Archive for April 3rd, 2017

Suffering is life.

(Thomas Szasz quoted by James Davies in Cracked – page 276)

I was walking back from town one day when my phone pinged. It was a message telling me my book was ready for collection from Waterstones. I was puzzled to begin with then the penny dropped. Just before my birthday someone spotted that I had scribbled, in my list of books to buy, the title of Cracked by James Davies.

I turned round and headed back to town again. When I picked up the book, for some reason I wasn’t impressed by its cover. Maybe the words ‘Mail on Sunday’ put me off, though Wilf Self’s comment helped to redress the balance.

Anyhow, for whatever reason, I didn’t get round to reading it until after I’d finished Rovelli’s Reality is not What it Seems. I’ll be doing a short review of that later, possibly.

Once I started Davies’s book I was hooked.

I’ve already shared on this blog a review of Bentall’s book Doctoring the Mind, which brilliantly, for me at least, brings the more grandiose pretentions of psychiatry back to the earth with a bump. I quoted Salley Vickers’ verdict:

Bentall’s thesis is that, for all the apparent advances in understanding psychiatric disorders, psychiatric treatment has done little to improve human welfare, because the scientific research which has led to the favouring of mind-altering drugs is, as he puts it, “fatally flawed”. He cites some startling evidence from the World Health Organisation that suggests patients suffering psychotic episodes in developing countries recover “better” than those from the industrialised world and the aim of the book is broadly to suggest why this might be so. . . .

I summarised my own view by praising ‘its rigorous analysis of the misleading inadequacy of psychiatry’s diagnostic system, its powerful and carefully argued exposure of the myths surrounding psychotropic medications and their supposed efficacy, and its moving description of the critical importance of positive relationships to recovery.’

The Davies book also covers much of this same ground and is equally compelling. What needs to be acknowledged is that he also takes the argument to another level towards the end of his book. He is concerned that we are exporting our Western model with all its flaws to country after country and goes on to explore other implications as well.

In the chapter dealing with the export issue he first summarises his case up to that point (page 258 – square brackets pull in additional points he has made elsewhere):

Western psychiatry has just too many fissures in the system to warrant its wholesale exportation, not just because psychiatric diagnostic manuals are more products of culture than science (chapter 2) [and have labelled as disorders many normal responses to experience], or because the efficacy of our drugs is far from encouraging (Chapter 4), or because behind Western psychiatry lie a variety of cultural assumptions about human nature and the role of suffering of often questionable validity and utility (Chapter 9), or because pharmaceutical marketing can’t be relied on to report the facts unadulterated and unadorned [and its influence has helped consolidate the stranglehold of diagnosis and a simplistic psychiatric approach] (Chapter 10), or finally because our exported practices may undermine successful local ways of managing distress. If there is any conclusion to which the chapters of this book should point, it is that we must think twice before confidently imparting to unsuspecting people around the globe our particular brand of biological psychiatry, our wholly negative views of suffering, our medicalisation of everyday life, and our fearfulness of any emotion that may bring us down.

I can’t emphasise too strongly the value of reading through the details of his treatment of all these other aspects. I am of course aware that physical medicine, even though there are biological markers for diseases in this sphere unlike in mental health, has not been exempt from the disingenuous manipulation of data and unscrupulous marketing methods practiced by the pharmaceutical industry, as Malcolm Kendrick’s book Doctoring Data eloquently testifies, but the scale of that abuse is dwarfed in the arena of mental health – and I mean arena in the fullest sense of that word: the battle here is damaging more ‘patients’ and costing even more lives.

Davies’s examination of exactly how this exportation of the psychiatric perspective is coming about is also disturbing and compelling reading. He adduces for example how skilfully drug companies have learned to read the reality of cultures into which they want to make inroads with their products, how effectively they target key figures in the prescribing hierarchy of professionals, and how astutely they now reach out to the public themselves so they will go to their doctors and request what the drug company is selling – all this to detriment of the many ways the social cohesion of the receiving culture has often (though not always, of course) been supporting those who are suffering from some form of emotional distress.

Where he takes his case next, in Chapter 10, I found both compelling and resonant. He is in tune with Bentall in seeing the importance of supportive relationships but, I think, explores that aspect somewhat more deeply.

He repeats basic points, to begin with (page 266):

What the evidence shows… is that what matters most in mental health care is not diagnosing problems and prescribing medication, but developing meaningful relationships with sufferers with the aim of cultivating insight into their problems, so the right interventions can be individually tailored to their needs. Sometimes this means giving meds, but more often it does not.

He then quotes research done by a psychiatrist he interviewed (page 267). Using two existing MH teams, Dr Sami Timimi set up a study comparing the results from two groups, one diagnostic, the usual approach, and the other non-diagnostic, where medication was given only sparingly, diagnosis was hardly used at all, and individual treatment plans were tailored to the person’s unique needs.’

In the non-diagnostic group the psychiatrist spent far more time exploring with his clients the context of their problems.

The results were clear (page 269):

Only 9 per cent of patients treated by the non-diagnostic approach continued needing treatment after two years, compared with 34 per cent of patients who were being treated via the medical model. Furthermore, only one person from the non-diagnostic group ended up having to be hospitalised, whereas over 15 people in the medical-model team were referred for inpatient hospital treatment. Finally, the non-diagnostic approach led to more people being discharged more quickly, and to the lowest patient ‘no-show’ rate out of all the mental health teams in the county.

Davies also interviewed Dr Peter Breggin, a US psychiatrist who is critical of the medical model. Breggin explained his viewpoint (page 279):

Most problems are created by the contexts in which people live and therefore require contextual not chemical solutions. ‘People who are breaking down are often like canaries in a mineshafts,’ explained Breggin. ‘They are a signal of a severe family issue.’ .  . . . For Breggin, because the medical model fails to take context seriously – whether the family or the wider social context – it overlooks the importance of understanding and managing context to help the person in distress.

Davies quotes Dr Pat Bracken as singing from the same hymn sheet (page 273):

We should start turning the paradigm round, start seeing the non-medical approach as the real work of psychiatry, rather than as incidental to the main thrust of the job, which is about diagnosing people and then getting them on the right drugs.

It’s where he goes next that I found most unexpected but most welcome to my heart. He leads into it with an interview with Thomas Sasz just before his death at the age of 92 (page 276). He asks Szasz, ‘why do we believe as a culture that suffering must be removed chemically rather than understood in many cases as a natural human phenomenon, and possibly something from which we can learn and grow if worked through productively?’

Szasz’s response is fascinating:

Our age has replaced a religious point of view with a pseudo-scientific point of view. . .   Now everything is explained in terms of molecules and atoms and brain scans. It is a reduction of the human being to a biological machine. We don’t have existential or religious or mental suffering any more. Instead we have brain disorders.

Davies summarises Szasz’s position on psychiatry (page 277): ‘It had become deluded in its belief that its physical technologies, its ECT machines and laboratory-manufactured molecules, could solve the deeper dilemmas of the soul, society and self.

Bracken’s view on this brings in capitalism (page 278):

What complicates things more is that we also live in a capitalist society, where there is always going to be someone trying to sell you something… In fact, some people would argue that capitalism can only continue by constantly making us dissatisfied with our lives.… You know, if everybody said I am very happy with my television, my car and everything else I’ve got, and I’m perfectly content with my lifestyle, the whole economy would come shattering down around our ears.

He continues (page 279):

What we customarily call mental illness is not always illness in the medical sense. It’s often a natural outcome of struggling to make our way in a world where the traditional guides, props and understandings are rapidly disappearing… Not all mental strife is therefore due to an internal malfunction but often to the outcome of living in a malfunctioning world. The solution is not yet more medicalisation, but an overhaul of our cultural beliefs, a reinfusing of life with spiritual, religious or humanistic meaning with emphasis on the essential involvement of community, and with whatever helps bring us greater direction, understanding, courage and purpose.

Unfortunately psychiatry, as with economics according to the writers of Econocracy, is failing to train psychiatrists in the adoption of a critical perspective on their own practice. So, he concludes, the pressure to change perspective has to come from outside the psychiatric system. He quotes Timimi again (page 285):

The things that get powerful institutions to change don’t usually come from inside those institutions. They usually come from outside. So anything that can put pressure on psychiatry as an institution to critique its concepts and reform its ways must surely be a good thing.

So, it’s down to us then. For me, promoting this book is a start. We all need to think, though, what else could be done, whether as a patient, a volunteer, a friend, a family member, an MP, a clinician or simply a citizen.

Currently, help is often tied to diagnosis. One psychiatrist quoted in this book is concerned that if categories of mental disorder are not confirmed as diseases, services will never be funded at the required level, the level, say, at which cancer services are funded. Surely, though, if opinion shifts to a tipping point not only the greater humanity of non-diagnostic treatments but also their relative cost effectiveness must carry the day in the end. But opinion will only shift sufficiently if we all play our part.

I know! I’ve got it.

You all could start by reading these two books. How about that?

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