mental Health Odyssey in India Episode 4 – Is Mental Illness Universal?: Culture & Psychiatry, Transcript, ABC Radio National, 23 March [Online], Available: http://www.abc.net.au/rn/science/mind/s811522.htm [2004, April 9].

Bradley M. 2004, ‘Predator psychiatrist left to strike again’, The Sydney Morning Herald, 13 March [Online], Available: http://www.smh.com.au/articles/2004/03/12/1078594568250.html?from=storyrhs [2004, April 9].

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Foucault M. 1988, Madness and Civilization: A History of Insanity in the Age of Reason, trans. R. Howard, Vintage, London.

Hearing Voices Network, n.d., Assisting people who hear voices, [Online], Available: http://www.hearing-voices.org.uk/welcome.htm [2004, April 9].

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Starcevic, V. 2002, Opportunistic ‘rediscovery’ of mental disorders by the pharmaceutical industry’, Psychotherapy and Psychosomatics, vol. 71, no. 6, pp. 305–310.

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Tarrier N., Lewis S., Haddock G., Bentall R., Drake R., Kinderman P., Kingdon D., Siddle R., Everitt J., Leadley K., Benn A., Grazebrook K., Haley C., Akhtar S., Davies L., Palmer S., & Dunn G. 2004, ‘Cognitive-behavioural therapy in first-episode and early schizophrenia: 18-month follow-up of a randomised controlled trial’, British Journal of Psychiatry, vol. 184, no. 3, pp. 231–239.

Natasha Mitchell hosts and produces the program ‘All in the Mind’ on ABC Radio National (http://abc.net.au/rn/science/mind). She has won a number of national and international awards, including two gold world medals at the New York Festivals, for her coverage of mental health and related issues. In a past life she qualified as an engineer.