Psychoanalysis and Schizophrenia?

I've just finished reading Christopher Bollas' newest book When the Sun Bursts, about his work providing psychoanalysis to people going through psychosis. I realised I feel very mixed about it, and I suspect this tells me about my ambivalence about psychoanalysis more generally.

Psychoanalysis and schizophrenia fell out with one another in the 1980s, when the idea that the latter was a brain based disorder began to usurp the notion (mainstream in the 1950s, 60s and 70s US) that it was a psychological reaction originating in family dynamics. Many things contributed to the therapeutic divorce. The overall background was the rise of biological psychiatry and the renewed interest in using the DSM as a systematic tool for empirical research, but several historical events also conspired to paint psychoanalysis in a particularly unfavourable light. One major blow was the Chestnut Lodge Follow Up Study, conducted by Thomas McGlashan, a psychiatrist with sympathies to psychoanalysis who became curious about how effective it was. He examined the long term outcomes of patients at Chestnut Lodge (pretty much the world center of psychoanalytic treatment for schizophrenia) and concluded they were not being helped by their treatment. Another was the Osheroff Case, in which a physician with severe depression was treated psychodynamically and tried to sue Chestnut Lodge for not deploying the most effective treatment.

The Osheroff case did not actually concern an individual with a diagnosis of schizophrenia, but the principle at stake (whether psychoanalysis was an effective treatment for a severe and enduring psychological difficulty) was highly relevant to that diagnosis. Furthermore the case concerned treatment at, again, Chestnut Lodge. Many histories of psychiatry cite these events as key factors in the decline of psychoanalysis as a treatment for schizophrenia. One such (Edward Dolnick's Madness on The Couch) reads as a stern polemic, taking psychoanalysis to task for victim blaming. Another, Jeff Lieberman's Shrinks (review by me here), is a good example of how contemptuous many psychiatrists are about Freudian therapies and ideas.

So in one sense, Bollas' book looks like an anachronism. Few now expect psychoanalysis to ameliorate psychosis anymore, and Bollas is aware of the of how widespread is this view. He skirts the issue:

But goes on to makes a claim (a few pages later) which is quite definitie in nature and would require just the sort of outcome study that Bollas has recently repudiated:

This sort of sophism is irritating; does Bollas want to claim his approach is effective, or does he not? It's tempting to dismiss him altogether at this point, but does reading someone like Bollas have anything to teach us? I think it might.

It is not totally outlandish to suggest that R.D. Laing wrote one of the 20th century's best books about psychosis. The Divided Self is an unparalleled masterpiece of phenomenology (read it if you haven't already). Yet at the same time, there is also something approaching consensus (from what I have read) that his major therapeutic innovation, the Philadelphia Association, was something of a failure. Sure you can read Mary Barnes and Joe Berke's favourable account of a "Journey Through Madness", but when it comes to a more overarching view of the project (as found in Daniel Burston's very respectful biography of Laing), it doesn't look like the majority of people were helped any more than they would have been without the Scottish guru.

What Laing offered the study of psychosis then was not a viable alternative therapeutics (ultimately it's not clear that his notion of psychosis, as a revelatory journey one must past through, offered the sort of safety and serenity that might be optimal in a residential setting) but a powerful vision of how we can approach highly disorganized and disoriented people as people, with a degree of empathy and openness to listening to their experiences. Whatever packaged and marketed therapies are regarded as appropriately evidenced and offered in healthcare services, this sort of humane engagement is not only highly desirable, it is unavoidable. Whether you are discussing a person's medication, their experiences or their occupational aspirations, you need some way of taking them seriously and understanding what it might be like to live in their head. Laing's description of ontological insecurity, followed by the development and ultimate collapse of a protective "false self" system allowed clinicians to at least imagine what might lead to behavior which is so confusing as to be routinely described as "mad".

It is this kind of imaginative material that Bollas offers, and it is what makes his new book worthwhile for clinicians, even if they don't follow him all (or even most of) the way. Bollas and many other analysts (and not just analysts) may eschew the value of evidence in psychotherapy, but that doesn't invalidate everything they have to say. Whatever you think of the benefits of psychoanalysis as a therapy, it still has potential as a mode of observation and phenomenological hypothesis forming. None other than Paul Meehl once wrote a very effective argument to the effect that the un-testability of many psychoanalytic assertions does not itself render them untrue or worthless. If you take empathetic and highly attentive individuals (psychoanalytic clinicians) and put them in a situation in which they observe people's verbal behaviour over long periods of time, it seems highly implausible that they wouldn't derive any very insightful and useful ideas about how minds work.

Bollas' book has many such ideas. He suggests that the symptom of hearing voices is the result of "despositing" unwanted parts of the self in the environment such that they start to talk back to you, representing aspects of your past in ways that demand to be listened to. He describes the experience of the separation of the "I" from the "me", such that people with psychosis may split their self and behave in remarkable ways once they have done so . He suggests that people in the grips of a psychosis may be so frightened by their thoughts that they take an (often bizarre seeming) action to prevent having them. This sort of deep meditation gives rise to some remarkably empathetic moments:

Such intuitive accounts may be "wrong" (in the sense that they don't really get at what individuals experience) but they strike me as preferable to a defensive dismissal of people's "crazy" experiences. Many mental health services for psychosis currently isolate patients and ignore their experiences, alienating rather than engaging them. If social isolation is an exacerbating factor in the deterioration of people's mental health, we need to find ways of spending time with such individuals, even at their most disorganized and frightening. At least Bollas (and he is in a long line of psychoanalytic clinicians on this score) is trying his damnedest to connect.

Some of his ideas I found intuitive and quite striking, others (the obscure theory of "Metasexuality") I found maddeningly arcane. As Meehl (and many others) have pointed out, there may be no decent way to adjudicate between them, but unless you subscribe to a sort of rigid Vienna-Circle logical positivism in which statements about the self can only ever be empty "metaphysics", they don't seem entirely worthless. Are we only interested in ideas that are testable scientifically? Surely not; many highly speculative and unverifiable ideas (the dialectic movement of history) are valuable, so long as you have a clear distinction in your mind between them and some notion of "truth". We value novelists and poets who can illuminate their inner worlds through their vivid writing, why not try and find some similar worth in the imagination of psychoanalysts?

If you are still queasy about such unscientific shenanigans, it's worth remembering that a phenomenological account is not inconsistent with an informed empirical one. I'll end with a quote from one of Paul Meehl's best papers:

In Defence of the Psyche

There is an admirable current tendency in my profession (described passionately and elegantly here by Masuma Rahim), toward an appreciation of the many environmental factors which contribute to bringing people into our offices. It's as though the headshrinkers are only just learning that people aren't just miserable in isolation; things happen and make us miserable. This truism is ubiquitous at the moment, and has even become something of a slogan:

The corollary of this environmental turn is an increasing appetite for the rejection of diagnosis or an "illness" way of thinking; an assertion that facts about the individual are ultimately less important than facts about their past. Despite feeling closely aligned with this politicised version of my profession, I also feel some unease. Is there a baby somewhere in the bathwater? I suggest there is, for despite the indisputable importance of the outer world we all also inhabit a unique inner world, the land of the psyche. If there is one idea psychologists should be interested in it is surely this.

Right now hundreds of thousands of people are flooding out of Syria, escaping from some of the most harrowing events imaginable. Their journeys to asylum will not necessarily be any better. While we know that many refugees survive and even thrive in their new lives, many others will be psychologically devastated. Nobody can say why that is but inter-individual differences in the psyche have to be important. This is more than just to say that some people get lucky in the great individual-differences lottery. The psyche is important in understanding why life's horrors so completely overwhelm some people, but is also what accounts for why something as impractical as psychotherapy could make a difference to the lives of those who have suffered them.

Why do I say any of this? Clinical psychology has spent most of its past in denial of the environment. If we overcorrect at the expense of the psyche, several risks emerge:

1. A focus on the environment to the exclusion of the psyche is liable to promote a sort of therapeutic nihilism. If we believe that people in dire material straits can only be helped by material changes to their lives, we risk neglecting them. Ultimately we are capable of astonishing changes to our own lives. How we think plays a huge role in doing so. 

2. Following on from the issue of therapeutic nihilism is the issue of professional burnout. If you believe meaningful change is possible only through means which are beyond you, cynicism and overwhelm will not be far away. Therapists who lose all faith in their capacity to help people are on the road to confirming their own worst fears. 

3. Too great an emphasis on the environment is a form of reductionism analogous to "biologising". Just as a restrictive "disease" model leads to the belief that all should get medication, a restrictive environmental model could lead to the neglect of individual differences in therapeutic need. Some people's misery is intelligible almost entirely in terms of things which have happened to them. For most of us, the struggle is in the complex and all-too-human dance between problems foisted on us and problems we make for ourselves. 

One model for what I am pointing to is bereavement counselling. While we recognise that not everyone who experiences death is in need of it, we readily accept that some of us can be so rocked by the resulting grief that it is helpful to see a therapist. This does not entail that only immortality can stem the tide of human misery. Some miseries are best adjusted to. Even those miseries which are not best adjusted to (such foes as discrimination, economic inequality and political violence) are nonetheless pervasive.

Perhaps there is an argument in the near vicinity that I will be accused of making: that psychologists should not be political, but should get on with the job in hand. I am not making that case at all. Psychologists should be highly political, just as should any profession which takes people seriously. To the extent that society makes victims of some of its members, we should change it. However if the history of humanity has anything to teach us, it's that suffering is inevitable. To think otherwise is not political, it's utopian.

Politics come in part from theories about human nature, and psychologists have those in spades. There is simply no incompatibility between believing in large scale political action, while simultaneously asserting the value of small-scale individual change. Just as our social world impacts on our psyche, so too our psyche impacts on our social world.

The Hickey-Lieberman Test

Phil Hickey has an interesting post over at his blog about what happened when Jeff Lieberman was asked if psychiatry over-medicated people:

Absolutely.  I had an experience with my own son.  I have two sons.  My older son was going to nursery school, and they said he’s not paying attention and were concerned.  ‘You should have him tested.’  We had him tested.  The neuropsychologist said, ‘Well there’s some kind of, you know, information processing problems, you should see a pediatric psychiatrist.’  I said, “Well, I am a psychiatrist, but I’ll take him to see a pediatric psychiatrist.’  We took him to see a pediatric psychiatrist, spent twenty minutes with him, and he started, you know, writing a prescription for Ritalin.  I said, ‘Why?’ and he said ‘Well, he’s got ADHD.’   I said, ‘I don’t think so.’
So, long story short, he ended up graduating from University of Pennsylvania, law school at Columbia, he’s in a top law firm.  So, yes, it happens, and part of that is social pressure.

There is something very telling about this story. I think one intuitively sides with Lieberman's sense that ADHD is an unnecessary label under the circumstances. But how can one avoid such undesirable clinical encounters? It's tempting to prescribe a healthy dose of "common sense", but this is a questionably useful. I am sure the paediatric psychiatrist in the story felt they were applying common sense in their work by applying a DSM diagnosis, so invoking it only leads to a conflict between two people's notions of what is meant by that rough and ready notion.

I want to propose we use Hickey's report of Lieberman's anecdote to formulate a test for ourselves as mental health professionals. I call this the "Hickey Lieberman test" to recognise the role of Jeff Lieberman in articulating the problem, and Phil Hickey in transcribing Lieberman's story. The Hickey-Lieberman test should be applied in any situation in which a psychiatric or mental health intervention (be it diagnosis, prescription, therapeutic plan, change in living circumstance, or really any substantive change) is being considered. It consists of four questions the intervening clinician(s) should ask themselves before taking action.

The Hickey Lieberman Test: 

1.How would I react if this intervention was to be applied to me, or to someone I cared about?
2. What would be the basis of that reaction?
3. If I would react negatively to this intervention, can I nonetheless justify it in terms of converging lines of evidence that it is an appropriate course of action?
4. If the answer to 3 is no, what would I change about this intervention to make it more reasonable for the person toward whom it is directed? 

The Hickey-Lieberman test is hardly water tight. If you agree with my reservations about "common-sense" then you will notice that this proposal also contains a great deal of subjectivity. However, a formal test does demand at least a moment's thought. When people act in ways they think are concordant with "common-sense", they may often be rationalising after the fact rather than thinking in advance. Much like the "reasonable person" test applied in legal settings, the Hickey-Lieberman test draws on the notion of a shared agreement about what it means to behave sensibly, which isbetter than nothing. 

Reasons and Causes

Some quick thoughts about an alternative way of weighing up the status of psychiatric problems. The conventional controversy is organized around the question of whether such and such a set of behaviours constitutes an "illness". Much ink gets spilled defining "illness" and then asking whether any given problem meets the criteria. Could we instead make the determination on the basis of the mechanisms that have given rise to any given problem?

To some extent a version of this already happens. People who advocate for the use of psychological formulation want us to ask "what has happened to you?" Not a bad way to go about things, but infections and closed head injuries happen to people, and they have a place in the world of illness/medicine. A finer grained distinction may follow from Karl Jasper's division between things that can be explained and things that can be understood. 

Into the former (at least for Jaspers) fall "ununderstandable" phenomena like delusional beliefs (psychopathological because incomprehensible), while into the latter category fall emotions that arise as responses to events (sadness in response to loss). I am not saying we have to agree with Jaspers about delusional beliefs here (this post is not a bid to police what is and what is not understandable) I am just saying that it is, in principle, a potentially helpful distinction.

It brings us on then to thinking about aetiology, which could be thought of in parallel terms of reasons and causes. I have reasons when something that has happened to me "makes sense" of my behaviour/feelings in light of some culturally shared system of meaning (i.e. depression in response to bereavement). We seek causes where we suspect we need to go down one level of explanation.

We might say that a person who is afraid of dying has reason to not see a small painting of a skull hanging on the wall in front of them. A person with a scotoma occluding their view of the painting has had their inability to see caused by a biological event. Under this scheme, problems which are primarily caused would belong mainly to "mechanistic" forms of cure, while events which have reasons would belong to more narrative/psychotherapeutic approaches.

The distinction already starts to break down of course. An individual with Parkinsons has had the shaking in their hands caused by dopamine dysregulation in their basal ganglia, but the slow pace of their walking might be something they have reason for ("I would fall over if I tried to go any faster"). Equally, consumption of large quantities of some substances will cause certain brutally physiological physical problems, but the consumption itself may have socially-comprehensible reasons (drinking to numb some emotional pain). The tangle of the mechanistic and hermeneutic approaches will not be dissolved, but at least we might have a better way of talking about it. 

Rethinking Therapist Drift

One of the strangest ways I have ever been evaluated in my career was while delivering a psychological intervention in a prison. My job was to stand in front of a room of young offenders and facilitate group discussions of their "thinking skills". The prison service has a clear idea of what this should look like, indeed so clear that every session I did was filmed. Auditors could then check that I was sticking to the protocol. 

This remarkable surveillance was an attempt to minimize what is commonly called "therapist drift", the process whereby a therapist ostensibly delivering an evidence-based therapy winds up doing something else instead. Psychotherapies are not easy things to administer, and in the face of diverse people and problems it's easy to see how one might end up straying from the guidelines outlined in therapy delivery manuals. But if you claim to be doing, say CBT when you aren't in fact doing anything of the sort, you might not get the same results.

For the most part, therapist drift is regarded as a bad thing. This makes sense (at least, it's internally consistent). Drift is a problem for people who are trying to research a therapy (because they don't end up testing what they intend to) and it's potentially a problem for people who are trying to deliver a therapy (because rather than delivering something that has been demonstrated to be effective, they do something which is not).

But there is a strand of thought in clinical psychology and psychotherapy that maintains suspicion about the notions of "adherence" and "drift", and of evidence-based therapy altogether. Critics of this stripe view evidence-based-approaches as overly rigid and formulaic, too focused on technique at the expense of relationship. There is some good quality criticism of manualized therapy (here's a good example), but also much exaggeration about manualized therapies making the process "robotic" (as though a set of instructive principles were incompatible with being human). 

Recently I looked into the topic (in a very non-systematic way) to see what research had found about the importance of adherence and drift. Most studies that have been done (and it is surprising how few there are that focus specifically on drift) seem to support the contention that "drifting" can lead to less impressive outcomes. However, one study had an intriguing result.

Examining CBT for panic disorder, researchers (Jonathan Huppert and colleagues) took measures of patient motivation (rated by the therapists) and adherence to the therapy manual (rated by listening to audiotapes of sessions). Perhaps counter-intuitively, the researchers found that among highly motivated patients, the therapist adherence did not have much impact on outcome (look at the graph and you can see the blue line only slopes upward a small amount; this difference was not found to be significant). However, among less motivated patients, adherence was associated with worse outcomes than drift.*

One possible explanation for this (one that Huppert and colleagues themselves suggest) is that patients with low motivation present an extra degree of complexity which cannot be adequately addressed by staying within the set protocol. An experienced therapist will depart from the standard protocol to address in some way the low motivation, before continuing with the planned process. Under this interpretation, the therapists who show the greater adherence with the "low-motivation" patients are paradoxically failing to do something with the low adherence therapists are succeeding at it. Although they are moving beyond the purview of the manual, it seems misguided to call this "drift". This squares with the extended discussion by Drew Westen and colleagues on the more tendentious implications of therapy manuals:

...manualization commits researchers to an assumption that is only appropriate for a limited range of treatments, namely that therapy is something done to a patient—a process in which the therapist applies interventions— rather than a transactional process in which patient and therapist collaborate. (p.639)

And yet still some idea of therapist "drift" seems important. Unless we believe there is no value to specific training for psychologists and psychotherapists, we want to have some reasonably defined sense of what we're up to; some sense of what it looks like to do the job properly. It is any deviation from this that can reasonably be considered drift. In other words: in the space between conforming, robot-like, to a predetermined protocol and doing whatever the hell you want, there lies a knowable range of skills which we ideally would want to adhere to. That set of skills is what constitutes being a good psychologist. This definition extends the realm of evidence based practice some way beyond the parameters of individual evidence based treatments. 

_________________________________________________________

*Though the authors note: "it is important to keep in mind that even when therapists were rated as less adherent, adherence was still rated as “good” or better, suggesting that therapists did not cease doing CBT for panic, but likely incorporated other strategies into their armamentarium" p.202

Why does "schizophrenia" persist?

I sometimes wonder if anyone in mental health really believes in the idea of an illness called schizophrenia. Sure there are true believers in psychiatry like Jeffrey Lieberman and E.F. Torrey who will happily claim that there is a distinct brain disease the word connotes. Their advocacy (such as in Lieberman's recent "Shrinks" and Torrey's ever popular family manual "Surviving Schizophrenia") is a big part of how the diagnosis has come to have broad currency.

But once you get interested in schizophrenia, it doesn't take long for the whole edifice to look a bit crumbly. For almost as long as schizophrenia has been around there has been contention about it as an entity. This contention is not just an expression of "phenomenologic relativism" (Lieberman's angry charge), it is a respectable doubt about whether the construct of schizophrenia is a valid object for scientific study. It has been articulated most elegantly by Richard Bentall and Mary Boyle, who both conclude that schizophrenia is not a valid construct. When you try to find examples of people refuting their position, it's hard to come up with much of substance. Thus, a chapter on the construct of schizophrenia in Daniel Weinberger's big textbook on schizophrenia says this:

The diagnostic criteria currently used (ICD - 10 and DSM - IV - TR) can be considered provisional and arbitrary constructs with some face validity that meet the objective of facilitating international communication and research. (p.9)

Meanwhile, in their Very Short Introduction to Schizophrenia, Chris Frith and Eve Johnstone acknowledge Mary Boyle's long and detailed book, but they dismiss it by saying simply "we are not convinced" (this comment appears in a Further Reading section at the back of their book).

Given all the articulate doubt, and its less than convincing refutation, why has the schizophrenia label survived? When this question has been asked by critically minded scholars, the answer has tended to be "money and professional esteem". David Pilgrim endorses a version of this argument in an essay in "Reconstructing Schizophrenia", and in "Madness in Civilization", Andrew Scull points out that "chronic conditions are chronically profitable" (p.393).

There can be no doubt that the financial and professional interests of psychiatry and pharmaceutical companies play a role in the survival of schizophrenia, but this explanation cannot be the whole story. Both motivations played a role in the brief flurry of interest in Paediatric Bipolar Disorder (an ugly controversy documented well in multiple posts by One Boring Old Man), but the APA, cogent of its many problems, ultimately moved to stop that diagnosis getting into DSM-5. That is not proof that the APA's mechanisms for self regulation are good enough, but it does suggest the need for another ingredient in order for a disorder to become as successful as schizophrenia.

What is missing in the economic account of schizophrenia's survival is the fact that, validity concerns notwithstanding, there is a way in which the diagnosis is very convincing; on the face of it many people who meet criteria for schizophrenia seem to be seriously unwell and many of them will testify to that fact. This is something that schizophrenia's many critics frequently seem to miss. It is largely (though not entirely) missing from the BPS's Understanding Psychosis document, and it is missing from the writing of Bentall, Boyle, and others, who tend to view their work as a foundation for moving away from an "illness model" of what they refer to as "psychological distress".

In fact, even the ultimate collapse of schizophrenia would not be tantamount to evidence that there are no illnesses in the space the diagnosis used to occupy. In a staunchly critical book "Schizophrenia is a Misdiagnosis", the psychiatrist C.Raymond Lake argues that schizophrenia cannot be distinguished from severe psychotic mood disorders, and also provides a long list of disorders which can get diagnosed as schizophrenia (see below).

Perhaps then the persistence of schizophrenia can partly be attributed to a case of a divided opposition. All of schizophrenia's critics can be seen as wanting to carve away chunks from the existing construct by placing people into alternative categories. For some these chunks are "psycho-social distress" (i.e. not ill at all), for others they should go into more precise medical categories (i.e. ill with something doctors actually understand). To some extent these players in the debate speak at cross purposes; they might even be construed as competing over territory:

Schizophrenia as shrinking territory.

By far the most vocal and high profile critics are psychologists who want to reframe schizophrenia as a form of psychosocial distress (they want to expand the purple section in the diagram). This effort is unlikely to be entirely successful because, even with skepticism about the DSM construct, many people's intuitions are that there is something illnessy about the experiences which commonly attract the diagnosis. This group tends to be reluctant to acknowledge the presence of any psychiatric illness (witness the BPS report-writing guidelines which sought to exclude even the words "illness" or "disorder").

Schizophrenia's medical critics believe that progress will come as more and more people currently in the "bucket" of schizophrenia are given a correct medical or psychiatric diagnosis (as the yellow section expands). This quieter territory expansion is constantly ongoing, with new "subgroups" of schizophrenia emerging periodically, associated with specific physiological characteristics (a very recent example is here). When these subgroups are sufficiently well understood they raise an interesting problem; are they still a form of schizophrenia, or (given that the DSM definition of schizophrenia has an exclusion clause saying that symptoms must not be due to the direct physiological effects of a [...] general medical condition.) have they become something else?

It is this ongoing uncertainty which surely accounts for the continued plausibility of schizophrenia in the psychiatric and public imaginations. Yes there are many people who fall in the purple and yellow overlaps of my venn diagram, but there are others (how many?) who currently do not. The hypothetical construct schizophrenia is a testament to the suspicion that, when everything tumbles out, there will be a well understood bio-psycho-social process giving rise to the symptoms in DSM-5. Should that process be sufficiently well understood, it might be what we end up giving the name "schizophrenia" 100 years from now.

Alternatively, the purple and yellow sections may keep expanding, finally squeezing schizophrenia out of the picture altogether. Only an omniscient being can currently say how much of the middle circle will be left in the end. For the time being no amount of political activity seems sufficient to quell people's suspicion that when psychiatry talks about schizophrenia, it is talking about something worth naming. 

Medicating History

The history of the discovery of neuroleptic drugs for psychosis is often (more often than not?) used for professional-political ends. I recently read Jeffrey Lieberman's book on the history of psychiatry, in which he provides a description of the first psychiatric use of chlorpromazine. If you take it at face value you get the impression that the new drug was immediately impressive because of its dramatic impact on the symptoms of psychosis per se. Here's Lieberman's description (with some underlining of parts I found particularly striking):

On January 19, 1952, chlorpromazine was administered to Jacques L., a highly agitated twenty four- year-old psychotic prone to violence. Following the drug’s intravenous administration, Jacques rapidly settled down and became calm. After three steady weeks on chlorpromazine, Jacques carried out all his normal activities. He even played an entire game of bridge. He responded so well, in fact, that his flabbergasted physicians discharged him from the hospital. It was nothing short of miraculous: A drug had seemingly wiped away the psychotic symptoms of an unmanageable patient and enabled him to leave the hospital and return to the community. (p.164)

Compare that to a 2007 piece by Thomas Ban, which is sufficiently similar that it could have provided the model for Lieberman's description, but for a few subtle differences (again with extra underlining):

Jacques Lh., a 24-year-old severely agitated psychotic (manic) male was the first psychiatric patient to receive CPZ; he was administered 50 mg of the drug, intravenously, at 10 am, on January 19, 1952. The calming effect of CPZ was immediate but since it lasted only a few hours several  treatments were required before the patient’s agitation was controlled. Repeated administration of the drug caused venous irritation and perivenous infiltration. Hence, on several occasions barbiturates and electroshock were substituted for CPZ. Nonetheless, after 20 days of treatment, with a total of 855 mg of CPZ, the patient was ready “to resume normal life.” (p.496)

It's amazing how word choice and subtleties of description can paint radically different pictures of the same set of events. I know nothing else about Jacques L/Lh. What were the nature of his psychotic symptoms? To what extent was he actually manic? Was it psychosis, mania or his agitation that was most affected by the chlorpromazine? Finally, what happened to Jacques, and what did he think of the new medication he had tried?

The Pleasures of Delusion

Would it be somehow crass or offensive to talk more about pleasure when we talk about clinical delusions? We tend to think of delusions (defined now in the DSM-5 as "fixed beliefs that are not amenable to change") as being principally aversive experiences, and so they seem to be. The idea that you are being persecuted, that you might die imminently, that your family have been replaced by imposters; these are all terrifying sounding notions. Apart from being frightening in content, delusions have the added misery of rarely being shared. If everyone else believes you are being persecuted too, at least you don't have to deal with the profound disorientation of never being taken seriously.

But despite the undoubted terror of holding certain beliefs, and the loneliness of being the only person you know who does, it would be hard to imagine anyone ever having them if there wasn't something about them that we sometimes needed.

And in fact we have become accustomed to thinking of delusions as a defence, that is as being at least preferable to something worse. For Freud they were elaborate ways of getting away from homosexual longings. You start with a forbidden love, and how you go about denying it determines what sort of delusion you end up with. Freud accounted for delusions of persecution (”I do not love him I hate him” gets projected to “he hates me”), "Erotomania" (”I do not love him I love her”), delusions of jealousy ("it is not I who love the man, she loves the man") and megalomania ("I do not love at all-I don’t love anyone”). So systematic was Freud that his equation hung around for close to a century (and still holds sway in some quarters).

More recently delusions have been construed as one way of managing negative emotions. An individual who tends to attribute experiences to the external rather than internal realm, the argument goes, may be interpret feelings of badness in terms of a persecutory world rather than as being about themselves. There is a whole family of theories which take issue with this "attributional" account of delusions. These tend to invoke multiple factors, including most frequently perceptual anomalies and some sort of over-hasty style of reasoning. However even less emotion centric theories seem to gesture toward a motivational component. Thus the famous "jumping to conclusions" bias (the tendency, to make a decision on the grounds of less evidence), which seems fairly robustly associated with delusional ideation, has been itself accounted for in multiple ways. Is it a response to a "need for closure", or of an "intolerance of uncertainty"?

In a related vein, the philosopher Lisa Botolotti recently suggested that delusional beliefs could represent a sort of epistemic damage limitation. Better that you entertain a single false belief than suffer a broader psychic overwhelm and become unable to believe anything. This is the delusion as adaptive, as the fuse which can be allowed to blow in order to stop the whole edifice burning down. What these accounts all share is the suggestion that delusions are the least worst of several bad options. Put it that way and we focus on the unpleasantness of what is being defended against, but what about the appeal of holding a delusional belief?  It begs the question of what role our everyday beliefs hold for us. Hang around delusions research for long enough and you start to ask why anyone believes anything.

This is what brings me to the question of pleasure. Think of how pleasurable it is when you know the answer and no-one else does, when you finally figure it out, when everything suddenly makes sense. Addressing herself to the difficult question of what constitutes a satisfactory explanation, psychologist Alison Gopnik described "explanation as orgasm". Think, she suggests, of the way children (those "little scientists") seek endlessly for explanations, would they really be doing that if it wasn't a lot of fun? Richard Feynman spoke about "The pleasure of finding things out". As a research physicist, Feynman really was in the process of "finding things out", but don't the rest of us get pleasure from thinking we understand things better than we do? Anyone who has spent time in a bar with some politically disgruntled bore will recognise the peculiar glee that accompanies the "conspiratorial whisper". It is the pleasure of seeing through it all; of knowing what other people don't know. Might delusions sometimes afford something of that pleasure?

Shrinks to Fit

Jeffrey Lieberman is gaining attention and opprobrium as he publicizes his new history of psychiatry "Shrinks". The book turns out to be a lively run through of the standard history-of-psychiatry over the last two centuries, though at first it's hard to know what to make of it. "Shrinks" initially reads as either the gentle reflections of a well intentioned psychiatric patrician, or a cynical attempt to skirt fascinating conceptual difficulties in the service of professional power. Which you pick depends on how much Machiavellian intent one imputes to its author.

Jeffrey Lieberman (very possibly the only psychiatrist 

alive who still wears a white coat).

In writing Shrinks, Lieberman does not just want to spin interesting yarns. There is an argument being made, and it explicitly invokes a narrative of progress. Psychiatry, according to Shrinks, has muddled through the Freudian intellectual backwaters of the 1950s and 60s; endured the clunking horrors of insulin coma and psychosurgery, and now it stands on the brink of a new scientific era. I might be missing something but this story strikes me as anything but "untold". It's a well worn and, I would argue, simplistic narrative which won't gain any traction among anyone even vaguely acquainted with the legitimacy crisis faced by psychiatry's classification system. You do not need to be one of Lieberman's "anti-movement" (I am not) to find passages like this a little too slick:

“For the first time in its long and notorious history, psychiatry can offer scientific, humane, and effective treatments to those suffering from mental illness. I became president of the American Psychiatric Association at a historic turning point in my profession. As I write this, psychiatry is finally taking its rightful place in the medical community after a long sojourn in the scientific wilderness.” (p.10)

That is not to say the book is not fascinating. For one thing Lieberman's prominence as a psychiatric researcher has given him front row seats for many of the major changes in psychiatry since the 1970s. He gives compelling accounts of the renegade neo-Kraepelinians gathering in St. Louis (far from the psychoanalytic powerhouse of New York) to assemble the "chinese menu" DSM-III which changed Lieberman's profession forever (entirely for the better by his account).

Lieberman also has some provocative personal perspectives on the broad debates concerning psychiatry, suggesting (on the basis of a conversation with E.F. Torrey) that R.D. Laing lost his argumentative lustre when his daughter started to suffer from a psychosis that was diagnosed as schizophrenia. Meanwhile, Thomas Szasz, "who I met several times [...] made it pretty clear he understood that schizophrenia qualified as a true brain disease, but he was never going to say so publicly" (p.113). He also peppers the book with clinical encounters, so we learn that Lieberman once gave ECT to the wife of a New York restaurant owner who was so happy with the results that he offered Lieberman free meals whenever he wanted.

We are also given to suspect that Lieberman harbours deep frustration with psychoanalytic dogmatism, and he concurs with Freud, who once muttered darkly to Jung that they were "bringing the plague to America". Lieberman writes like someone who endured a feeling of disconnection from his profession when he was starting out:

"If a trainee wanted to rise within the ranks of academic psychiatry or develop a successful practice, she had to demonstrate fealty to psychoanalytic theory. If not, she risked being banished to working in the public-hospital sector, which usually meant a state mental institution. If you were looking for an indoctrination method to foster a particular ideology within a profession, you probably couldn’t do much better than forcing all job applicants to undergo confessional psychotherapy with a therapist inquisitor already committed to the ideology.” (p.77)

However, he is no Freud-basher, calling the latter a “tragic visionary far ahead of his time" and suggesting that psychoanalysis remains the best way of understanding certain sorts of psychological problem (though this comes early in the book, and is soon buried by his aversion). Like Tom Burns in 2013's "Our Necessary Shadow" Lieberman has a story about helping a patient overcome an apparent conversion hysteria, lending weight to Freud and Breuer's early formulations of that fascinating disorder. He even mounts a rather good defence of Freud's approach to drawing empirical inferences from clinical data:

"Freud had no tangible evidence whatsoever of the existence of the unconscious or neurosis or any of his psychoanalytical ideas; he formulated his theory entirely from inferences derived from his patients’ behaviors. This may seem unscientific, though such methods are really no different from those used by astrophysicists positing the existence of dark matter, a hypothetical form of invisible matter scattered throughout the universe. As I write this, nobody has ever observed or even detected dark matter, but cosmologists realize that they can’t make sense of the movements and structure of the observable universe without invoking some mysterious, indiscernible stuff quietly influencing everything we can see." (p.43)

But Shrinks, like the proverbial psychoanalytic patient, might be most revealing where it least intends to be. This book is full of peculiar sentences whose brusqueness may reveal a studious irony or unfortunate lack of reflection:

“After watching shocked pigs become oblivious to the butcher’s knife, Cerletti decided that shooting 100 volts of electricity through a person’s skull was worth the obvious risks.” (p.167)

"While the publication of the DSM-III had been marked by tumult and controversy, the release of the DSM-IV was as routine and uneventful as the opening of a Starbucks." (p.271)

The breezy glibness on ECT, combined with the terribly unfortunate analogy between the DSM project and an oft-maligned international coffee chain, might have been calculated to provoke the dismay of the very people Lieberman seems keenest to convert. But then, perhaps it's just that Lieberman thinks he can best connect with a readership in modern corporate America. Just look at how he describes Freud's approach to leadership:

"If Freud was the CEO of the psychoanalytical movement, his management style was more like that of Steve Jobs than of Bill Gates." (p.54)

Baffling!

In a penultimate chapter on the creation of DSM-5, Lieberman sounds touchingly hurt by all the outrage the manual provoked (he puts it down largely to the Internet, and appears to lament the loss of a time psychiatry could go about its business in private), but puzzingly unwilling to acknowledge what was driving it. Detractors are either antipsychiatrists (Gary Greenberg) or purveyors of "epistemic hubris" (Thomas Insel). Only the DSM-5, for Lieberman, achieves the theoretical pluralism which must be psychiatry's future. Such pluralism is a noble goal for a discipline as wide ranging as psychiatry, but Lieberman is too sanguine about the ways that notorious "bible" (Lieberman favours "bible", a term I normally associate with critics) stifles rather than promotes it.

"Shrinks" is an entertaining read, and at least in some regards more nuanced than I expected. But Lieberman's unwillingness to wade into the conceptual confusions his specialty is still dealing with, combined with his true-believer optimism about its imminent brave new world (genetic tests for forms of psychosis; cognitive behavioural therapy apps), make for an all too smooth ride. This is a work of unabashed advocacy, even propaganda, and should be read as such.

-------------------------------------------------------

Postscript:

After writing this, I found a wonderfully scathing review of the book by Rebecca Twersky-Kengmana, who draws out more of Lieberman's weird disdain for psychoanalysis. More than me she views Lieberman's position on it as a flat contradiction. Her post also includes some great Amazon reviews by people dismayed at the quality of Lieberman's historical scholarship:

Shrinks: The Untold Story of Jeffrey Lieberman's Oedipal Victory Over Papa Freud

Spare Me the Sanctimonious Bleating About Trigger Warnings

The New Republic is carrying an article by Jerry Coyne lamenting the rise of the trigger warning, and specifically the idea that college literature courses should consider applying them to the Western canon. Without much explanation, Coyne links trigger warnings to the "decline in free speech at American universities". It is not clear exactly what a trigger warning prevents one from saying.

He is particularly concerned about an article by Columbia University's Multicultural Awareness Advisory Board that had appeared in that college's paper. It described a student's distress after reading rape scenes in Metamorphosis (which had triggered memories of her own experience of sexual assault) and being dismissed by the teacher. Evidently unable to suppress his own sympathy, Coyne hedges about the specific case:

There is something gloriously stupid about this. Coyne seems to be trying to have it both ways: "I would have provided a trigger warning to this student, but I would never have been so crass as to say the words 'trigger warning'". This is a familiar reactionary tic, driven by the same pig headedness that detests political correctness for its requirement that people don't always spew the first offensive crap that jumps into their heads.

Having concluded that trigger warnings per se are not that bad a thing after all. Coyne could have stopped after four paragraphs, allowing us to agree that warning people about potential personal sensitivities is hardly an attack on the first amendment. Instead he spends the rest of the article talking about how much he hates them.

Coyne trenchantly enumerates all the great works of literature that no-one will be allowed to read anymore (probably) if trigger warning Fascism (and he does use the word Fascism) takes hold. The Bible sanctions rape; Huckleberry Finn is full of racism and Anne Frank's Diary contains antisemitism. Perhaps there's an argument in there somewhere, but Coyne lost sight of it long ago. His article becomes an ill tempered rant about other people's sensitivity, culminating in a weirdly defiant account of his trip to Auschwitz.

Should everyone go to Auschwitz? Perhaps. I should certainly go, but what about people whose parents died there? Or survivors who remember it just fine thankyou very much? Unlike Coyne (whose appetite for understanding the worst in people is laudatory), some people don't need a reminder that ordinary people are capable of brutal things.

"Life" as Coyne says "is triggering". Nobody denies as much, but what the trigger warning sensibility acknowledges is that it is not always triggering for everyone to the same degree. Some of us (Coyne is clearly one) can blithely ignore the warnings. Others can be grateful that they increasingly get a choice about whether to follow link that may lead them to get lumbered with flashbacks to their own sexual assault, accident or suicide attempt. 

These sorts of consideration can be managed entirely without any impact on freedom speech; the inclusion of a brief parenthetical "TW" next to links or items on a syllabus is all it takes. If that offends you (and being offended by trigger warnings themselves is infinitely more obtuse than being offended by violence, sexism or racism) then you can simply refer to the content in advance as Coyne helpfully suggests. It's easy. 

Pushing Explanations

Clinicians of my temperament get worried about forcing our explanatory views on the people with whom we work. Whatever explanatory frameworks we may have encountered during our training (medical, cognitive, psychodynamic models), however helpful we may have found them, we have a basic reluctance about regarding them as the explanation, and are more comfortable drawing on the idiom an individual uses to explain their life. One way to accommodate this kind of reluctance is to adapt a form of explanatory pluralism, where multiple models are held in mind, sitting comfortably alongside one another.

This approach is useful because it not only allows us to think in terms of multiple philosophical models, but also leaves space for the language used naturally by individuals whose experiences we are trying to discuss.

Much of the time this approach is relatively trouble free. That is to say, most of the time there is no benefit in substantially disagreeing with a person about how they account for their experience (I am thinking of an individual I knew who heard voices and was perfectly clear there was nothing wrong; who was I to disagree?) .

However, despite my basic sympathy with explanatory pluralism (what I could call my conviction that, when it comes to talk of "mental illness" there is basically no fact of the matter) I realise that I can cook up some uncomfortable cases for myself, which make the approach less satisfactory. Sometimes simply going along with an individual's account of themselves won't be sufficient.

Here is one problem case:

A parent approaches you, the clinician. Their child is causing problems at school. These are not insubstantial problems. The child is disruptive and, on the face of it, unpleasant to teachers and making it difficult for the classroom learning to proceed. You do a school visit and discover things are just as bad as you were told. The teachers are at their wits end. The parent knows the nature of the problem and implores you to help by providing an official diagnosis: according to them the child has a disorder called ADHD and your help is needed. If you can test the child and affirm that yes, they do meet the criteria for ADHD, you can ensure necessary accommodations at school. The child is absolutely certain too, that they have ADHD. They feel like they are not in control of themselves, that they are not to blame for the trouble they are caught up in, that a "disorder" is the only possible explanation. 

You are uncomfortable. Yes the child meets the DSM criteria for ADHD, but you worry about this construal. You note that the child has recently had to deal with some life events which anyone would find emotionally disruptive (let's say a close relative recently died, or they moved school, or they are being bullied). You have a sense that if the family system was able to address this emotional disruption in some way (with help from a systemically inclined clinician for example), the "ADHD" might be substantially resolved. Further, you have worries about the use of the diagnosis ADHD. Sure you could oblige and diagnose, but you feel if you do that then the parent will be less inclined to view the child's problems in a way that might be helpful. In short, you feel it is incumbent upon you to try and discourage them from the explanatory framework (my child has a disorder) that they have adopted. This is not because you think they are straightforwardly wrong (you can see their point) but because you think their metaphor will encourage damaging courses of action like the prescription of avoidable stimulant drugs and the neglect of the child's emotional life. 

Here's another:

An individual you know lives in the community. They have suffered several episodes of disorganization and confusion before and these have tended to lead to dangerous and self destructive behaviour. At best the individual has had sustained periods of self-neglect. Now they are becoming disorganized again. You are worried about them. If they could be persuaded to allow themselves to be looked after (temporarily in a caring inpatient respite center you could refer them to) then they would be safe while they recovered. But although they are frightened they do not feel they need any extra care as there is nothing the matter. As far as they are concerned they are fine.

You disagree. You feel they are being overcome by some psychological change, that they are becoming unwell. You don't buy a "chemical imbalance" theory of their problems, but you can see they are not themselves, and the idea that they have succumbed to an illness would be a useful metaphor. You don't think they will always have this illness, nor be defined by this illness, but that characterisation seems a powerful way of accounting for the need they now have for extra care. 

What both of these stories have in common is a narrative brought to bear on them by the people whose lives they primarily concern. The acquiescent part of you wants to go along with these stories (they are the account that makes most sense to the person), but a concerned part of you does not. Let's not take away the easy way out; the optimistic proposal that you can always construct a joint understanding. In both these cases the person resists your interpretation, some degree of conflict is unavoidable. Even without saying the other person is "wrong", you are trying to give life to an explanatory framework which is at odds with their view of how their situation is functioning. In these cases, are you doing something beneficent or are you enacting a failure of mutual understanding? I would suggest the former. Helpful though it is to try and adopt language that "makes sense" to an individual, it won't always fit with our best image to how to help people.

New BPS Guidelines on Diagnostic Language are a Move Against Pluralism

(A commenter on this blog-see below- has pointed out that I did not include reference to the scope and purposes of the document I am writing about. To try and address their concerns I have edited the post, striking out some sentences and inserting a few new ones in blue.)

Something incomprehensible and unpleasant happens to a person. It behooves them to make sense of it. Into this vacuum of understanding steps language: an attempt to give form to an experience in a way that allows them to live with it.

The BPS's Division of Clinical Psychology has released new guidelines on the use of language in official documents which pertain to such circumstances.

Consisting of three principles (guiding on language to avoid and language to adopt)  It is a clear statement that illness-talk and disorder-talk are out:

Such guidance is on a clear continuum with other efforts to discard the language of disorder, and concerns the organisation has raised about the DSM, a manual which can itself be viewed as a hyper-regulatory set of guidelines about how to talk. 

I am all for questioning the language of the DSM. Naming people "disordered" or "ill" is often experienced by them as an insulting effacement of subjectivity. What is more, once illness-language gets into the pool of possible interpretations it seems to hand power to the only people with sufficient expertise to deal with illnesses, the healthcare professionals (who of course stand to gain from their status as knowers).

But there is calling into question and there is discouraging ruling out. The problem with an official language (the DSM is a dictionary rather than the "bible" it is often claimed to be) is that it sets up a seemingly "correct" and an "incorrect" way of talking. In some cases this is necessary (the much scorned "political correctness" is an appropriate effort to rule out ways of talking which offend minority groups in society), but there is always a trade off. The downside of being "PC" is that it can make people less considerate about their linguistic choices, while leaving them feeling righteous nonetheless. Think of the character Gareth in The Office, bemoaning the fact that his dad says "darkies, instead of coloureds"

This is one way in which the new BPS guidelines look to me like a misstep. Moving from "mental illness" to "mental distress" is superficial in itself. Language surely interacts with habits of thought, but a guideline like this just replaces one jargon with another.

The Turn Against Pluralism:

If this were my only complaint then I would lump it. We should be careful about language, and sometimes guidelines are the only way to do that. But the language of mental health is different from the language of race. There are racial terms so bound up with hate that officially discarding them is the only sensible choice. The same is not true of "illness", "OCD" and "Anxiety Disorder". 

We don't yet have the definitive account of who is and and who is not ill (defining illness turns out to be a dreadful philosophical tangle) so for all practical purposes there is no fact of the matter. One way of dealing with this uncertainty is to adopt a form of pluralism which allows for multiple frameworks for understanding. 

Some people see themselves as ill, others don't. Some people think of themselves as ill because they feel themselves to be ill. While not unproblematic, pluralism puts a person's experience at centre stage, affirming their chosen framework as a way to make sense of them. This is a principle I thought I saw affirmed in the "Understanding Psychosis" document released last November:

Plenty of first person accounts attest to the value of "illness-talk" (some of them in Understanding Psychosis itself), but the BPS has just discounted those experiences in a stroke. The approach adopted in the new guidelines is a solution that DSM-detractors have been descrying for decades. Rather than expand the repertoire of explanatory terms, this document shrinks it. Some language is good, some bad; some frameworks more correct than others. This works for people who are served by the new official language (those for whom "mental distress" is personal preference), but it alienates anyone who falls outside the charmed circle. Given how strongly the BPS has opposed the regulating languages of official psychiatry, I am astonished they have chosen this route. 

Election 2015: Those Pathetically Vague Mental Health Pledges in Full

I'm working on a longer post about the manifesto pledges that have been made on mental health. Manifestos are supposed to help people decide which party to vote for on the basis of concrete promises for which they could later be held to account. As I read through the different parties' mental health pledges I noticed that many of them were so vague as to amount to no promise at all. In this post I bring you the crappest and most hopeless mental health election pledges of 2015.

Conservative:

How's this for conjuring an empty promise out of thin air and giving it the veneer of credibility despite the total absence of any concrete objective? The Tories seem to suggest that there are not already therapists in "every part of the country", but this seems like a hard claim to defend. Do they mean in every town, in every borough, in every post code? Exactly which parts of the country have no therapists, and when can this promise be judged to have been fulfilled? The Tories here acknowledge that there could be more therapists, but without saying what they are committing themselves to precisely zero action on changing the status quo. Crafty!

Green

Perhaps because they have the least to lose (no-one anticipates a Green led government after May, sorry!) the Greens actually have the most concrete list of promises on offer. However, this one stood out. Which party is not going to "invest in dementia services", and in what sense will the Greens' offerings be different than anyone else's in terms of "support"?

Labour:

Let's get this clear, you're going to "encourage" social and emotional skills. How will you "encourage" them exactly? Billboards? A daily radio broadcast? This is a sentence comprised almost entirely of rather zeitgeisty hot-air with "mindfulness"crowbarred in as a very tokenistic buzzword.

Liberal Democrat:

The Liberal Democrats are going to get kudos for developing probably the most detailed plans on mental health (though it's a close race between them and the Greens), but this bullet point struck me as a little weird. First there is this idea of a "clear approach" which, in the absence of detail is actually anything but. Second, there is the notion of the well being equivalent of the "Five a Day" campaign. I have no idea what it is that one should do to improve mental resilience that is "the equivalent" of eating five pieces of fruit or veg. The Liberal Democrats clearly don't either. 

Another strikingly vague promise from the Lib Dems here. I can't argue with the sentiment , but neither can I tell you what it really means

UKIP:

UKIP win the competition for the greatest number of half arsed bullshit empty pledges.

What would the mental health world do without UKIP? In these two promises they affirm that people should be directed to mental health professionals "when appropriate" (begging the more interesting question of when UKIP feel it actually is appropriate) and that there is "often a link" between addiction and mental illness. Excuse me while I completely reconfigure everything I thought I knew about psychiatry! Why offer a specific policy formulation when you can have the half-baked wittering of some bloke in a pub?

Here's another half arsed thought:

Gee...thanks guys. UKIP seem to have heard of stigma but, unclear exactly what it means, they offer some vague handwaving around the issue, assuming apparently that it mainly has to do with not having a job. Feeble.

Book Review: A Prescription For Psychiatry

This month I have a review of Peter Kinderman's "A Prescription for Psychiatry" in the BJP. This post is a more extended version of the text published there.

      "Is the problem you're allergic

       To a well familiar name?
       Do you have a problem with this one
       If the results are the same?"

           -The White Stripes:

Girl You Have No Faith in Medicine

Battle-fatigued psychiatrists could be forgiven for wanting to steer clear of what looks like another attack on their profession. More waggish readers may wonder about responding with their own “formulation for clinical psychology”, and then there is the combative note. Does not the title seem to indicate a barely concealed desire to give psychiatrists a taste of their "own medicine"?

However, such aversion would be a tremendous shame, for while there is some familiar ground trodden here, there is also much that is new, positive, and well worth some serious thought. There is also an idea that is more audacious and direct than usually be found in books about psychiatry.

The book is made up of nine chapters, the first three of which occupy just over half the space. In this first half, more than in the second, there is a focus on criticism. The “disease model”, the use of diagnosis, and the role of medication are all subjected to scrutiny. Some of this ground is wearyingly familiar. On the subject of illness as opposed to “psychosocial problem”, we must ask whether Kinderman is giving full due to all the available evidence. The roles of trauma and of life events in schizophrenia are offered to raise our credence that this problem is best considered a psychological reaction. A major alternative theory, that some manifestations of this behavioural presentation may best be considered a developmental disorder, (after all, not everyone who meets the DSM criteria will have been abused or suffered other traumas) is not even mentioned, let alone appraised.

On diagnosis: It is quite right that psychiatry should face the shameful aspects of its history. The tremendous psychic damage wrought by pathologising homosexuality for decades, and the odious debacle of draetopmania are not to be lightly dismissed. However, given the intentions of the present book, Kinderman might have done more to explain why these despicable examples have a substantive bearing on the question of modern diagnostic practice in general. The DSM is a problematic and contested document, but while we should feel queasy about its politics and many of its categories (“Oppositional Defiant Disorder” gets a justified grilling), even the most sceptical clinician cannot shy away from asking whether we can as easily dissolve those two major categories “Schizophrenia” and “Bipolar Disorder”.

A superficially appealing argument raised here is that "abnormal psychology" is an unreasonable field of study; after all, we don't speak of "abnormal physics". There is an important idea here with which I find myself aligned. Using the word "abnormal" is indeed a needlessly unpleasant way of speaking about people, but the physics analogy doesn't fly. All physical phenomena are subject to the same basic laws (as far as we know), but that hasn't prevented the fruitful subdivision of their study into solid state physics, condensed matter physics, and so forth. When people have experiences of psychological distress, these tend to manifest in a propensity toward particular states of mind. Is it really so unreasonable to study these states in their specificity, cautiously categorising them until some better framework is offered?

Kinderman favours a dimensional approach to mental distress, and a recent international survey of psychiatric attitudes (Reed et al, 2011) suggest that close to half of psychiatrists could feel the same way. A more significant question is whether this is really inconsistent with a system of classification; unless mental health problems could somehow be incorporated on the same single dimension (as opposed to a psychotic spectrum, an affective spectrum etc.), there is no reason it should be.

The book is, in my relatively ill-informed view, sensibly skeptical on medication, suggesting (via Joanna Moncrieff) the adoption of a “drug centred” model, with prescription based on anticipated effects of a compound rather than the anticipated imbalances caused by a disease. Such caution seems laudatory, though there is an interesting debate about how to judge the risks and benefits of specific medications, and Kinderman prefers to leave this in the hands of others.

Those readers who get beyond the first half will find themselves on more interesting territory. Books that criticise psychiatry are common enough, but a considered and viable set of suggestions for improvement of the mental health system is much harder to come by. A number of the issues Kinderman raises are very important, and the book is good on linking its own position to the debates that are taking place within the profession of psychiatry itself. What is more, many of the suggestions made in the last six chapters are not dependent on his having won over the reader in the first three. Alzheimer’s is a brain disease, but that shouldn't rule out the provision of psychosocially oriented residential care for sufferers. Down’s Syndrome is a genetic disorder, but it would be extremely myopic not to provide care and support of an imaginative and holistic nature for this population.

Thus, regardless of his audience’s prior commitments on the nature of mental health problems, Kinderman is going to find much more agreement on the broad thrust of chapters 4 to 9. Many of these questions go well beyond a simple question of which profession is dominant and which intervention is the “correct” one. He is quite right to advocate a holistic approach to wellbeing, and his proposal for comfortable, decent residential care (“a place of safety”) over psychiatric hospital wards should be a public health priority. These latter can be traumatising and chaotic (not to mention expensive) places, and the “medical” context can place unnecessary limits on the nature of the care that is provided. Under Kinderman’s model, a new generation of local authority funded homes would provide safe, calm places for “respite” rather than “cure”. A suggestion that mental health nurses be renamed “psychosocial therapists” (on the grounds that “nurse” is overly medical) seems, to my mind, unnecessary given that the verb to nurse has thoroughly humanistic connotations.

Hanging over all this is the audacious idea referred to above. In "Our Necessary Shadow", Tom Burns doubted psychiatry would even exist without Schizophrenia and Bipolar Disorder. Kinderman's most radical conclusion pushes that logic to it's ultimate conclusion. In a chapter on promoting health, he suggests that psychiatrists add little value to mental health beyond a general medical consulting role. In his breathless (and well thought out) penultimate chapter he even insinuates that we could save considerable expenditure if our mental health system did without them altogether.

While it has often occurred to me that other professionals could perform many of the legal and leadership roles currently undertaken by psychiatrists, to argue they are entirely redundant relies on the acceptance of a conclusion that Kinderman has already taken for granted. Namely, that the field currently denoted by those two headline diagnoses is one devoid of anything resembling an illness or disorder. I am considerably more agnostic than Kinderman on this score, so while I have to credit him for such an invigorating interrogation of the “value added” of psychiatrists, I don’t think the argument has been won. Further, even if you do accept such a premise, the expertise required to distinguish "organic" psychiatric presentations from "functional" ones (yes this is something like a dualism, but it's really just a loose way of talking: think of the distinction between a drug induced psychosis and a psychosis whose causal factors are more diffuse) is not something psychologists are trained to develop.

This is a rip-roaring book; readable and broadly constructive. Like the broader debate of which it is a part, it succeeds where it is most surprising and lets down where it is most predictable.