Book Review: Psychiatry The Science of Lies

Reading this short book by Thomas Szasz is a real challenge. Each chapter contains half-a-dozen spring-loaded boxing gloves, which punch you on the nose as you read. That's what it felt like to have my assumptions and settled ideas about psychiatry and mental health challenged by Szasz. I had expected the attack on psychiatry, but was unprepared for his attack on patients as malingerers or the neo-liberalism that drives his approach to social reform.

The Szasz argument goes something like this: psychiatry is fake and has nothing to do with medicine. Mental illness does not exist, it is conjured into existence when a psychiatrist makes a diagnosis. So in psychiatry disease is the same thing as diagnosis. He suggests there is an unholy alliance between the state and psychiatry. The state has delegated to psychiatry the power to incarcerate individuals guilty of no crime. 

Here is Szasz in his introductory chapter, a passage that sums up his argument:

Because there are no objective methods for detecting the presence or establishing the absence of mental diseases, and because psychiatric diagnoses are stigmatizing labels with the potential for causing far-reaching personal injury to the stigmatized person, the "mental patient's' inability to prove his 'psychiatric innocence' makes psychiatry one of the dangers to liberty and responsibility in the modern world (3).

Later Szasz makes clear why psychiatric diagnoses are so damaging: 'Attributing a medical diagnosis to a healthy person does not transform him into a bodily-medically ill person, whereas attributing a psychiatric diagnosis to him does indeed transform him into a mentally-psychiatrically ill person' (15). 

If mental illness does not exist then Szasz must find a reason why so many individuals claim to be mentally ill. Szasz argues that individuals who claim to be mentally ill are in fact malingering. Szasz winds the clock back and shows us the Victorian consulting room. He says the patient arrives believing he or she is ill. The doctor must conclude that the patient is malingering or that he, the doctor, can find no disease. In the face of this unpalatable dilemma a third option emerges: the patient is mentally ill or, in the language of the time, suffering from hysteria: 'Thus arose the modern idea of mental illness, the product of the conflation of having a disease and occupying the sick role (voluntary or involuntary)' (23).

Szasz doesn't explore the 'role' of the patient much more than this. His book tends to get lost in the history of psychiatry and the wickedness of Sigmund Freud. It wages war on a number of unlikely subjects: Kay Redfield Jamison's bi-polar disorder is described as 'an alleged illness'; whilst the author, Lauren Slater, belongs on a 'list of "mad persons" using their madness to build successful careers as celebrity experts on madness' (100). Particular ire is reserved for the psychologist David Rosenhan who tricked the psychiatry establishment into admitting him and his colleagues into a dozen psychiatric hospitals despite having no symptoms of psychosis apart from a pretend 'auditory hallucination' - they told doctors that they repeatedly heard the word 'thud'. Szasz condemns Rosenhan's use of the word pseudo-patient arguing that Rosenhan was actually a real patient with a pseudo mental illness. Szazs thinks that Rosenhan had unwittingly supported the coercive system of mental health care rather than exposing it as prone to error..

If mental illness is a myth then I'm left wondering how Szasz understands the real fear and distress that people experience. There's no indication in this particular book. I see the feelings of distress that individuals experience as an understandable and legitimate reaction to stressful events.I don't see people experiencing psychosis as malingering, but as coping best they can with the circumstances of their lives. I imagine Szasz would say, 'fine' but let's not call it mental illness, and if an individual requires help let it be a be a private arrangement between the client and their chosen mental health professional, which has nothing to do with the state and it's coercive power.

This New American article, Critics Blast Big Psychiatry for Invented and Redefined Mental Illnesses, deploys the Szasz arguments against modern psychiatry and its revision of DSM-V. So Szasz is current and worth reading for his radical and alternative viewpoint, but I'm going to turn to his classic works rather than rely on this collection of essays.

Moral Compass Shifts as Roles Change

As I was going through my favourite blogs today and avoiding work, I came across this report in Psych Central News: Moral Compass Shifts as Roles Change. It describes research with individuals working  in a dual role; like army medics, for example, who perform the role of soldier and doctor. The subjects were tested to see if their moral decisions were influenced by their social roles. The results were affirmative: ask a guy about the sanctity of human life and he'll give different answer depending on whether he is thinking as a soldier or as a medic.

So the traditional belief, that moral integrity is a fixed character trait, seems rather inaccurate; actually our ethical thinking (and the decisions that follow) is influenced or even mediated by the social roles we are performing at the time. This reminds me of the famous Stanford Prison Experiment where mild mannered undergraduate students became brutal prison guards or recalcitrant prisoners within days of having those roles randomly assigned to them. By the way, there was a good article in the Stanford Magazine last year, celebrating the 40th anniversary of Zimbardo's famous experiment available here. 

So these two pieces of research answer the question I asked myself last month as I followed the Judge Rotenberg Center trial and blogged about it here. I had wondered if the staff at the Center, using aversive therapy, had left their morality at the door when they arrived for work. These two articles remind me that morality is not a fixed thing to be taken on and off like a coat, rather it shifts and changes with the roles we play and the environments in which we operate. Would a member of staff working at the Rotenberg Center apply electric shocks to the skin of their own defiant children? Probably not. But in the 'clinic', where aversion therapy is given legitimacy and moral authority, where it forms part of the individual's work role, then aversive therapy becomes an acceptable form of 'treatment'.

There must be thousands of similar institutions that have become detached and isolated from the norms of society - like that Scottish island in the 1973 film, The Wicker Man. As social norms change, as the tide of liberalism and tolerance advances, islands of traditional belief are left behind as craggy old outcrops - very much like Lesley Pilkington. It's why we need regulation, accountability, professional standards, openness, public scrutiny and democratic controls - because the culture within an institution and the role an individual performs, has such a powerful influence on the identity, morality and behaviour of the staff who work there.

Women Offenders and the Talking Therapies

In my nine years working for the National Probation Service I didn't have the opportunity to work with women offenders. I worked in a residential setting with high-risk male offenders; there were never any female residents staying with us. The other Approved Premises in Lancashire had four female beds at one time but they were rarely used and before I was employed that hostel also became male only. Just recently, a couple of years after I took voluntary redundancy, a regional facility opened in Preston: a female only residential unit for women offenders from across the North West. They employ women workers only, some of them are friends of mine. I don't know how the place is running but I can imagine it's challenging work.

According to the Centre for Mental Health (2011) and their briefing, Mental Health Care and the Criminal Justice System, as of August 2011 there are 4289 women in custody (out of a total prison population of 86,821). Women in prison are five times more likely to suffer from a mental health problem compared to the general female population. Women tend to serve short sentences, which do little to address their criminogenic needs, but often result in their children being taken into care, loss of employment and housing, and increased risk of further offending and worsening mental health. As a result of these poor outcomes, policy makers have asked for alternatives to prison for women. Maybe that has resulted in the opening of the residential unit for women offenders in Preston I mentioned earlier. Usually probation hostels take high-risk offenders on conditional release from prison. I'd be interested to know whether or not the facility in Preston performs a similar function or is it in fact a community based alternative to custody.

I'm writing about women offenders today because I've just read an article by Toby Chelms in CBT Today the magazine of the British Association for Behavioural and Cognitive Psychotherapies (BABCP). Chelms writes about his own experience at Leeds Counselling, where he says it's very difficult to reach women offenders with cognitive therapy. Let me provide a summary of the interesting things he says.

Chelms says that talking therapies for female offenders in Leeds have traditionally focused on counselling, an approach suited to the kind of 'wellbeing' issues that affect women offenders: domestic violence, sexual abuse and childhood abuse. In addition to these issues Chelms says women may also develop mental health problems whilst in prison or have pre-existing conditions made worse. He cites depression, panic disorder, obsessive compulsive disorder and agoraphobia. Chelms points to the high rates of depression and anxiety amongst the female prison population. It's easy to see why these conditions might be a response to the chronic stress of prison life; but it's worth mentioning that for some women prison may meet the basic physical and psychological needs more than the outside world.

Evidence based practice suggests and the National Institute for Clinical Excellence (NICE) recommend cognitive behavioural therapy for depression and anxiety. It would make sense, therefore, for female offenders to be referred (or to self-refer) to the Leeds IAPT service for free CBT for their depression and anxiety problems. 

Chelms makes the point that whilst CBT is advertised in local GP surgeries there is little done to promote the intervention in probation offices. This is a problem because on release from prison few women offenders are in touch with primary health services whilst most of them are in touch with the National Probation Service. In fact the problem is a little more deeply rooted than this. Reading Psychological Therapies in Prisons and Other Secure Settings (reviewed here) it's clear that problems exist with the way that mental health services in prison communicate with mental health services in the community and that referrals, joined up work and hand-overs just aren't happening. That female offenders are not accessing primary care services is a systemic failure that points to their marginalised status and contributes to their social exclusion.

To Chelm's credit he has tackled this particular issue in a number of ways. First of all by promoting his IAPT service (and other mental health services) within and outside prisons, distributing a 'directory of mental health services' to the probation service. Secondly, he has recognised the importance of female friendly spaces when promoting mental health services to women. He refers to the Corston Report (2007) which recommends female-only environments, arguing that: 

'By encouraging women to feel physically and emotionally safe, less marginalised, and therefore more able to feel confident and express themselves in a way which is needed for progress, female-only environments would in turn lead to higher attendance and engagement levels, while increasing access to support and rehabilitation'.

In my own area there are two very good Women's Centres in Accrington and Blackburn, which offer a range of interventions, including low intensity and high intensity IAPT work; as well as counselling, support groups, employment advice and family interventions. It seems like a good model, 'women friendly' and a range of services under one roof so that a package of support can be tailor made for each woman. Now GPs and the Probation Service are referring clients directly and these two Women's Centres, under the leadership of my friend, Sarah Swindley, have become important service providers for women and families in East Lancashire.

Chelm's third intervention to broaden participation amongst women offenders was to set up a pilot project at the Together Women's Project in Leeds. Promoting the service to the probation service generated nine referrals. Of those nine referrals, all attended and were assessed as suitable for talking therapies. But of those only one went on to attend CBT sessions. Clearly it's not enough for women offenders to be aware of services, those services must be accessible; but even then other priorities take over and motivation shifts to basic needs and coping.

DVD Review: Rollo May and Existential Psychotherapy

This is a busy time of year for me. The courses I'm teaching come to an end, the assignments flood in and the marking begins. It's great to be able to give feedback and reward my students' hard work, learning and development with medals and missions; but marking is a time consuming business and results in numerous late nights and early mornings ... well, late nights mainly.

The last book I finished was Yalom's latest, but that was several weeks ago and I haven't started another yet. When I've a lot of work on I can't concentrate sufficiently to read and enjoy a book. Instead I tend to spend a lot of time flitting round the Internet: from Twitter to Facebook, to email and back to Twitter again. I learnt yesterday, from an article published by Science Daily, that this is indicative of depression. I'm not depressed, just suffering from a little bit of stress. In fact the research described in the Science Daily article makes a bit of a leap when it says flitting around the Web indicates an inability to concentrate and that indicates depression - I go with the first conclusion but hesitate at the second. 

So, unable or unwilling to dedicate time to reading I have hit upon a clever alternative. Several months ago I noticed that Psychotherapy.net DVDs were available for purchase on Amazon. I've bought them before, from the USA, and been slugged with a £28 import tax, so seeing them on Amazon and available in the UK was a pleasant discovery and flicked the 'buy me' switch in my mind - at this point imagine a railway line, a clanging bell and a locomotive carrying hard-earned cash towards Amazon INC's company HQ.

Despite the expense, watching DVDs of expert therapists working with actor/clients is great learning and very satisfying. I've recently watched Gestalt Therapy with a difficult to engage client and brief psychodynamic therapy with an elderly depressed client. My latest is an interview about existential psychotherapy with Yalom's own therapist, the existential psychotherapist and author, Rollo May. 

The sound and picture quality on the Rollo May DVD is pretty poor. It was made in the '80s on VHS - or possibly a machine that has a revolving foil drum. There is one camera, which pans around the participants when it might have more fruitfully remained exclusively on Rollo May. The participants are dressed for the1980s, early 1980s, when the moustache enjoyed a final blaze of popularity before its final death rattle and demise everywhere but Northern Ireland. 

The video has the flavour of the '80s for other reasons too. May constantly repeats his opinion that other therapies are 'gimmicks' - gimmicks in comparison to the therapy he practices, the therapy of Freud and Jung. Indeed he doesn't recognise short-term problem-focused therapy as psychotherapy at all. 

Remember that this is the time when managed care became popular and funding shifted from long-term psychoanalysis to short-term interventions and in particular Cognitive Behaviour Therapy (CBT). On reflection Rollo May seems rather zealous and intolerant of other therapies. We have come to accept the existence of a multitude of brief, outcome orientated or problem focused approaches.  For May they are quick fixes (gimmicks) whilst true therapy is a philosophical and mythological endeavour, an exploration of how to live the good life. I can sympathise with this, it treats seriously our existential concerns, but I see nothing wrong with helping clients to solve problems or reduce the symptoms of trauma and distress. May believes, with some justification, that these remedies are short-term and that symptoms return. Indeed symptoms tell us that all is not well, that we need to attend to the existential roots of our distress. 

There is no way to settle this dispute except to say that watching the DVD crystallised the problem for me at a time when I wasn't able to concentrate on reading any of the Rollo May books I have just bought for Summer reading ... from Amazon INC.

Book Review: The Spinoza Problem by Irvin Yalom

I've already blogged about my admiration for the psychotherapist and author Irvin Yalom. I've also mentioned how much I've been looking forward to reading his latest novel, The Spinoza Problem. So I was delighted when it dropped on to the doormat in its Amazon package and I set aside three days over Easter, dedicated to reading the book.

Yalom always writes a fascinating book. In When Nietschze Wept he imagined a curious scenario where the German existentialist philosopher Friedrich Nietschze seeks help from the father of psychoanalysis, Sigmund Freud. In the Schopenhauer Cure a follower of the pessimistic philosopher, Arthur Schopenhauer, attends a therapy group. Philosophy in novel situations is a Yalom speciality.

In his latest book it's the thought and attitude of Baruch Spinoza that provides Yalom with the philosophical tool bag he requires to meditate on such issues as religious belief, community, belonging and the nature of evil. On a more personal level Yalom also reflects on what it means to be Jewish and what it means to stand outside the religious beliefs of one's culture and community.

The book is a double narrative. We read about the life and thought of free-thinking philosopher Baruch  Spinoza and his excommunication from the Dutch Jewish community in the late Seventeenth Century;. This alternates with the life and thought of Nazi philosopher Alfred Rosenberg in 1930s Germany. 

So the Spinoza Problem exists on a number of levels. For Jewish leaders in Seventeenth Century Holland the problem is Spinoza's heresy, his critique of Jewish dogma. For Spinoza the problem is a personal dilemma: to accept the religious dogma of ones community and continue enjoying the benefits of fellowship or follow ones conscience and pursue knowledge and truth wherever it leads. For Rosenberg the Spinoza Problem is a problem for a Nazi bigot: how to reconcile the fact that the greatest of German writers, Goethe, admired the Jewish philosopher Spinoza.

Spinoza lived the life of a thinker - grinding lenses and writing philosophy. Rosenberg was an anti-Semitic  idealogue, besotted with Hitler and totally committed to the Nazi Party. They have nothing in common, but Yalom's alternating double narrative means that each is seen in the light of the other. So, for example, Rosenberg's pathological need to be well-regarded by Hitler and the Nazi leadership is contrasted with the heroic truth-seeking of Spinoza: his stoical acceptance of excommunication and internal exile. In Yalom's book Rosenberg sees a psychotherapist, so we are treated to the fantasy of Irvin Yalom treating the Nazi philosopher for depression! The book ends rather randomly and an epilogue completes the two narratives. I don't think this book is as satisfying as Yalom's previous novels, but it is nonetheless a thoughtful and thought provoking read.