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.

Book Review: What is Madness by Darian Leader

I’ve just finished reading Darian Leader’s latest book, What is Madness? It’s an absorbing read – sometimes difficult – but ultimately, fascinating and humane. Leader explains the roots of psychosis using the psychoanalytic theories of Jacques Lacan and at times the explanations seem rather more complex that the phenomena being explained. The discussion of Lacan’s client, “Aimee”, for example, is labyrinthine in its use of competing psychoanalytic explanations for her psychosis and behaviour. That's why I appreciated Leader's comment that, "A psychoanalytic theory of psychosis does not imply a psychoanalysis of psychotic subjects" (294). Indeed Leader points out that individuals experiencing psychosis are suffering from too much meaning and do not benefit from the interpretations of therapists.

The book opens with a chapter entitled, “Quiet Madness” in which Leader draws our attention to a mistake commonly made in conversations about psychosis. According to Leader it is wrongly assumed that madness and the visible symptoms of madness are the same thing. For Leader the symptoms of madness - hallucinations, paranoia, delusions - are the individual’s attempt to make sense of the horror that has befallen him or her: ‘responses to madness, attempts at self-cure’ (17). This is a fascinating insight and extends my own belief that emotional disorders such as depression or anxiety are perfectly functional when seen in the context of the individual's history and current experience. This realisation ought to guide the therapists approach. Attempts to remove the symptoms of psychosis without helping the patient to explore their condition may well interfere in the process of self-healing. As Leader says, medication is useful because it tempers the intensity of psychotic symptoms but should also serve as a 'platform for dialogue'.

Leader emphasises the importance of symbolism and language when explaining madness. He sees madness as a breakdown in these structures, resulting in a terrifying loss of meaning and a disconnection from reality. In response to this the individual cobbles together what he can to make sense of his experience. This may show itself as paranoia or other delusions. The individual may believe he or she has been abducted by aliens if this restores meaning and makes sense of a catastrophic event. Psychotic individuals (and psychoanalysts?) cling to the most unlikely ideas in their attempt to make sense of the world.

In what Leader calls, “Quiet Madness”, the individual may appear balanced, keeping his delusional world under wraps and thereby achieving the semblance of normality. In an interesting chapter, Leader suggests that the serial killer, Harold Shipman, is an example of “Quiet Madness”. To his patients and colleagues he appeared to be a professional, kind and diligent doctor; but it was this role that enabled Shipman to stabilise his madness, part of which involved the murder of hundreds of patients.

Leader argues that quiet madness can erupt into full blown psychosis through various trigger events, often associated with rites of passage. Marriage, divorce or having a book published, all have the potential to trigger psychosis: moving the individual from ‘being mad’ to ‘going mad’. Events have this potential because they require from the individual a new set of symbols, and if the individual cannot symbolise this transformation they are at risk of becoming psychotic. Leader spends several chapters exploring this process so my summary here is incredibly superficial.

The final chapter of this complex book suggests ways of working with psychosis. Following his hero, Jacques Lacan, the author uses the metaphor of the secretary - to quote Lacan, the therapist ought to be, “the secretary of the alienated subject” (305). Leader likes this description, likening the therapist to a secretary who faithfully records, asks for clarifications and doesn’t intrude too much (305). The therapist as secretary helps the client to build a personal history, helps the individual to explore their own frame of reference and thereby helps in the work of self-healing. Leader is honest about the amount of time, hard work and commitment required to work with clients experiencing psychosis. He is hostile to therapies that seek to return clients to “normal” and measure success by how far their clients have adapted to social and community norms. Instead Leader suggests that an “investment in dialogue and a curiosity about the logic of that person’s world can open up new therapeutic directions and offer the possibility of change. Therapy can do no more and no less here than to help the psychotic subject do what they have been trying to do all their lives: create a safe space in which to live” (330).

Leader, D. (2011) What is Madness? London, Hamish Hamilton

The Lobotomists on BBC Radio Four

I have just listened to an excellent BBC radio programme on the history of the Lobotomy. Hugh Levinson, the producer and presenter, has written a BBC News article about the programme here.

The programme was about the short lived idea that patients living with mental illness could be cured if only the connections between the frontal lobes and the rest of the brain could be severed. The operation (called a Leucotomy in Britain) involved drilling holes into the patient's skull just behind the eye sockets and below the temples, and then inserting a long spike, like an overly long ice-pick, into the brain to make cuts behind the frontal lobes. One commentator observed that the procedure contradicts the standard medical view that cutting healthy tissue tends to make things worse not better.

The programme featured three famous exponents of the procedure: Egas Moniz in Portugal, Walter Freeman in the States and Sir Wylie McKissock in the UK.

The Lobotomy was popular throughout the 1940s and into the '50s. The programme estimated, for example, that within that short period Sir Wylie McKissock carried out 3000 lobotomies. He would even tour provincial hospitals at the weekends operating on patients. Freeman also was an advocate of the procedure, even making a movie to advertise the benefits of the operation.

Shockingly there was no research done into the procedure and no follow up investigations to see how patients recovered after surgery. The Lobotomists convinced themselves that about a third of patients were helped by the surgery whilst the rest were no worse for it. There was no evidence for this and in fact many patients suffered catastrophic harm as a result of the treatment. With the discovery of anti-psychotic medication in the 1950s the practice faded. The history of medicine is full of such horrors.