In 'Doctoring the Mind: Is the Current Treatment of Madness Really Any Good?' Richard Bentall does not mince his words. Conventional psychiatry, he charges, has failed “because it has been profoundly unscientific and at the same time unsuccessful at helping some of the most distressed and vulnerable people in our society”. This charge is all the more startling given the much-heralded new approach to modern psychiatry at the end of the 20th century – mental illness finally understood as a genetically influenced disorder of brain chemistry that could be successfully treated by a new generation of drugs.
Bentall, a professor of clinical psychology, has form here. His previous book, Madness Explained, described the new picture of mental illness that has begun to emerge from a body of scientific research – a picture that is dramatically different from that found in conventional textbooks of psychiatry. The goal in his new book – “being shorter and (I hope) more accessible” – is to disseminate his ideas more widely. Shorter it is, but this book is not for the fainthearted. He marshals a formidable body of scientific findings in genetics, neuroscience and pharmacology. He tries explaining complex statistical concepts like meta analysis. But for those who really want to understand the basis of his charge against psychiatry, il vaut le voyage.
Over three chapters, he describes the history of modern psychiatry. It makes for dismal reading: more than a century of state asylums and extreme remedies, botched surgery, prefrontal leucotomy, insulin therapy and ECT. In the 1980s, the modern era of psychiatry was ushered in with the introduction of the new antipsychotic drug chlorpromazine. Although undoubtedly more humane than the earlier extreme remedies, the widespread use of drugs to treat mental illness, far from heralding a new era of successful treatment, has disappointed.
Bentall’s review of the psycho-pharmacological literature does indeed attest to the power of the newer generation of drugs, at least in the short-term. However, he goes on to excoriate the pharmaceutical industry for what he claims are systematic scientific distortions, or at the very least commercial hyping of drug trials, and the consistent neglect of the extremely unpleasant side-effects they have on patients. Between a quarter and a third do not benefit from any antipsychotic medication. Yet, such is the reliance on drug treatment that nowadays it is the most common treatment offered to those hospitalised with serious mental illness.
During the period of hospitalisation, the patient will typically be seen by the psychiatrist fairly infrequently, perhaps once a week for 10 minutes or so, during which time the patient’s symptoms will be assessed and the psychiatrist will determine whether the treatment is having the desired effect. The patient may also be offered some group or cognitive behavioural therapy but Bentall argues there is no serious attempt to fully understand the life history and circumstances of the patient that may be central to his or her difficulties.
HIS MORE FUNDAMENTALattack, however, is on the very central assumptions of psychiatry – what he calls the three myths about mental illness: that psychiatric diagnoses have meaning; that psychiatric disorders are genetic diseases; and that mental illnesses are brain diseases. He cites studies that show an alarming level of disagreement among psychiatrists in how they diagnose schizophrenia and bipolar disorder, despite using the most valid and reliable diagnostic systems available such as DSM-III. Poor reliability is not the only problem affecting the current diagnostic systems. Major epidemiological studies show that all psychiatric symptoms, includ- ing those of psychosis, are surprisingly common in the general population. Moreover, many patients meet the criteria for more than one psychiatric diagnosis. In other words, the diagnosis, which is the basis of the drug treatment chosen, does not reliably pick out discrete diseases after all.
The additional finding that antipsychotic drugs are useful not just in the treatment of those suffering from schizophrenia but also those diagnosed as suffering from bipolar disorder suggests that common biochemical processes may underlie these different diagnoses. In other words the diagnosis given to the patient may have virtually no implications at all when it comes to treatment.
Bentall also mounts a strong argument against the now widespread assumption that schizophrenia and bipolar disorder are primarily genetic conditions. He shows that the so-called heritability or h2 factoris one of the most misleading and most misunderstood statistics in the whole of psychiatric research and attacks what he calls “nakedly dishonest but often repeated statistical tricks” that have led to inflated estimates of the contribution of genes to mental illness. Citing modern and methodologically sophisticated studies, he concludes that the real picture is that genes play some role at some point in increasing the risk of mental illness, but nothing else. Bringing the effects of the environment back into the equation, he shows that factors such as sustained stress, trauma and early childhood influences can be reliably linked to particular symptoms of mental disorder. In short, he argues that “there is a long and incredibly complicated causal pathway running from the DNA we inherit from our parents to our behaviour in adulthood, and under these circumstances it is perhaps naive to imagine that there are genes ‘for’ any particular trait”.
He next turns his attention to studies that show a number of anatomical differences in the brains of patients suffering from mental illness, which he describes as the last line of defence of biological psychiatry. Although he concedes that it is hard not to be impressed by the mountain of findings showing structural brain differences in MRI scans of schizophrenic patients, he argues that many factors other than illness can affect the shape of the human brain, not least negative life experiences. For example, the brains of people who have survived sexual abuse in childhood, compared to the brains of other people, show structural changes in much the same regions of the brain that psychotic patients do.
The same set of problems affects the interpretation of neurochemical differences found in the brains of psychotic patients. Reviewing the studies in this area Bentall concludes that the overall picture provides no support, for example, for the widely-held notion that dopamine receptor abnormalities cause psychosis. Thus, the problem is not the differences but working out what these differences mean.
Despite the harshness of his criticisms, this is not a negative book. Bentall advances a positive and humane alternative to the current treatment regimes offered to those suffering from serious mental illness, an alternative based on solid scientific findings that show that the quality of the therapeutic relationship, the psychological alliance built between the patient and the therapist who treats him or her has a very significant effect not just on the patient’s symptoms and attitude towards treatment but also on a wide range of outcomes, including the patient’s quality of life, how much time is spent in hospital, the patient’s ability to function socially and his willingness to engage with psychiatric services.
This is a serious book and merits serious reading by all those who have a personal or professional interest in people who suffer from serious mental illness. Undoubtedly it will provoke controversy, if not fury, among psychiatrists, because they may disagree with his interpretation of scientific findings, but also perhaps because of the occasional professional sniping at psychiatrists which detracts somewhat from the cooler evaluative tone that generally characterises the book.
Let us be clear, however, that even if current psychiatric and psychological treatments for those suffering from serious mental illness vastly improved this would not be enough. Two years ago, the National Economic and Social Forum (NESF) published a report calling for an entirely different approach to treating mental illness, an approach that recognises that people who suffer from serious mental illness are among the most socially excluded in our society. The NESF called for a recovery model, one in which employers, trade unions, and community groups need to establish a strong partnership with the medical and psychological community to enable those suffering from serious mental illness a real opportunity for full participation in society.
Originally published in The Irish Times.
Posted: 18 July 2009