This post links intimately with The Standardization of Psychiatry – you might even call it A Necessary Shadow. Standardization was a lecture on psychiatry given in the Royal Society of Medicine on October 5. To find out what’s going on you need to read the Back Story to Standardization.
Back in 2013, I was asked to review Necessary Shadow and Strictly Bipolar by Literary Review.
These reviews map surprisingly well onto Standardization – 8 years later. The lecture drew a possibly predictable reaction from Tom Burns recently as perhaps the review did 8 years ago. Darian Leader’s book is included here because both books were part of the same review and teasing these twins apart would not easy. Despite differing superficially, they have a lot in common.
Our Necessary Shadow. The Nature and Meaning of Psychiatry.
Tom Burns and Darian Leader are both engaging men. Reading either of these books, and both are an easy read, you think a transatlantic plane flight or longer journey would fly past effortlessly in their company. Both know a lot about that most fascinating of things – what makes us tick. Both are well versed in the academic theories about why we do what we do but wear their knowledge lightly. Both have a fund of stories about people they have treated and the extraordinary things that have happened to them, but remain relatively modest in what they offer the rest of us by way of options.
It’s the modesty that leaves you hoping that if things go wrong, if you have a mental breakdown, all would go well if you saw one of them. It also leaves you thinking that whatever about the local mental health service difficulties we hear about from time to time, if there are people as reasonable as this running the services things surely cannot be too bad.
But here’s the problem – the books are engaging, and their authors likely are too, but mental illness is a lot less accommodating.
Tom Burns concedes that there will inevitably and always be difficulties with psychiatry given that it has a police function and is called on to intervene when we pose a threat to ourselves and others. This gives psychiatry powers that sit uncomfortably with any ideas of feeling good about ourselves. Darian Leader finds it a little harder to see that there might be a comparable problem with psychoanalysis. But there is.
Whatever about the difficulties we hear with community care, Burns tells us, there cannot be any going back to the asylums. But, here’s the rub, if you have schizophrenia now you are 10 times more likely to be dead at the end of your first year of treatment than if you had been admitted to one of the old asylums 100 years ago. There is an explosion in the number of people who have bipolar disorder compared with 100 years ago but despite a raft of mood-stabilizing medications, people are likely to have many more admissions to hospital now than 100 years ago.
There are other areas of healthcare where medical care seems to be going backwards in comparable ways rather than forward – diabetes care for example – but the data on mental illness are starker than anything else. The problem is you’d never guess it from either of these books.
It would probably horrify both Tom and Darian to find themselves described as part of Pharma’s distribution channel, but they are. Fuller Torrey memorably described the role of psychotherapists and others in modern psychiatry as the straight man in a burlesque show. Those running the show know you need to give the punters a little let up from time to time. Social psychiatrists and psychotherapists fill this role at present.
Darian Leader tells wonderful stories about colourful people he has seen but how many of them have manic-depressive illness? He has no way of knowing and nor do we. Stephen Fry is cited heavily but this is someone who has portrayed himself as bipolar disorder rather than someone who bears the classic stigmata of manic-depression – hospital admissions and suicide attempts.
It’s almost unquestionably the case that significant numbers of us with neuroses of various sorts or what was once called borderline personality disorder by the analysts are now being called bipolar disorder, or are calling ourselves bipolars, or will be attracted to do so by Darian Leader’s book. Converting these softer disorders into bipolar disorder is a one way ticket to mood-stabilizers. Today psychotherapists are among the biggest advocates of antidepressants for their patients who just don’t seem to improve – tomorrow it will be mood stabilizers. And all without a pharmaceutical company having to spend a penny.
Darien Leader does the splits over the role of drug companies. He notes that the current rise to prominence of bipolar diagnoses is closely linked to company marketing efforts but he then goes on to wonder whether our current bipolar culture is responsible for the popularity of bipolar disorder rather than company marketing efforts. Companies love statements like this
In contrast, Tom Burns notes that one of the significant influences on him was Andy Scull who’s Museums of Madness in 1979 and later books have done so much to draw attention to the way vested interests, yesterday the medical complex today the pharmaceutical companies, manufacture mental illness.
But Scull’s work also triggered a vigorous debate about the origins of mental illness – there are no descriptions of schizophrenia before 1800. What’s going on? The critics of psychiatry use this fact to claim that mental illnesses aren’t real, when in fact real illnesses rise and fall – as tuberculosis did and lung cancer in men is now doing. Schizophrenia rose through the 19th century. Could schizophrenia vanish? There are claims it is disappearing now. If it vanished, would it take psychiatry with it? Not a chance. Under the guise of managing risks to self and others, psychiatry is being deployed ever more widely. There is little hint of any of this in Tom’s book.
There is however a certain grace and wistfulness in Our Necessary Shadow when Burns recounts his early advocacy of community treatment orders (CTOs), later involvement in a controlled trial showing they do not produce the hoped for benefits, and final concession that this trial has not and is unlikely to lead to the abandoning of CTOs. This is a book that will make any psychiatrists who have been practicing for some time feel comfortable with themselves. They will likely recommend it to their juniors on this basis. It may find an even wider audience among other mental health professionals for the same reasons. But it is less likely that anyone outside the business or anyone who is one of the businesses clients or consumers will be engaged. .
A common feature of both books is they are heavily British in their focus. On the plane flight to the US, its fellow Brits rather than Americans who would be engaged. Americans, Germans and French would read these books for what they say about the British rather than what they say about mental illness.
Another common feature is a lack of references. This makes for easier reading but will annoy some readers who might want to engage with some of the points in greater detail – “listeners” who rather than sitting through the plane flight entranced might want to take issue with some of the points..
He’s Not Here to Answer Questions
At the end of the Standardization talk, there was a Q and A that brought up issues about the disappearance of schizophrenia and other points in the talk.
At the end of the meeting Tom Burns was called on to comment on the all the lectures. I missed this at the time. He said:
Tom Burns didn’t ask any questions in the Q and A. Neither he nor any of the other people in the audience on the verge of a stroke have been in touch since by email or whatever to quibble with any of the points made.
Two weeks after several emails, without a response, the RSM version of Standardization turned up. It can be accessed HERE.
The final few minutes of this are rushed owing to time constraints, which meant that some of the points that might have actually caused a stroke were missed or softened. They can be caught in The Standardization of Psychiatry in video form along with text and slides.
Since posting, Peter Selley sent this image with a comment –
Royal Society of Medicine meeting participant has lucky break