Giving an Account of Myself

At a time of year for reflection, and in the light of this lovely news, perhaps some explanations are in order. It's been a fascinating 9 months. At the start of this year I had no notion of starting a blog. My one previous attempt (a brief foray into documenting my life in a very depressing post-university bar job) had no structure, poetry or intrigue. I got no hits, I saw no point in the enterprise. But halfway through my first year in a clinical psychology PhD programme in New York, I found I kept having recurring ideas around the same themes; nagging ideas that I kept picking over and couldn't straighten out satisfactorily. My thoughts yearned to be written out and discussed with people. Was I the only one having them?

Pseudo-dialectics?

If a brief dalliance with the writings of the preposterous Stalinist/Lacanian showboater Slavoj Zizek, taught me anything, it's that when we are trying to understand the broader meaning of a debate's structure, a dialectic framework can be immensely helpful. What do I mean in saying this? Take a look at almost any political or ethical debate; the structure works like this: one side puts forward a case, a counterargument is proposed and the two protagonists fight it out in a bid to be the triumphant winner. Unfortunately, given the intractable nature of many such disputes and the near unshakable attachment of people to their chosen side, it is rare for one or the other side to "win" per se. Instead, the best possible outcome is the emergence of a third position in which the disagreements can be dissolved and for a "synthesis" to be achieved. This is not some politically correct peace agreement in which everyone goes home polite but silently furious, it's a genuinely new way of looking at the situation that finds and integrates some of the truth from both positions.

A Debate Which Stretches into Infinity...

In the case of the mental health debates I was trying to enter in starting this blog, the dialectic structure seemed to be framed as something like this; first there was powerful, scientific psychiatry penetrating the gloom of madness with its rational gaze, then along came plucky independent, socially aware clinical psychologists, activists and service users to show that in fact the psychiatrists were perpetrating all manner of heartless alienating abuses behind a mask of objectivity and reason. From where I was standing this structure had become sterile, leaving people on both sides repeating the same (or sometimes more extreme versions of) arguments over and  again "you're not socially engaged" ; "you're not empirically validated".

Pattern Recognition:

It's what the more psychodynamically inclined observer might call an enactment, in which two sides endlessly slip back into roles they are familiar with (like the way you feel like a 12 year old as soon as you spend any time with your parents). The trouble with enactments is that they are a form of behaviour we never learn from. Instead they reinforce our own prejudices as our expectations fail to be violated and we lurch back into the same old defensive pattern. Cognitive psychologists have filled long fascinating books with the sorts of biases we deploy to sustain these comforting positions.

Sonic Youth: Pattern Recognition

This blog has been my response to what I felt was a dialectic impasse in mental health. I knew that psychiatrists numbered among some of the kindest and most socially and psychologically adept people I have encountered. I knew that psychologists have vested interests, not just doctors, and I knew that "service users" are simply far too heterogeneous, complex and raucous to be held together by convenient notions that they all want exactly the same thing.

It was this complexity I wanted to honour by writing here. There are so many problems with how we look after people when they are confused, miserable and frightened, and yet the predictable chorus of complaints laying the fault at the door of diagnosis, medication and "biogenetic explanations" seemed rather simplistic. That these things play some role in alienating, angering and even harming people seems to be undeniable, but in the rush to descry them none of the detractors seemed to be interested in a conversation about how we could use them constructively. More importantly perhaps, it also strikes me that the way we talk about these common explanations may be stopping us from moving forward. Are we overlooking the possibility that part of why we aren't very good at providing effective mental health care is that it is hard, complicated work? Are there not other social factors-fear, sadism and ineptitude to name just a few-which might be playing as big, if not a greater role?

I am delighted that some within the community of "bloggers" and "tweeters" in mental health have read and engaged with this rambling and indecisive collection of ideas. It has been an addictive and educational joy to argue with and learn from people, to have my factual errors and failures of politeness pointed out to me. Social networks and the "blogosphere" allow for a plurality of views that other media cannot sustain. Thanks to the "Mentally Wealthy" blog for their efforts to coordinate some of this diversity, and thanks to everyone who has shown an enthusiasm for thinking (and helping me think) about the ideas we need to grapple with.

Just Like You: The Temptations of Over-Identification

A supervisor of mine told an amusing story recently. He had been talking to another psychologist who had said that in his work he gets to know his clients at a deep level, coming to understand them in a profound way. For the man in question it seemed, psychotherapy was about a sort of extreme human empathy, listening so intently that you are something like "at one" with the person you are talking to. My supervisor was skeptical, and the anecdote was delivered to me as a lesson in the dangers attendant in assuming we know more about people than we really do. It went on in alarmingly sinister detail: "I really get inside my patients" this psychologist had told my supervisor "just as I'm inside you now". Recounting this all with a pained expression of simultaneous horror and amusement, my supervisor narrowed his eyes and said "so I told him, 'get the fuck out of me!'"

There is a movement afoot in mental health to emphasise the extent to which mental health problems are "understandable" responses to the stress of the environment, an ethos is captured in the dictum that mental health professionals should ask "not what's wrong with you, but what's happened to you". This can be the handmaiden of a certain therapeutic arrogance, but there is still-it seems to me-a great deal of inherent value in placing more focus on giving people the space to talk about how they have made sense of their lives.

 

Getting to Know You:

Nonetheless, the "understand-ability" assumption, though well intentioned, is subject to problems. At the most basic level it has epistemological difficulties; how well can you ever "know" another person's experience, to what extent is one person "like" another? Even if we assume that our normal intuitions about being able to empathise with others are substantially accurate we still need to remain conservative in estimating what we know. Just as there is arrogance in assuming that a diagnosis tells you all you need to know about a person's experience, there is arrogance in assuming you can basically figure someone out on the basis of your interpretation of their story.

"Just Like You"- a confused sentiment: is anyone really "just like" anyone else?

 

The "Me-too" Fallacy:

An "experience based approach" seeks to reel back from a psychiatry which prescribes people pills or brutally restrains them without consideration for what those experiences are actually like. You don't need an evidence base to argue for the position that people's experiences should be given high priority in arranging how they are cared for and paying attention to experience seems a plausible guard against needless institutional cruelty.

However, over-identification with the plight of another can cause havoc with our intuitions. Experiences can appear "understandable" even when they are not. As is so often the case with sloppy clinical thinking, Paul Meehl articulated this problem 40 years ago with his description of the "me too" fallacy:

If, like me, you have some residual aesthetic discomfort with Meehl's notion that people can be "mentally healthy" and "mentally unhealthy", it is worth remembering that we do not do anyone any favours by ignoring the possibility they are in need of more than just basic human kindness or even the best-available psychological help. Even if you reject a clear boundary between those who are "well" and those who are "unwell", there still exist mental health problems so severe that they benefit from recognition as illness and medical intervention. To suggest otherwise is a failure to take experience seriously and seems, ironically, rather un-empathic.

What Do Therapists Actually Do? Views from a Trainee

Part of my job is to sit in a room with people regularly and talk to them. We talk about what is on their mind, what is going on with their lives and how it all causes them distress. It is a strange and humbling sort of thing to do because even more than with reading, teaching and writing (the other components of my training) there is contention over how to do it successfully and limited information available about what it looks like when I do. I get little immediate feedback and some unknown proportion of that is necessarily misleading. Supervisors are amazingly helpful but they don't have the benefit of hindsight or unbiased vision, and can't be there in the room. Improvement I see in someone I work with may be a self serving illusion on my part ("of course they improved after I helped them") or may be attributable to something else.

In conversation, people ask me about "delivering therapy" with a hint of bemusement and incredulity. "What are you actually doing in there" is the implicit question underlying these queries. It is a very pertinent one. People who work in most jobs can describe almost everything they do with greater or lesser success. Therapists hover around in a weird hinterland, doing something which threatens professional vertigo and demands constant re-evaluation. I realised the other day that I think about it nearly all the time.

It is easiest of all to say what I don't think I am doing. I don't view myself as "healing" people, that is too Christ like. In matters psychological "healing" is a metaphor. Wounds heal when scabs form and bones start to re-grow. Subjectively experienced minds are what it feels like to be conscious and so when people say that their mind feels healed, although I have no reason to doubt it, I leave that sort of language to their discretion. Maybe someone might speak to me sometimes and feel healed. I would even hope for that to be the case, but it isn't my prerogative.

If I don't think I heal, I certainly don't think I "cure". People are cured of illnesses-to my mind-when the body has overcome an internal pathogen successfully. I might think someone seems better, but how do I know if the unseen underlying problem doesn't remain in some meaningful sense? Some forms of sadness may never leave us. "Cured" is what we say when we can be sure we have banished an affliction. I don't think I can confidently say I cure people.

I don't think I can generally be thought of as "training", "coaching" or "teaching" people, though I might talk in a pedagogical register from time to time. It seems useful to deliver information in an educational way under certain circumstances ("you know lots of people lose their appetites when they have been through what you have") but I don't feel knowledgeable enough to be a teacher, and I reserve a special distaste for the portmanteau "psycho-educational". I don't think I specialise in helping people to "find themselves" or to "self-actualise". In America's hyper-speed therapy-marketplace I see people describe themselves as "self-actualization consultant" or "life coach". Life and the self are huge and baffling ideas. I wouldn't want to shy away from talking about them, but the quasi religious quality of "self-actualisation" (as though one had found a higher purpose) seems an unlikely fit for the sort of thing people generally manage to do simply in order to be less miserable (or be miserable in less self-destructive ways). However, like "healing" I would still be very happy if someone felt they had been "self-actualised" (see, it doesn't even seem to be a transitive verb-phrase) after meeting me.

With ever increasing numbers of descriptions rejected, I find myself left with only quite workaday verbs to talk about what I do. I certainly try to listen sympathetically, to reserve judgement, and to speak a little bit from time to time. This seems insufficient though. Those things aren't therapy, that's just what we call "having a conversation". Therapy is a conversation, but it isn't just a conversation. When I sit and listen and speak, I do so in a more structured way than I do when I'm not working. I try (if working with someone in a psychodynamic way) to point out things that seem interesting to me about what the other person has said and how they've said them. I hope that in so doing I will call to their attention things that inform us both about what they are avoiding, or find themselves unable to say. Other sorts of things I might notice (when working within the framework we call "CBT") are over-generalisations or abstract statements whose accuracy we can both agree may be contestable. We can never successfully put our lives entirely into words, and finding new ways to systematically describe them can thus be very helpful. I could list other helpful ways of talking, but it would detract from the purpose of the post, and I would never be able to be as comprehensive as I would like.

These different sorts of conversational style sound easy and organic here, but I can't claim to be undertaking them this smoothly in person. There are instructions about how best to make these kinds of comments effective. We practice them in a more or less structured way depending on whom we are working with and what we set out to achieve. They get gathered together into manuals and books about "technique". Different styles and combinations of them are labelled with the notorious Three-Letter-Acronyms (TLAs). This is a necessary way of trying to find out which sorts of conversation help more than others, and we need to bunch styles together to try and keep understanding what works, when and for whom. However words like "technique" and, even "therapy" itself, can easily distract from the reality of what is going on, giving it an undeserved and magical power.

Whenever we say that we are "delivering therapy" we are always talking about two (or more) people having a conversation in a room. We hope the conversation will be helpful, and there are ways of talking that have been shown to be more helpful than others. If they get bottled and marketed as "cures", conversations can acquire a mysterious sense of magic, which may be unwarranted. It is better to remind ourselves that we can only ever be people who talk sensitively and intelligently with others. This is not to deny conversations their power; they can be very helpful indeed, but our claims for them should not strain the limits of credibility. Conversations can even be unhelpful too, perhaps devastating. You don't need to have had one with a therapist to know that.

The Headclutcher Strikes Again

In May I posted this about the peculiar tendency for newspapers to run a "headclutcher" image with any story about mental health issues. Silly though these pictures are, their use raises some interesting questions. How do we see people with mental health problems? Who are the acceptable faces of mental health in the mainstream media? What representations of distress are we prepared to look at when we scroll through the news? These questions are linked to the issue addressed in this pertinent New Statesmen article by Glosswitch, that not everyone with mental health problems will fit into a comforting "normal" image.

Today there has been a brief flurry of activity around the headclutcher below, which was originally used to accompany this article about voice-hearing by Charles Fernyhough and Eleanor Longden. Though still certainly a headclutcher, this lady has a more aggressive, scary presentation than usual. She is trying to block her ears in a flamboyant over the top way and appears to be shouting in anger or distress. We may note that the Guardian chose a red-head, perhaps seeking to bring to mind the lazy associations people have about their being tempestuous or hot tempered. 

Fernyhough immediately expressed discomfort with the Guardian's choice of image on Twitter, and he and Longden appear to have had words with the article's editor. The piece is now garnered with a tasteful screengrab from Longden's recent TED Talk.

Though they may sometimes seem a mere distraction from the main event, the media's use of illustrative pictures is important in the public consumption of mental health stories. Stigma is a huge problem and recent experiences with Asda's "mental health patient" halloween costume and Thorpe Park's "Asylum" have shown that it takes sensitive and thoughtful people to notice the implicit messages that are finding their way through to us. Headclutchers are not stigmatising in the same way as tasteless Halloween products but they are embarrassing and lazy; a form of journalism that is subtly derogating its subject. It's time the media thought a little harder about what images they used to accompany such important stories. 

The Scientist and the Practitioner: Some thoughts on A Vexed Relationship

The first thing I ever knew about clinical psychology was that it was based on the "scientist-practitioner" model. This paradigm, dating from a conference in Boulder Colorado in the 1940s (just as clinical psychology was taking off after the second world war), has largley defined the profession on both sides of the Atlantic ever since.

However, despite the fact that the science of psychology has expanded wildly since 1949, the scientist practitioner model seems ever less central to the profession. There are instances of outright disregard for the "scientist" part evident in many quarters and I find myself in interesting debates with psychologists and other therapists, trying to figure out how to define the role of "evidence" in that cumbersome phrase "evidence based practice". For many I detect a current of hostility to thinking in data and a general preference for using common sense and seeing the person with whom you are working. Data, by some accounts, is the kind of thing upon which we can become "hung up". Perhaps people are wary of becoming cold hearted Spocks:

"I'm Listening"

Although I have previously been scornful of the woollier arguments used against evidence in psychology, I have sympathy for some of what people are (I think) trying to express in these reservations. This post is an attempt to persuade them there is less disagreement than they fear.

Basic Problems:

Let's put our hands up right away and get a few things straight about the science of therapy. First, what gets called "evidence based practice" is not necessarily always (or even most of the time) living up to the lofty ideal of the name. For some institutional bodies, the existence of plausible seeming figures in some journal is good enough to plough ahead and recommend a therapy. I have even seen people make quite important decisions on the basis of a single pie chart (of unknown provenance) in a promotional brochure:

Even Data Can be Meaningless

Equally, much research is compromised by financial interest and driven by large pharmaceutical companies. Furthermore, the terms under which research is conducted are largely defined by political considerations of what is in vogue or popular. CBT gets more attention than any other modality, especially ones that don't sound snazzy or mysterious (like ordinary "befriending" or "supportive therapy").

Empathy and Therapeutic Skill:

There are definite limits for the role of science in the practice of therapy. The skills and considerations of an effective therapist can probably be determined by data, but perhaps their cultivation is a separate thing. I am sure there is no contradiction between being an empathic, kind and effective therapist and being statistically competent to assess efficacy, but I am aware of no reason to believe that proficiency in one automatically helps with the other. Whatever it is we do to cultivate kindness and empathy (an empirical question), it seems pretty clear we should do it.

The Role of Values and Outcomes:

The question of what kind of society we wish to have cannot always be answered empirically. A neat example of this is in a debate I recently had with a friend. In New York, unlike London, people have to pay to get into museums. In a basic way this doesn't feel right to me and I was trying to articulate why. "Societies just seem better when their art and culture is accessible to anyone" I argued. "Can you prove that?" asked the friend, and of course I couldn't. There may exist some quantitative indications that free cultural activities are good for people, but I doubt they are very robust, and in any case I am not interested in them. Even if you couldn't show conclusively that free access to culture improved people's lives, I would still maintain it was a social good. This is because it is not a question of tangible effects, but of what kind of society I want to live in.

To transpose this onto the field of mental health and social care; at least some proportion of what is at stake in the debates cannot be settled by data. Walking onto a mental health ward for the first time, I was struck by a sense of how cold and cruel it seemed. Apparently abandoned residents walked about in distress and staff members callously (so it seemed to me) bossed and condescended to them. Leaving the place behind felt like a palpable relief. Who knows how you would begin to quantify what it is like to live in such places; what kind of impact it would have on your sense of self. This is not to say that we shouldn't try, nor that we can ignore good quality data, but we can't depend on quantitative data to know everything we feel to be worth knowing. Sometimes the feelings that philosophers call "intuitions" are worth listening to. Debates outside of science, about what we should value are worth having too.

Rapprochement:

However, none of these readily acknowledged limitations is straightforwardly an argument against the centrality of the scientist practitioner position. I see a definite tendency to martial the limitations of science-based practice and attempt to assemble them into a case against data, but that way danger lies. One line of attack is to identify a scientific persuasion as a kind of arrogance. The logic apparently being that the scientifically oriented are vulnerable to using data to somehow over-ride the immediate experience of the service user, perhaps by steadfastly maintaining that they continue to do something (take a pill, undergo a form of therapy) when it is not working for the individual. This is indeed a risk of following evidence-based recommendations blindly, but it would in fact be a deeply unscientific thing to do. Reasoning from samples to individuals is probabilistic, and even if an intervention worked for 95% of cases, there are still 5% for whom it won't. The rational scientist-practitioner treats every case as a new instance of reality and pays attention to what is and is not working. This is what Jacqueline Persons (here) calls "Treatment as Experiment".  People who say that therapy is an "art" or that clinicians need to "be confident enough not to need to know all the answers" can, I hope, see a direct parallel with what they are proposing. 

Therapy, like most complex human behaviour, can probably be described as an art, but that doesn't mean it can ignore science. Is architecture an art? Plausibly yes, but if architects ignore the principles of engineering and physics, their buildings will kill people.

No the DSM is not like Astrology

I am genuinely ambivalent about the broad line of arguments we can call "the case against the DSM". I don't mean ambivalent in the modern sense ("a bit confused and unsure what to think"), I mean ambivalent in the classic psychoanalytic sense; harbouring strong feelings in both directions. On the one hand there is the interesting and essential level of critique which brings to our attention the experience of feeling labelled and the unsettling bureaucratisation of medical terminology. This line of argument I feel very positive about and engaged with. On the other there is the ever resounding echo chamber of over-confident assertions about the malign intentions of the APA and the total unusability of the DSM for research or clinical purposes. One recurring theme in the latter category is the quip that the DSM is no better than astrology. It appears in this (otherwise excellent) piece by Edward Shorter, in this interview with Richard Bentall, and in many other places besides.

DSM diagnoses would be just like the signs of the zodiac 

if  it weren't for the fact they're very different in many ways.

In the Bentall profile, the New Scientist interviewer opens by asking if comparing the DSM with astrology isn't "a bit strong". "No" says Bentall. I happen to agree with him, but not with the reasons he gives. Comparing the DSM with astrology isn't "a bit strong" (criticism of something you dislike should be strong) it's wildly off the mark. Why? Well although you can derive some superficial comparison between the categories of the DSM and the signs of the zodiac (both describe classes of people; both aspire to some degree of reliable prediction) there are also clear differences.

The most obvious and important difference is the way the way the categories are derived and assigned. The signs of the zodiac are assigned to people on the basis of their date of birth and based upon the idea that these dates are linked to personality characteristics in a meaningful way. Meanwhile DSM diagnoses are applied on the basis of set of criteria describing patterns of behaviour. Someone designated as having, say, OCD, can be expected to resemble a particular broad set of clearly defined features. However a Libra is not just someone who is "on an even keel" (which may way not be an unreasonable classification in itself) but someone who was born between the 22nd September and 23rd October and is regarded as "on an even keel" in virtue of this fact. In short, astrology makes a needless jump--the linking of birth dates and personality traits--that the DSM doesn't.

Why does this matter? It's not as though it puts the DSM above criticism after all. My answer is that the debate about mental health and diagnosis is very important, but if we want a serious discussion about DSM's flaws we need to accord some respect to considerations of plausibility. You can hate the very guts of the manual and its creators and still martial the strongest possible case against it. If you spin off into crowd-pleasing claims and ignore reality people will stop listening.

Aberrant Salience and a New Meaning of "Lynchian"

Fans of the director David Lynch have a clear sense of what it means for something to be "Lynchian", but if we are pushed to put into words what this adjective captures we confront an extremely difficult task. Urban Dictionary gives us this: "having the same balance between the macabre and the mundane found in the works of filmmaker David Lynch." but that definition seems almost circular. Lynch isn't the only person to balance the macabre and the mundane (see also the ubiquitous slasher films of the late 70s and 80s) and we are left with a sense that the word just means "Lynch-like". David Foster Wallace had a go at a definition in the essay here, but was still forced to admit that it is "ultimately definable only ostensively – i.e., we know it when we see it."

There is something that unites all Lynch films for me, and that is the sense that one is being invited to take as significant and sinister various encounters in the plot which turn out to have no ultimate explanation or meaning. I have been struck how this reminds me of the Aberrant Salience account of psychosis. The aberrant salience theory arose out of a brilliant review by Shitij Kapur positing that the mesolimbic dopamine system regulates the salience of elements of our environment, and that it is this process which becomes dysregulated in psychosis and gives rise to phenomena like delusions. When faced with a feeling that something is inexplicably salient or significant humans, story telling creatures that we are, cook up a story to account for the feeling. Part of the beauty of the theory is the way it offers a means for thinking about the interaction between the biological and the psychological. Kapur's language also makes the idea wonderfully intuitive:

By Kapur's account, a dysregulated dopamine system is "the wind of the psychotic fire" and helps us to understand how people can get wrapped up in terrifying implausible stories, but what does any of this have to do with David Lynch? 

Lynch's films, by my account, do a similar thing with our tendency to tell ourselves explanatory stories. Lynch can't dysregulate your dopamine system for you (that's a bit too "This is Your Brain on Cinema" for me), but what he can do is obey nearly all of the conventions of straightforward story telling while artfully ignoring others. Thus we have a series of wonderfully opaque and seemingly significant moments throughout Lynch's oeuvre. Each one seems to add something highly meaningful to the plot, but we can't be sure what. Who is the Cowboy who appears to Adam Kesher (Justin Theroux) in Mulholland Drive to tell him how to cast his film? We don't know, but the exchange has all the hallmarks of a plot-changing moment and we wait eagerly to find out what sinister forces lie behind this sinister man's authority: 

Mulholland Drive's Cowboy: A Vagueness we Are Forced to Explain

What we are doing here, filling in a story in the absence of being let in on its details, bears a striking similarity to what Kapur describes in the formation of a delusion. Something salient has happened and our minds go into overdrive to impose meaning on it. Something similar takes place when Betty and Rita visit Club Silencio and are moved to uncontrollable sobbing as they watch the singer's rendition of Llorando:

Club Silencio

The sense of significance is reinforced by the appearance in Betty's hands of a locked blue box, which appears to be a key clue for understanding the entire film. Unfortunately, no clear resolution exists, and we are left with a plurality of efforts to untangle the multi-layered plot. Film critics have tried but can't agree, and the Internet is home to an endless quantity of logorrheic accounts cooked up by obsessive fans. 

Mulholland Drive is just one example of the way an entire Lynch plot can feel like it hangs on a meaningless symbol. Apparent clues abound in nearly everything Lynch makes. In Twin Peaks, agent Dale Cooper solves the mystery of the death of Laura Palmer after a dream in which he is told "that gum you like is going to come back in style":

The Red Room

Has he solved the crime, or is he just subject to the feeling that something highly significant has happened? What about the severed ear on the lawn which opens Blue Velvet? To the viewer here is a moment that seems so macabre that it must explain something. Whose ear is it? Why was it cut off and by whom? The human tendency to paranoia goes into overdrive and is never resolved.

Blue Velvet's Ear on a lawn: The Macabre and the Banal in spades

Lynch's last film, Inland Empire, consisted almost entirely of such floating signifiers; bedside lamps and bizarre unconnected characters; extended sequences with rabbits talking gibberish. As Laura Dern navigates this confusing world she finds herself outside Room 47, which seems (from the horrified look on her face and the lingering camera work) like it must be a scene of some highly significant event. 

Inland Empire: One Long Paranoid Detour

But like the rest of the film, there is little in the way straightforward resolution to this encounter. Something profoundly creepy happens right afterwards (I'll let you find the clip on YouTube if you're curious) but with no explanation as to why. In many ways Inland Empire was the logical end point of Lynchian cinema. Over the last few films he had eroded the coherence of his plots and emphasised the apparent meaningfulness of moments, symbols and exchanges. The two most recent films especially look like an exercise in discovering how much you can ask the viewer to fill in for themselves. Because of the reliable beauty of Lynch's imagery, and his mastery with creating salient episodes, we go along with him. The resulting experience is an exquisite paranoia, more chilling and rich than almost any other thriller.