By Richard Bentall (Allen Lane, £25)
Uniquely difficult among medical disciplines, psychiatry has the task of conceptualising, studying and treating illnesses for which there may never be any objective physical evidence. There is no blood test, no brain scan, no genetic profile that a doctor can use to identify even acute schizophrenia, let alone any of the more minor conditions. The only diagnostic materials psychiatrists have at their disposal are a patient's history, behaviour and language.
If psychiatric disorders are diseases at all, they are diseases of the mind rather than of the brain. This is what makes psychiatry so fascinating—and so confounding. For, in a profession with such a fragile diagnostic framework, there remains a very real possibility that its principal disease categories have been misconceived. No other orthodox medical discipline is so open to dispute at its very foundations. It's hard to imagine a meaningful movement of anti-oncologists, say, who deny the very notion of cancer. "Anti-psychiatry," however, is a serious minority activity.
Today, Richard Bentall stands out as the main purveyor of the anti-psychiatric tradition in Britain. This, his second book, is shorter and more accessible than his first, Madness Explained (2003), but it does very much the same job. It provides a workmanlike history of psychiatry—but is basically driven by an angry rejection of a profession whose model of the mind, he believes, is an excessively biological one.
Bentall's driving purpose is to condemn psychiatry as a tradition still in thrall to the ideas of Emil Kraepelin—a German psychiatrist who, in the late 19th century, sought to define a single disease of the brain that he claimed lay behind a variety of psychiatric symptoms. This disease, which Kraepelin dubbed dementia praecox, was later renamed schizophrenia.
The thrust of Bentall's argument is to characterise psychiatry as a narrow field now dominated by "neo-Kraepelinians" obsessed by the futile search for a physical test with which to explain the biological nature of mental illness. In the process, he provides some effective illustrations of the problems with which psychiatry is beset: the dilemmas of pharmacological treatments, the dubiousness of some of its trials, the merely cursory attention often paid to patient histories, the arbitrariness with which diagnoses can be applied. To anyone familiar with the routine problems of the profession, this is uncontroversial stuff. Where Bentall aims for something deeper, however, is in his attempt to undermine the most basic concepts on which modern psychiatric diagnoses are based.
To this end, he makes some nice observations about the way in which "co-morbidities"—conditions in which symptoms from one disorder seemingly appear in another—suggest that those symptoms may belong to a continuum of disorders rather than to distinct types of illness. He also effectively argues against the assumption implicit in much research that, behind psychological symptoms, there must lie a single biological cause. Yet this is slippery territory. Bentall himself believes that the causes of mental illness are chiefly circumstantial or psychological. Yet the history of psychological interventions is just as littered with accounts of arbitrary and distorted interpretations of patients' conditions as it is with stories of misapplied surgical, pharmacological or electrical treatments. Take the "recovered memory" movement of the 1990s, in which some therapists encouraged patients to "recover" memories of sexual abuse that hadn't actually occurred. Bentall is no quack of that sort. Nevertheless, he is credulous to assume that the psychological view is essentially benign while the biological is essentially oppressive.
But Bentall's most disfiguring assumption is that he is saying something radical. What is it that he wants in place of psychiatry? The solution he suggests is "a radical new approach to understanding severe mental illness, which brings together the evidence on the social, psychological and biological causes of psychosis." Most conventional psychiatrists would be bemused by this as a battle-cry. Far from battering down the walls of an ideological fortress, Bentall is frolicking in a large field of consensus. Much of the research he cites in favour of his arguments comes—without any sign of self-consciousness on his part—from the Institute of Psychiatry in London, a body that explicitly endorses the "bio-psycho-social" model. Similarly, many of the authorities he cites are psychiatrists themselves.
Bentall is himself a clinical psychologist. He is not opposed to notions of madness as such, or of its symptoms. He just doesn't believe they can be grouped into disease entities called schizophrenia or bipolar disorder. If, despite his hot rhetoric, this sounds like a suspiciously tepid proposition, the real test is what he proposes as an alternative system. And here, frankly, Bentall could do with a dose of his own caustic medicine. Alongside a model of treatment that would principally respect the "self-esteem" and "autonomy" of the patient, here is the nearest he gets to proposing causes for mental illness: "Insecure attachment and victimisation appear to contribute to paranoia, sudden trauma appears to cause hallucinations, and parental communication deviance has been implicated in thought disorder."
Leaving aside the psychobabbling sound of terms such as "parental communication deviance," his basic demand—for more research into psychological influences on mental disorders—is already being answered in spades. Cognitive psychology is one of the fastest-growing disciplines in the NHS, with official guidelines recommending its offshoot therapies for most mental disorders. To be fair, Bentall is interestingly sceptical of some cognitive research. But there is no big thesis here.
Psychiatry needs better critics than this. It also needs more powerful advocates: big minds able to cope with the great conceptual problems at stake. Here is a profession capable at its best of drawing together the social, psychological and biological sciences and bring them to bear on the toughest clinical front-line of them all, mental health—a realm where tragedies are played out daily and there is nothing so simple as a prognosis or a "cure." That's not a mistake of medicine, but a fact of life. Psychiatry addresses the most profound questions there are about the assumptions that underlie medical science—and there is a story yet to be told, not just about its cruelties and flaws, but also about its human truths and even, perhaps, its glories.
