Unravelling Sane Privilege

It is increasingly common to see calls for people to check their privilege. This is apparently hard for some to understand, but at least most have some semblance of the fact that our society is generally racist, generally sexist and generally hetero-normative, and that we should bear in mind when we speak to each other that our prejudices and privileges have in impact on our worldview. Our society is sanity-normative too, and this is more difficult still for us to get to grips with. Being "mad" in some sense is something that we generally take to be undesirable, and the existence of mental health services is testament to the fact that society seeks to limit the misery and misfortune which accompanies experiences of psychosis, mood-disorders or "personality disorder". Hoping to affect an improvement in the lives of people with mental health problems should not, however, spill over into the assumption that everything about such individuals is a "deficit" to be fixed, or a "vulnerability" to be managed.

With the rise of identity politics as a lens for thinking about mental health, the languages of anti-(hetero)sexism and anti-racism have been finding their way into the discourse of "mad-chat" too. What does it mean for their to be a "sane" or an "insane" identity, especially when it seems so hard for us to pin down a hard distinction? Just as race, gender and sexuality can become concrete (even sometimes unwanted) identities in spite of considerable fluidity, so too can one's identity as "mental-patient" or "sufferer". Medical histories hang over us, and mental health histories follow people into domains of their lives they had never anticipated. Such individuals acquire "mad" identity. Unlike people of "sane" identity, the question then arises-do I embrace this, or minimise its significance?

If white-privilege, male-privilege and straight-privilege can act as blinkers to participation in online debate, then so too can "sane-privilege", speaking from a position of comfort and failing to consider the ways in which your ideas or suggestions have missed the point or caused offence. As a straight white male who is training to be a psychologist, I am a prime candidate for this sort of oversight, and I have probably made my fair share of blunders in conversations on Twitter where the comforting boundaries keeping professionals and academics safe no longer pertain.

As an exercise in checking my own sane-privilege, I had originally intended to do my own version of Peggy McIntosh's "Unpacking the Invisible Backpack", but I discovered that someone else had already done that much better. Instead, here are some additional ideas about what it might mean, specifically in online discussions:

1. Sane-privilege is communicating only in the set of academic-linguistic rules we have learned in our professional or academic training.

2. Sane-privilege is being able to get angry and express it, without having it taken for a sign of problems with our mental health.

3. Sane-privilege is the freedom to exhibit erratic, playful, explicit or irrational behaviour in online social forums, without the assumption that it is undesirable and beyond our control.

4. Sane-privilege is the freedom to pontificate about whether disorders really exist, drugs or therapies really work or whether ideological positions are or are not superior to others, and not have our hearts sink because the outcome of these debates matter deeply to our well-being.

5. Sane-privilege is the presumption that you can tell other people what else they can try to help them with their mental health and that they should give a damn.

6. Sane-privilege is presuming to tell someone that even if they are sometimes knocked clean off their feed or chased into bed for days at a time by their own state of mind, they do not have an illness.

7. Sane-privilege is presuming to tell someone that even if they spend happy hours conversing with heard voices, or fervently arranging the cosmos into divine and self-referential order, that they do have an illness.

8. Sane-privilege is presuming to tell someone how significant their history of abuse should be to them.

9. Sane-privilege is telling someone how they could redirect their overwhelming desire to self-harm, in a way that won't disturb other people.

10. Sane-privilege is deciding which risks in a person's life are acceptable and which are not.

11. Sane-privilege is the ability to get as drunk, high, sleep-deprived or wired as you like, without it being assumed that you are "relapsing".

Calling out privilege should never be just a silencing tactic. In the contested field of power, dialogue is our only way to proceed. Social media has been excellent for this, putting greater numbers of people on a more equal footing than has been possible previously. It will often make us uncomfortable, especially those of us who are professionals used to speaking in particular languages; but this discomfort is to be positively embraced as part of the ongoing agitation and uncertainty that necessarily accompanies human affairs.

The Language of Mental Health

The language of mental health can be baffling for the most fluent speaker. Being new to the vocabulary must be overwhelming. In our field words get un-moored from their more familiar meanings and float into new configurations. While academics may delight in such shifts, a drift into jargon can be a sign that somewhere a plot is being lost. What follows is a half-baked and entirely partial view of some troublesome words:

"Bipolar": This may win the award for the topic with the most balls talked about it. Luckily ace blogger Charlotte Walker never seems to miss a chance to point out the excesses that surround Bipolar-talk. From the idea that it is "fashionable" because Stephen Fry has it, to the extraordinary presumptuousness of Darian Leader's views on the subject, Bipolar Disorder has had a funny recent history.

"Clinical Judgement": Much as clinicians would like to know the "correct" answer to any given ambiguity, we cannot avoid making judgements in clinical practice as in life. I judge that something I say will provoke aggression, I judge whether it would be good for someone to try this or that therapeutic intervention. Even when guided by evidence, our judgements involve reasoning from the general to the particular. Often these sorts of decisions get called "clinical judgement". While this may have a superficial accuracy (judgement about clinical issues is undeniably clinical in some sense) it also seems calculated  to cloak a professionals pronouncements with spurious authority. What lay-person can successfully argue against a "clinical judgment"? When do professionals start to acquire it? I am just 2 years into a clinical training program, but already I have been encouraged by mentors to use my "clinical judgement". I am not saying my judgements don't count for something, and equally they are presumably worth less than those of a seasoned professional who has seen hundreds of cases; but judgements can, by their nature, be contested. If offering them with the haughty prefix "clinical" makes that harder to do then something fishy is probably going on.

"Distress": We could here examine the words "disease" or "disorder" but they have been so thoroughly gone over by various mental health theorists that I have little to add. As a result of that ongoing contention, the safest way currently to talk about mental health problems is to call them "distress". This inoffensive term has banality on its side, but seems to equate the existential terror of a psychotic break with the frustration of having had a bad day at work. Unsatisfactory.

"Evidence Based Practice": A noble ideal, but seldom followed as closely as it might be, and utterly useless if the people who are supposed to provide it are under-qualified to interpret the very evidence upon which their practice is based.

"Formulation": I can't really argue with this use of language. A Psychological Formulation is roughly the same thing as a formulation in regular language use. Alright Formulation, you can go.

"Group": When I worked in mental health, any constructive-seeming activity that more than three people did together could be packaged up and classed as a "group" to make it sound like a bone fide mental health intervention rather than just some people doing something worthwhile. "Cleaning group"; "cooking group"; "young person's group" are all genuine examples. It drove me up the wall.

"Healing": I am extremely skeptical about "healing", which we can use describe our own experience, but not to make promises to others. Health interventions can be shown to change various sorts of "symptom scores", but I am not aware of a decent "healing" measure, in psychology at least, that has much construct validity. We should probably calm it on the "healing" talk.

"Identity Politics": I think that the notion of "mad" identity is fascinating, and has a long way to run in combating mental health stigma. How compatible is it with the movement against psychiatric diagnosis? On the one hand we have the notion of neurodiversity and a distinct "mad-identity", which calls for accommodation of a range of different neural-cognitive types. On the other hand, there's the tendency to focus on people's commonalities while denying that differences could be meaningfully "diagnosable". These two ideas are not incompatible, but they are very different directions of travel. Twitter's @SchizoTribe account is "run by Schizophrenics" for anyone "with a Schizophrenic illness". This makes me wonder if denial of the existence of an illness is no less an infringement of someone's identity than making a diagnosis; an idea with which I think psychologists have to engage more seriously.

"Manipulative": I once had the good fortune to work on an excellent female inpatient ward. Prior to the hospital's opening we were given a very good talk about how frequently it is said of people with personality disorders that they are being "manipulative". The take home lesson was that this word should not be used to describe the behaviour of vulnerable people as it stigmatises their actions. I agree entirely, and I would add that the feeling among staff of being-manipulated is nonetheless sometimes very real. If you feel like you are being manipulated then you are very likely in the presence of someone who is generally deprived of something they feel they desperately need. Your feeling manipulated is not the result of something perpetrated by conniving, dastardly-patients, it is a circumstance arising from an adaptive response to a subjectively desperate situation.

"Practice-Based Evidence": The rejoinder to Evidence Based Practice. This is espoused by clinicians who feel the information we can glean from "clinical experience" (see "clinical judgement") is marginalised by nomothetic research. Is this true? Maybe, but let's be clear, even the most experienced clinician does not have experience which equates to a meta-analysis of multiple RCTs documenting health outcomes for thousands of people. This is not just a numbers game either, it's about a long view and the systematic ruling out of confounds and examination for bias. Experience and case reporting is very valuable but it has a different, complementary, role to play in the development of reliable knowledge.

"Recovery": Imagine asking a doctor the following question: "Can you help me recover?" What would you hope for them to say? The answer would surely involve an estimate of how likely you are to feel better on the basis of information about your problem and likely interventions. In mental health recovery means...something else altogether. I would not descry the general thrust of "recovery-oriented" approaches, but the fact that we find it so hard a word to define suggests that our use of it is in a state of disrepair. There is a difference between the advocacy of therapeutic optimism alongside societal accommodation of the needs of a diverse range of people, and telling clients-regardless of their difficulties-that you can do something that will help them "recover".

"Service User": I have a personal dislike of this awkward little two word phrase. Who wants to be a "user" of anything, let alone anything so non-descript as a "service". Strictly speaking this usage ought to unite people who use oncology services, mental health services and those who go to a garage get their car checked over. In reality it seems mainly to apply in mental health, a field sufficiently fraught that it needs as banal a vocabulary as it can muster. I am not advocating some fightback for the word "patient" per se, instead I try as far as possible to refer to people as "person", "individual" or, ideally, whatever they feel comfortable with.

"Survivor": I wouldn't begrudge anyone the use of "survivor" as a way of talking about their identity; being a psychiatric patient seems a tremendous ordeal to say the very least. However this post by Natasha Tracy gives an alternative view on the ways this word has come to be used.

"Therapy": (See also "Group"). Examples: "eco-therapy" "insulin-coma therapy". If something sounds like a good idea (spending time in nature) then lets explore the reality of how helpful it can be. If it doesn't (putting someone into an artificial coma and seeing what happens when we bring them round) then that may tell us something too. As the Mental Elf's close relative the Mental Sprite might say: image is nothing, evidence is everything.

"Validity": Often used alongside the phrase "psychiatric diagnosis has no..." Less often (with notable exceptions) accompanied by a description of what sort of information would be taken to satisfactorily rebut the claim.

"Wellness": In a situation where you can't sensibly talk about "illness", you are equally debarred from a sensible discussion about what constitutes "health". Luckily the language of "wellness" is sufficiently elastic that mental health professionals can, if they choose, be both paternalistic (deciding what is and is not in line with "wellness") and hypocritical (denying they are engaging in value judgements). Enter "wellness" which, like "recovery", can mean everything and nothing all at once.

Psychoanalysis and the Scientific Imagination

This post is about the part of psychology that has maybe caused more disagreement than any other. Doomed and tragic, dogmatic and sometimes foolish, psychoanalysis has been derided and "killed off" multiple times over. Like a religion it inspires dogged loyalty among followers which embarrasses people of a more skeptical mindset. Nonetheless, I retain an ongoing fascination with psychoanalysis as a way of thinking.

As an undergraduate I was discouraged from even thinking about picking up a book by Freud. His work was taken as the paradigmatic example of how NOT to do psychological science. The prototypical psychology undergraduate who makes assured statements of the form "Freud has all been disproven" has not really got it right (could they even say what it would mean to disprove such a huge body of work?), but they are not wrong either. How can I be both empirically minded and interested in the metaphysical suppositions of a patrician doctor from fin de siècle Vienna?

The privilege of "Sciencey-ness":

Here's the source of one potential form of mistaken thinking about the science of therapy. Contrary to intuitions, psychoanalytic theory is no less capable than cognitive theory of leading to treatments that can be manualised and tested. We may assume Cognitive Behavioural Therapies are more appropriate for modern clinical settings because the language of "cognition"; "schema" and so forth lends an additional superficial "sciencey-ness". However, the real litmus test of a therapy is neither its sciencey-ness nor its poetic intuitive appeal, but its ability in clinical trials to effect the sort of changes it claims to be able to make.

Unfortunately, it is a shabby truth that psychoanalytically inclined clinicians have resisted seeing RCTs as a legitimate way to validate their insights. Where they have (Fonagy and Bateman's Mentalisation Based Therapy and Clarkin and colleagues Transference Focused Psychotherapy-both interventions in the field of "Borderline Personality Disorder") they have produced some promising results. Some service users have reported that DBT, with its talk of "emotion regulation" can feel infantalising and restrictive. If alternative approaches can avoid these complaints then that would seem an important advance in the direction of greater choice for a group of people who are often otherwise offered very little.

Psychoanalysis and Science:

"Basic" psychological science isn't just a set of methods for verifying theoretical statements. Although such tools for verification are the main subject matter for philosophers of science, we also need a way to generate theories and new ideas to test. This requires creativity, imaginative flair and some familiarity with what you are trying to study. Einstein's creative thought experiments are lauded by the popular imagination because they challenged the conventional wisdom about how energy worked. If we view psychoanalysis as a rich field of imagination-stimulating ideas about the mind, its utility to science comes more to the fore. Nobel prize winning brain physiologist Eric Kandel has called psychoanalysis "the most coherent and intellectually satisfying view of the mind", albeit in the context of a plea to its practitioners that they up their game in terms of scientific theory development. Another Nobel winner Daniel Kahneman tells a fascinating story here about the value of reading Freud closely to generate new ideas for experimental testing:

In thinking scientifically about the way the world works we perhaps need to start with a proliferation of theories and ideas which we only later cut down to size through empirical investigation. If nothing else, psychoanalysis has been provocative and stimulating in developing detailed ideas about what sort of things minds are.

Psychoanalysis and "the ecstasy of truth":

Somewhere beyond the deliberately limited and precise technical vocabulary of scientific psychology there lies an explanatory and expansive language of mind to which we aspire. Novelists and poets have the ultimate privilege in this domain, they deal in fiction and verse, which provides the ultimate disclaimer for saying whatever you want and sometimes landing upon something that feels deeply and wonderfully true. 

Werner Herzog explains the distinction between two different views of truth

Psychologists have a duty to write and think in a different way if they have any hope of saying things which are verifiably and usefully accurate. We are-nobly I think-purveyors of what Werner Herzog would call the "accountants' truth". The price we pay for this is that we limit our capacity to get at the fullness of "the ecstacy of truth"; the truth of what it is and means to be human. Nonetheless we all surely want, at least in some part of ourselves, to go beyond cautious psychometrics and deploy words that really get at what it is like to feel and think. Why otherwise would we have become psychologists?

Psychoanalysis is not just a theory, it is a different way of having theories; a different way of writing about people. It is also a phenomenology. When Freud differentiates mourning and melancholia by saying that in the former it is the world which has become "poor and empty" while in the latter it  is the Ego itself; when Winnicott speaks of "annihilation anxiety" or of "holding" as a metaphor for the way that a clinician can help bear disorganising feelings of dread, these sorts of descriptions would seem to bring us close to lived experience in a way that technical scientific writing cannot.

Psychoanalysis is surely a dying art, surrounded by obfuscation, obscured by shroud waving, but for me it retains a valuable intellectual core. Freud was a staggeringly good writer (arguably too good; his capacity to convince and convert people can be viewed as intellectually problematic) and he developed a beautiful and detailed view of the psyche. Unfortunately for us, the truths that are contained in the enormous corpus of psychoanalytic writing are fleeting and hard to pin down. Some might suggest that analysis and analytic training can help you grasp them more firmly. I dislike the hierarchy and authoritarian nature of psychoanalytic "received" truths, but many of its texts are poetic, imagination expanding and enriching nonetheless.

Agendas and Anxieties: CBT for Psychosis

I have been watching discussion about the latest CBTp trial with interest and some weariness. If you haven't kept up, at least 3 expert blogs have painstakingly critiqued the results and reporting of a new study in the Lancet. Their work may have led the BBC to water down initially highly enthusiastic but inaccurate coverage:

Before and after: The BBC's shifting versions of the same study

I remain a fairly novice methodologist so I have nothing of value to add to this dispute. However, one striking and familiar pattern has emerged, apparently driven by particular anxieties upon which it is interesting to speculate.

Defenders of CBTp have emerged in the comments of these blogs angrily seeking to discredit its critics without providing much substantive defence of the data. Among the more striking things about these comments is their tone; irritable and impatient, levelling accusations of personal agendas and talk of "cabals". Perhaps for the most part, this can be attributed to the familiar fact of modality-affiliation-bias on the part of defenders. People want CBT to be effective for psychosis because they have invested time and energy in it as a cause. The same bias of course motivates overly-enthusiastic defences of any treatment. 

I think there is another anxiety present too however, one which, however misguided, is perhaps more noble. This other anxiety arises out of the current topography of the mental health debate, which appears to pit "medical"/"evidence-based" interventions against "intangiable"/"humanistic" interventions. With these binary goggles on it can look as though CBT is just about the only "humanistic" intervention that has any chance of passing the stringent hi-tech tests of an atomistic neoliberal psychiatry. Discrediting CBT is not just about one intervention; it entails a further discrediting of any provision of psychological care in this field. 

This reasoning doesn't follow, and I am not trying to motivate a case in favour of CBTp of the back of it. Why then have I said it is "noble"? Well, whatever the evidence for different specific interventions in psychosis, we would seem to want to provide in addition to them  "old-fashioned" "holistic" "person-centred" (call it what you will) care. Care, as it were, in the straightforward "folk" sense of the word rather than in the jargony bureaucratic sense. One person I interact with on Twitter has suggested calling it "psychiatric palliative care". Although I can anticipate some protests at this idea ("palliative" implies pessimism; a degenerative, fatal trajectory) I understand where she is coming from and think it's a neat coinage. Care is about a sort of ethical responsibility and it draws on a certain instinctual sense that people ought to look after and love one other. It is the sort of care which Jenni Diski recently eulogised in the LRB, sad to realise that the loss of Victorian asylums (good riddance) had also entailed the loss of "asylum" in contemporary society's treatment of mental health.

It would be misguided to rally to a therapy that cannot substantiate its claims to efficacy. We should be advocating treatments that really help people, and it is a strange thing when we don't. We need to understand why we get into such ruts if the debate is to progress. At least some of the problem is an unspoken fear: that if we see all of our caring efforts simply as testable technologies, we might lose them altogether. 

Making the Case: Thoughts on Social Construction in Psychiatry

I have written a post for the blog maintained by the Salomons Clinical Psychology course. The piece is available here and some really interesting comments are unfolding "below the line".  

3 Questions (and 3 answers)

At this point in the "psychodiagnosticator" project, I keep meaning to review my thoughts on psych diagnosis. So far I have never found a good organising structure for a post; there is lots I want to say as a sort of recap but my ideas have been too sprawling. Then, last week @agteien posed three questions on Twitter and cc'ed me in for a response. I have taken the opportunity to write a self-indulgent review of where my thinking is at the moment.

1. To you who are positive to keeping today's psych diagnosis system. What are the main reasons that you are?
— Anne Grethe Teien (@agteien) January 10, 2014

I am not especially positive towards existing diagnostic structures-I see that it is insulting and disempowering to speak of "personality disorders", that Schizophrenia is probably not an unitary illness construct, capturing people with divergent (not always pathological) experiences; that the DSM is still too embedded in its past (American psychoanalytic psychiatry) to claim "theory neutrality". Equally, once I started interrogating the case-against, I found that the most sound arguments seemed to be for revisions to particular diagnoses, additions to the diagnostic system, possibly a new way of diagnosing. Critics who put all these elements together into a general call to reject diagnosis entirely are trying to make a case which is more than the sum of its parts. In some versions of the debate, the idea of diagnosis per se seems to become a blank screen onto which all the angers and frustrations of mental health get projected, with the accompanying promise "if only we stopped diagnosing people, then we could have a humane mental health system". I don't buy it. I am not especially positive toward keeping today's psych diagnosis system, but I think it has acquired a near-mystical status of evil in some people's eyes, and that stymies interesting debate.

2. To you who want a new (psych) diagnosis/categorisation system. What kind do you want - and why?
— Anne Grethe Teien (@agteien) January 10, 2014

Maybe this one is the question best fitted to me, I not only struggle to imagine doing without some form of classification, I think that DSM's critics can't do without one either. In his new year "message from the chair", Richard Pemberton of the DCP reflected on the division's statement against the DSM-5 back in May. In the same paragraph he announced forthcoming DCP publications "understanding depression" and "understanding psychosis". You don't, of course, need to construe depression or psychosis as medical "illnesses", but the DCP's use of these terms raises an interesting question about what we necessarily do when we classify. If we reject an illness model of mental health problems but nonetheless continue to speak of them as distinct entities then we are not travelling very far from the position of diagnosing. Depression and psychosis remain things that are worth talking about and "understanding"; they remain things about which clinical psychologists presume to write and explain. If we think we can develop an understanding of their causes, course and potential interventions, in what way are we doing anything radically different from those who "diagnose"? To recognise a problem and believe you can generalise from other similar cases to provide help is, to my eyes, to confer a diagnosis. The broad rejection of diagnosis starts to look more like a turn away from a specific type of diagnosis and it's historical/theoretical implications.

3. To you who want complete abolishment of any "psych" diagnosis system: Why? What's your alternative? Are you against "somatic" dx as well?
— Anne Grethe Teien (@agteien) January 11, 2014

In the spirit of a debate that is a bit more developed than can be allowed on Twitter, I would encourage people to whom this last question is aimed to reply to it in the comments section on this post; I too would be interested in the answer.

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.