Review: Psychiatry: Madness Explained by Richard P Bentall
MADNESS EXPLAINED Psychosis and Human Nature by Richard P Bentall Allen Lane £25 pp640 Richard Bentall once wrote an article for a learned journal in which he proposed that happiness should be classified as a psychiatric disorder. It often leads to irrational and reckless behaviour, he pointed out; it is associated with abnormal activity in the right cerebral hemisphere of the brain, and people vary in their genetic predisposition to the condition. “Top Doc Talks Through His Hat”, said the Daily Star, and New Scientist magazine suggested he might make better use of his university salary.
People get angry with Prof Bentall. They are rude at his seminars; they fume at his conference presentations, and they tell him his ideas are dangerous — all of which he records with a disingenuous air of bemusement; the insouciance of the seasoned controversialist.
The point of this book is to stir things up. Its central contention is that the orthodox medical approach to understanding madness is deeply flawed. The classifications enshrined in textbooks and diagnostic manuals — schizophrenia, manic-depression, paranoia and so on — are meaningless (“There are no discrete mental illnesses”) and there is no clear boundary between mental health and illness. Too many psychiatrists adhere to a crude biological reductionism, assuming that the root causes of mental disorder are to be found in abnormalities of the brain, and downplaying influences in the social environment. Schizophrenia is one of the “myths of 20th-century medicine”.
Such language is reminiscent of the radical (and doomed) anti- psychiatry brigades of the 1960s and 1970s. But Bentall is careful to distance himself from the likes of R D Laing and Thomas Szasz, his charismatic, revolutionary forebears. Indeed, he points to a curious parallel between the anti-psychiatrists and their conservative adversaries. Both held fast to the simplistic belief that disease should be defined only in terms of faults in the biological machinery of the body.
From this premise, biological psychiatrists took the view that mental disorder was ultimately reducible to physical disease processes and that the discovery of some core brain pathology would eventually establish schizophrenia as a biomedical condition. For those in the opposing camp, the evident lack of such brain disease put madness beyond the biomedical sphere. In other words, both sides sought to resolve disputes by reference to biological data.
That the medical model prevailed was partly due to the intellectual flatulence of the anti-psychiatrists, and partly to what Bentall calls the “industrialisation” of psychiatry. Health insurance companies in America would not reimburse claimants for psychiatric treatments without a clear diagnosis, and the US Food and Drug Administration was requiring drug companies to be more specific about the disorders their new compounds were to treat.
Meanwhile, on the political front, gay-rights activists were lobbying the American Psychiatric Association for the removal of homosexuality from the list of “disorders” in its influential Diagnostic and Statistical Manual of Mental Disorders. One way and another the psychiatrists were under pressure to produce more reliable systems of classification and diagnosis. The resulting new edition of the diagnostic manual (DSM-III) placed psychiatry firmly within the biomedical camp and set the agenda for at least the next generation of psychiatric practice and research.
But, according to Bentall, the psychiatry/anti-psychiatry debate was profoundly misguided. The polarity of opinion on the nature and causes of madness — “biomedical disease” versus “psychosocial problems of living” — reflected a naivety about the relationship between biology and psychology. Like Szasz, Bentall is firmly opposed to the biomedical model, but he also takes issue with extreme social relativists who would deny the reality of madness.
Psychiatric symptoms (he prefers the less medical “complaints”) are essentially psychological phenomena — aberrations of feeling, cognition and behaviour. As such, they call for description and explanation in psychological terms. But psychology is a multi-faceted discipline. Mental life, aberrant or otherwise, is the product of biological and social forces — not one or the other.
Accordingly, psychiatric problems must be viewed from multiple perspectives, including the neurosciences, cognitive psychology, sociology and anthropology. Bentall acknowledges the influence of genetic factors and evidence for structural brain abnormalities in some psychotic individuals, but argues they are neither necessary nor sufficient for the expression of madness, and he seeks to accommodate such observations within a wider framework of explanation.
In Bentall’s view, there is no clear boundary between the sick and the well. While this feels plausible for conditions such as anxiety and depression, the suggestion that psychotic experiences run through the general population on a continuum from bland normality to florid schizophrenia has always met with resistance from psychiatrists. The received view is that psychotic symptoms, such as hearing voices or believing that thoughts are being inserted into one’s brain by alien forces, are by definition beyond the realm of ordinary experience.
Not so, says Bentall. In fact, otherwise well- adjusted individuals commonly report “schizotypal” experiences such as these. He cites a study of the “normal” population of Dunedin, New Zealand: “20.1% of the sample were recorded as having delusions . . . 12.6% were judged to be paranoid.”
Bentall cannot (and does not) claim originality for many of the ideas and arguments he presents. His key theoretical proposals — that distinctions between forms of psychosis are false, and that psychotic symptoms merge into the continuum of normal experience — have various historical precursors. George Engel anticipated his plea for a “joined-up” biological, psychological and social approach to psychiatry a quarter of a century ago.
Certain contemporary developments — in cognitive neuroscience, for example, and evolutionary psychiatry — might have received closer attention from Bentall, but Madness Explained remains an impressive survey of the field.
Towards the end of the book we learn that the author has encountered the consequences of severe mental distress on a personal as well as a professional level. His brother killed himself by leaping from the 14th floor of a tower block. He had drifted from his middle-class moorings into a life of drug-taking and unemployment. Prone to strange and magical beliefs, he complained of acid flashbacks and hallucinations, and once stated an ambition to absorb all the knowledge in the universe. Bentall’s brief, stark account of the tragedy is a touching reminder of the deep seriousness of the author’s intellectual mission.
Madness Explained is a substantial, yet highly accessible work. Full of insight and humanity, it deserves a wide readership.
Paul Broks’s Into the Silent Land is published by Atlantic at £14.99. Madness Explained is available at the Books Direct price of £20 plus £1.95 p&p on 0870 165 8585
Read on... websites: www.mentalhealth.org.uk Information on mental health problems and their treatment
Read on... books: Madness: A Brief History by Roy Porter (OUP £7.99) How perceptions of madness have altered radically through the centuries