Kendall - Social psychosis

DR TIM KENDALL attacks psychiatry’s tendency to stigmatise mental health patients, and proposes a more pragmatic approach

In spite of the deeply romantic view of the mentally disordered being the only people to ”see the world as it really is”, there is no underestimating the utter strangeness and devastating nature of madness or ”psychosis”; in fact Euripides may have had it right when he said that ”sanity is a pain but madness is a vile thing”.

As a psychiatrist I have to subscribe to a non-romantic view of mental disorder, but that does not mean that I do not constantly question the often dehumanising aspects of confronting and attempting to treat psychosis, and how psychiatry itself can perpetuate stigma and influence how mental illness is perceived. To discuss this I have restricted most of this article to addressing the psychoses (characterised by delusions and hallucinations); although similar, but more subtle arguments could apply to many less distinct or severe forms of mental illness.

One of my patients who made a long-lasting impression on me is ”Horace” (now deceased). I first met him when I assessed him for compulsory admission 20 years ago. Although he had probably always been mentally ill, it was only when he retired that he was diagnosed with schizophrenia. Horace told me that he had woken up some five years before to “‘find” that the CIA had implanted two electronic bugs, one in each ear, using glue. These bugs meant that he now received brainwaves through the ether, and the CIA could suck out his thoughts.

Although Horace was quite happy to talk to me, he didn’t really need a psychiatrist (why would he?); he really needed a surgeon who could undo what the CIA had done. With two policemen and a social worker present, Horace quietly told me that they were also trying to make him do things to himself; one of which was to kill himself (he had no intention of doing such a thing – he didn’t approve). The other was to masturbate. And this, he knew was down to the CIA as sometimes he had allowed them to force this upon him, and when they had, he was made to use his left hand to do so, a hand he would never have used if he had chosen to do it to himself.

Horace was the product of his mother being raped in about 1929. He knew she was ashamed and, under the influence of her father, sought out a husband quickly after the birth. The family grew and Horace became known as “the bastard”. The man his mother married was violent to both her and Horace; and as she became depressed in Horace’s early childhood, the guilt Horace felt led to his only suicide attempt at the age of five (by drinking bleach).

Horace left home at 15, got a job on a crane for the rest of his working life, following the same routine each day. He shared a couple of drinks with some acquaintances after work, but these relationships never developed into anything meaningful; in fact neither he nor they knew each other’s surnames. He had never had a sexual relationship and never saw his family again from 16 years-of-age onwards, despite living in the same town all his adult life. When he died the only people at his funeral were a social worker and me.

Horace’s story tells us something about the strangeness of psychosis (this led to the view, most famously proposed by the existential philosopher and psychiatric phenomenologist, Karl Jaspers, that psychosis is fundamentally different from ordinary human experience, in that, as the sane person – the psychiatrist – you cannot imagine yourself in the other person’s shoes) but also about the way in which people with a mental illness can drift into a life that disconnects and alienates them from other people and stigmatises them.

Mental health problems are largely unseen or invisible, and therefore often ”unknowable” because they affect the ”interior” of our being, the hidden and most deeply subjective aspects of our lives. And there is nothing more fundamentally human than the outpourings of a person suffering a psychotic breakdown or in the throes of a severe depression, when their disorder brings them closer to the deeper human experiences such as dreams, mourning, envy, fear and self-loathing. It is as if, by succumbing to a mental illness, a person sheds the layers that hide these inner workings and stands shamefully naked, exposing the interiority of their soul.

Psychiatry and other scientific fields have ways of explaining and/or ”understanding” Horace. Had he been born in the 19th century he may have come under the purview of the French physician Bénédict-Augustin Morel and his followers, who subscribed to a view of mental illness as a sign of degeneration, and first introduced the term ”dementia praecox” (which later became ”schizophrenia”). At the turn of the century Emil Kraeplin characterised the symptoms and signs and chartered the natural history of dementia praecox.

Those so diagnosed were believed to suffer an inevitable deterioration, from being a recognisable person with an integrated personality and capable of communication and affection, towards chronic hallucination and delusion, erosion of the personality and inevitable personal and social decline. Kraeplin compared this with manic depressive insanity which, unlike dementia praecox, was an intermittent psychosis involving delusions, significant mood changes and preservation of the personality, at least between episodes. By the early-to-mid 20th century, dementia praecox had mutated, expanding its boundaries and transforming itself into schizophrenia under the influence of Eugene Bleuler. The diagnostic category of schizophrenia captured ten times more people than its predecessor diagnosis, but there was no real improvement in prognostication. Indeed, many people so diagnosed were either sent home, effectively with a death sentence, or dispatched to an asylum, never to return.

On the other hand, Freud would have had a different view of Horace; he may have focussed on the guilt that Horace felt over his mother’s depression and his early suicide attempt. Moreover, psychoanalysis might posit Horace’s repressed and deeply unacceptable homosexual needs and orientation (are the CIA employees who are making him masturbate all male?) as the cause of his psychosis. A more contemporary view comes from ”biological psychiatry” – essentially reducible to the question “how has Horace’s brain malfunctioned?” In the world of biological psychiatry, Horace’s psychosis is fundamentally the result of faulty genes, mediated through abnormal neurotransmitters and receptors, and recordable through brain imaging.

These theories have been critiqued by the ”anti-psychiatry” movement. For R. D. Laing and David Cooper mental illness did not exist; instead it was invented by psychiatrists as part of the repressive apparatus of the capitalist state that valued only productivity, order and profit. The psychiatric patient was really a person in transition, going from the ontologically strangled state of a conforming individual in modern family life under capitalism, and through a voyage of self-discovery (psychosis) they rediscovered their inner selves, previously petrified and hidden from them through an excessive identification with a false outer self. The repressive psychiatric response is to repress the psychosis through the use of antipsychotic drugs and restricted freedoms.

Now although this may at times be a fair reflection of the constraining nature of some psychiatric responses, the followers of anti-psychiatry misunderstand the nature of power as fundamentally in opposition to freedom. To the degree that a person is free to act precisely reflects the extent to which another can bring influence to bear upon the actions they may chose. It is not that power is inherently ”bad” and repressive. Power, as distinct from a relationship of physical restraint, hinges upon freedom and is, as such, always potentially productive. I don’t doubt that power, as exercised by psychiatry, often aims to produce docile subjects; I am suggesting that the ethical use of power in mental health should always aim towards productivity. The important issue is not that power is exercised; it is how it is exercised. Making schizophrenia disappear and blaming the family, the state and psychiatrists seems to avoid rather confront these issues.

All of the theories espoused, whether biological, psychological or socio-political, generate a new discourse about Horace which attempts to impose reason upon madness. This raises fundamental questions about how can we grasp ”unreason” and madness through reason. In L’histoire de la folie, the historian and philosopher Michel Foucault posited that the history of psychiatry and insanity was ”a monologue of reason about madness”, a monologue in which unreason had, through the agency of medicine and psychiatry, been rendered silent, an empty category. The mad had once been seen, inversely, as full of potential wisdom, certainly enough to interest King Lear and persuade him to swap his crown for the cap and bells. But madness finally succumbed to medicine in the late 19th and early 20th centuries as an illness defined purely by the contentless form of experience, and in this case an illness with no cure. Madness, and now mental illness, becomes the perfect empty canvas upon which 19th and 20th century societies have projected their own deepest fears of an uncontrollable and uncontainable unreason – the unbounded root, I would argue, of the inevitable stigma that psychiatry gives to its patients.

We therefore have to accept that psychiatry takes some of the humanity away from the person with a mental illness, and leaves in its place a fearful stigma. And precisely because of this, it is also the moral responsibility of psychiatrists to address this issue pragmatically and ethically with minimal theorisation but sustained dialogue and partnership with the patient about what works for them, preferably on their terms.

We are only just beginning to do this systematically, for example through the widespread development of new approaches and teams that have broad applicability to help prevent admission for people with psychoses, such as crisis resolution and home treatment; and focusing upon how we can best help people with mental health problems get back to work through supported employment schemes – or giving service users under the Mental Health Act greater choice through advance directives. More recently, the evidence that some talking treatments have widespread efficacy and applicability and are generally desired by patients is, perhaps, our most recent step towards a more pragmatic and ethical approach to people with mental health problems.

Being concerned with what works, for whom it works and what “works” actually means;; being concerned with the ordinary fabric of people’s existence, such as work, homes and physical health; being concerned with preserving choice and freedom, even in the context of restricted liberties under the Mental Health Act – all these things may seem prosaic and undoubtedly lack the magic of discovering a cure or finding the secret wisdom within madness. They are, nevertheless, important steps to restoring a fractured dialogue and hearing more clearly the voices of those silenced by our objectifying monologue and the stigma we generate. For a pragmatic psychiatry at least, what’s important is not so much our differences, but the ordinary lives we share.

Dr Tim Kendall’s current posts include joint-director of the National Collaborating Centre for Mental Health and deputy director of the Royal College of Psychiatrists Research Unit. He was previously founding director of the Centre for Psychotherapeutic Studies at the University of Sheffield (1992-1998) and set up the world’s first Masters programme in psychiatry, philosophy and society. He is also currently the medical director of Sheffield Care Trust and still practices as a consultant psychiatrist.

Dr Clare Taylor contributed to the writing of this article. Dr Taylor is editor at the National Collaborating Centre for Mental Health.