Psychiatry has always been controversial – there never was an extended ‘Golden Age’ of peace and tranquillity when everyone was in agreement. You probably bought this book after some heated discussion about the rights and wrongs of something psychiatrists do. Because it deals with the mind, and because psychiatrists can act against our wishes, it will always generate a degree of suspicion and fear. And it isn’t good enough simply to put this down to ignorance and say that if people knew more they wouldn’t have such concerns. There are very real questions to be asked about psychiatry – both about its legitimacy, its status as ‘just another medical specialty’, and also about how it is practised. The power of modern medicine invariably brings ethical challenges and controversies and psychiatry has its fair share. These will be taken up more in Chapter 6. This chapter will focus on the contradictions and tensions which are inherent in psychiatry, that stem from its very nature, rather than problems with practice.
The French philosopher René Descartes (1596–1650) is often blamed for how we distinguish between the mind and the body in Western thought (often referred to as ‘Cartesian dualism’). His ‘cogito ergo sum’ (‘I think therefore I am’) is snappy and memorable; it expresses his scepticism about certainty in knowing about the material world. It is hard to understand why he has been singled out for all the ‘blame’ for an issue which exercised most of his empiricist philosopher contemporaries. He didn’t invent the problem of the mind; he simply put some of the issues better and they remain essentially unresolved 350 years later. What the mind is, and how it interacts with the material world, still remain mysteries. Most of us do think there is a difference and most of us accept that there is an interaction. We have to live our lives believing we can directly influence the material world (e.g. I decide to stretch out my arm and expect to turn on the computer). We also need to believe that we can know the minds of others (e.g. I’m sure that you will go to the library or hand in your essay). Without these beliefs we would effectively be paralysed.
The mind–body question is unavoidable in psychiatry. The relationship between the mind and the brain is the big issue. It would be simple if psychiatry were just about ‘brain diseases’ in the way that nephrology is about kidney diseases or cardiology is about heart diseases. Psychiatry, however, is concerned with ‘mental’ illnesses. We know that many mental illnesses involve disorders of the brain (e.g. disturbances in transmitter chemicals between cells in depression and schizophrenia) but not all brain diseases are mental illnesses or the responsibility of psychiatrists. Multiple sclerosis and Parkinson’s disease are both undeniably brain diseases but it is neurologists, not psychiatrists, who deal with them. These neurological disorders often cause psychiatric problems, just as a wide range of physical disorders can. Many psychiatric disorders include physical symptoms (e.g. tiredness and pain), just as physical disorders include psychiatric symptoms (e.g. depression, anxiety, and even hallucinations).
Psychiatric disorders are those where the main disturbances are in thoughts, feelings, and behaviour (Chapter 1). Physical diseases don’t just have physical causes and cures and mental diseases have mental causes and cures. Illnesses can have physical causes and even physical cures (e.g. a depression caused entirely by Parkinson’s disease which is effectively treated by antidepressant tablets) and still be ‘mental illnesses’. The division is based on the main disturbance and on the skills needed to help the patient. ‘Mental disorders are brain disorders’ has been a popular slogan with some psychiatrists and patient groups. Its purpose is to emphasize the similarity between mental and physical illnesses, reducing stigma and blame. These are admirable goals but it is an oversimplification. Psychiatry has to struggle with an ambiguity fought out on two main battlegrounds.
Nature versus nurture: do families cause mental illness?
Whether you’re tall or short, whether you’re good at sport or hopeless, most of us believe this depends on a mixture of our genes (the biological potential we were born with) and our upbringing (our diet, exercise regime, even the sort of school we went to). Nothing controversial in that. The moment we mention psychology, however, the balloon goes up. Is IQ inherited or could everyone do just as well with the same opportunities? Is personality or criminality something we’re born with or can we change it? Can we avoid depression by healthy living? Few issues polarize us as much as how changeable we believe human behaviour to be. The disagreements are not just calm, academic ones but fuel (and are fuelled by) political and social beliefs reflecting fundamentally different worldviews.
Psychiatry originally was very much at home in the ‘nature’ camp – mental illnesses ran in families and were inherited weaknesses. It was our job to ameliorate them and make life as bearable as possible, hoping for a speedy recovery. Freud and his followers began to change all that, shifting the balance to ‘nurture’. Psychoanalysis is firmly based on the belief that what happens to us in early life, and the memory of those experiences, is the cause of many illnesses. Even more convincing, Freud showed that addressing those memories could cure some mental illnesses. So an individual’s personal history (their ‘narrative’) wasn’t just the context for understanding their illness but possibly its origin.
Psychoanalysis dominated psychiatric thinking and training from the 1940s to the 1970s. The attraction of psychoanalysis to the Americas should come as no shock. After all, these societies were established by those who escaped the pessimistic fatalism of Europe with its fixed social orders and hereditary monarchies and aristocracies. Those who moved west were those who rejected this and grasped the opportunity for each individual to shape their own future. No surprise then that they espoused a psychology that enshrined this capacity for growth, where the individual could overcome early limitations and forge their own destiny. The role of nurture and experience was strengthened by observations of battle trauma in both world wars (Chapter 3). The revelation of the eugenic and racist policies of Nazi Germany (including the liquidation of ‘genetically inferior’ psychiatric patients) finally guaranteed nurture’s moral unassailability.
An attraction of emphasizing nurture is that it holds out much greater possibility of cure. If mental illnesses are essentially caused by relationships then they should be curable by relationships (i.e. psychotherapy). However, the downside of this approach is its potential for blame – in particular blaming parents. Freud himself quickly realized these risks when he began to suspect that the reported sexual abuse by parents (which he originally considered the cause of his patients’ neuroses) might be fantasies. The great German psychopathologist and philosopher Jaspers pointed out that, while understanding the personal relevance of symptoms was essential in psychiatry, it was not the same as understanding what caused the illness. Such fine distinctions have not, however, generally characterized this debate publically.
The origins of schizophrenia
This controversy has raged most fiercely over the origins of schizophrenia. Schizophrenia had always been known to run in families and it had been observed that these families could seem ‘odd’ (eccentric or withdrawn), often with strained or intensely over-involved relationships. As schizophrenia is a disorder expressed in thinking and relating there is an obvious possible link between it and early upbringing. Family life is, after all, conducted through thinking and relating and aims to equip the growing child with skills in these areas. As psychoanalytical thinking was applied to schizophrenia (something that Freud explicitly avoided) a number of theories were proposed, some of which had enormous influence and have entered the language.
The ‘schizophrenogenic mother’
The most notorious (and probably the most damaging) of these was that of the cold, hostile, and yet controlling parent – the ‘schizophrenogenic mother’ (literally ‘schizophrenia-causing mother’). This was proposed by the analyst Frieda FrommReichmann who, along with Harry Stack Sullivan, engaged in long-term intensive psychoanalysis with hospitalized schizophrenia patients in the USA. Her most famous patient, Joanna Greenberg, later described her experiences in her best-selling autobiographical novel I Never Promised You a Rose-Garden.
Fromm-Reichmann described a powerful, but cold and rejecting mother figure who bound the patient close to her, preventing the growth of healthy independence and sense of self. Schizophrenia was then understood as a disorder of ‘ego-development’ resulting in weak personal boundaries (hence the confusion of internal and external experiences in hallucinations). Fromm-Reichmann’s conclusions are preposterous by current standards. She based them entirely on her patients’ reports in analysis and never actually bothered to meet or interview the mothers. It is reputed that her ideas derived from the analysis of only 11 patients. Despite its early rejection within the profession, the conviction lives on that families can ‘cause’ schizophrenia. This has led to endless self-blame by parents and, in some circumstances, their rejection and exclusion by mental health staff.
The anthropologist Gregory Bateson proposed that persistent, logically faulty, and contradictory communication with a child prevented it forming a proper sense of itself and its relationships to the external world. Bateson was influenced by Bertrand Russell and A. N. Whitehead’s mathematical writings. One of their proposals was that the number which designated a series of numbers could not itself be a member of that series – as the designating number was of a ‘logically different order’. Bateson said that there were similarly logically different levels of communication and that we sent messages to each other (often in an oblique manner) where one part of the message indicated how the main part should be understood. He called these oblique messages ‘meta-communications’ (i.e. communications about communication). Typically meta-communications were emotional and non-verbal and became family assumptions (e.g. ‘mother can only love her children and always feel positive about them’).
Bateson called it a double-bind when the non-verbal message and verbal message contradicted each other (e.g. an obviously angry mother saying she didn’t mind at all that the child had broken a glass and holding her arms out for an embrace). A double-bind required three components: a clear simple message, a contradictory meta-communication, and an absolute ban on the contradiction being acknowledged. All three were necessary but it was probably the family culture of denying the contradiction that was most pathological. After all, all families give contradictory and confusing messages. The term ‘double-bind’ is now used loosely to imply any contradictory communication but Bateson’s theory was much more precise.
These theories have all been conclusively demolished by careful scientific examination. One approach was to get independent researchers to listen to tapes of families with and without schizophrenia and rate the occurrence of double-binds, or to interview families and rate them for coldness, hostility, overinvolvement, etc. Reliable differences were simply not found. Adoption studies, however, delivered the coup de grace. Very rigorous studies of children adopted away at birth to healthy families found rates of schizophrenia when they grew up just as high as if they had been brought up with their schizophrenic mother. Similarly twins adopted away at birth to different families demonstrated the same difference in rates between identical and non-identical twins found in those brought up in their natural families. None of these risks are 100 per cent and clearly upbringing and environment have quite a lot of influence.
While family influence as the cause of schizophrenia has been conclusively dismissed it remains implicated in the course of the illness. Individuals with schizophrenia in highly emotionally charged families are likely to break down more often. This could, of course, be because families with more severely ill members are more stressful (see Chapter 4). However, training families to respond less emotionally does reduce the rate of breakdown, so high expressed emotion probably does have an effect.
Social and peer-group pressure
While family influence has been questioned, wider social influences have received increasing recognition in the last half century. For example, the rise in eating disorders (anorexia nervosa and bulimia) has spread from the West, closely tracking the cultural ideal of thinness in women. The epidemic of self-harm (particularly overdosing and cutting in younger women) is clearly affected by group norms and expectations. Local outbreaks can often be linked to specific events such as suicide attempts in TV soap operas.
Alcohol and drug use are highly variable between different cultural groups (both between and within nations) and the power of group expectations on such behaviours is undeniable. These are enormously important public health issues and the status of these behaviours as ‘mental illnesses’ will be picked up again in Chapter 6.
The fading relevance of the nature–nurture argument has recently been revived by the rise of evolutionary psychology. A more sophisticated understanding of Darwinian evolution (survival of the fittest) has led to theories about the possible evolutionary value of some psychiatric disorders. A simplistic view would predict that all mental illnesses with a genetic component should lower survival and ought to die out. ‘Inclusive fitness’, however, assesses the evolutionary value of a characteristic not simply on whether it helps that individual to survive but whether it makes it more likely that their offspring will survive. Richard Dawkins’s 1976 book The Selfish Gene gives convincing explanations of the evolutionary advantages of group support and altruism when individuals sacrifice themselves for others.
A range of speculative hypotheses have since been proposed for the evolutionary advantage of various behaviour differences and mental illnesses. Many of these draw on ethological games-theory (i.e. the benefits of any behaviour can only be understood in the context of the behaviour of other members of the group). So depression might be seen as a safe response to ‘defeat’ in a hierarchical group because it makes the individual withdraw from conflict while they recover. Mania, conversely, with its expansiveness and increased sexual activity, is proposed as a response to success in a hierarchical tussle promoting the propagation of that individual’s genes. Changes in behaviour that look like depression and hypomania can be clearly seen in primates as they move up and down the pecking order that dominates their lives.
The habitual isolation and limited need for social contact of individuals with schizophrenia has been rather imaginatively proposed as adaptive to remote habitats with low food supplies (and also a protection against the risk of infectious diseases and epidemics). Evolutionary psychology will undoubtedly increasingly influence psychiatric thinking – many of our disorders fit poorly into a classical ‘medical model’. Already it has helped establish a less either–or approach to the discussion. It is, however, a highly controversial area – not so much around mental disorders but in relation to social behaviour and particularly to gender specific behaviour. Here it is often interpreted as excusing a very male-orientated, exploitative worldview. Luckily that is someone else’s battle.
Why do families blame themselves?
If so many of the family theories have been discredited why spend so much time on the issue here? Family theories in mental illness continue to exercise a remarkably powerful hold over us despite the evidence. And not just in schizophrenia but in depression, anorexia nervosa, personality disorder, drug and alcohol abuse, etc. Parents seem to have an endless capacity to blame themselves for what happens to their children (and perhaps children to blame their parents). This is probably because we need to believe it. Just as we need to believe in free will and our influence on the outside world, family members need to believe that they influence each other. If we didn’t why would we bother? The evolutionary psychologists would say that parents need to believe it to invest years and years bringing up their children. We’re biologically programmed to look after our children so we need some belief system to support it (just as they might say we’re biologically programmed to mate and need to believe in love to support it). It is proposed that such a belief is a mechanism for sustaining our attention to our biological task.
The downside is, of course, guilt and blame. If we believe we have an influence we feel we have failed if things do not work out well. It is inescapable. Even in expressed emotion work where therapists insist emphatically that no one is to blame and that the aim is solely to find more effective coping strategies, families do feel blamed. ‘If only we weren’t so over-involved he would not have so many relapses.’ ‘Other families must have dealt with it better otherwise how would the therapist know what to advise?’ For some families feeling responsible, despite the guilt, is preferable. It implies the logical consequence that there must be something they can do to influence the outcome. Cultures which value resignation are less likely to blame themselves (high expressed emotion is less common in India than in Europe).
The anti-psychiatry movement
Arguments over mind and brain and nature and nurture have always been part of psychiatry and are likely to remain so. They supported the most sustained and celebrated ‘external’ onslaught on psychiatry. This occurred during the 1960s and 1970s in what came to be called the ‘anti-psychiatry movement’. The mental hospital scandals of the early 1960s and publication of Erving Goffman’s Asylums had prepared the ground for a devastating attack. This was not to be a criticism of some of psychiatry’s practices or of failures in the system; this was to be an assault on the very legitimacy of psychiatry.
The anti-psychiatry message was that psychiatry did not so much need improving as scrapping. At its best it was confused and confusing and at its worst a truly evil instrument of oppression masquerading as a benign medical practice. Three charismatic authors came to personify the movement. Two were practising psychiatrists. Their books became campus bibles in the late 1960s and the 1970s at a time of widespread student unrest and they were hugely influential in the Paris student revolt of 1968 and its international consequences.
Thomas Szasz, a Hungarian immigrant to the US, rose to fame with his book The Myth of Mental Illness in 1961. In this he argued that ‘mental illnesses’ were fabrications to deny socially deviant individuals their legal rights. He argued vigorously against involuntary treatment and for the separation of psychiatry and the state and the abolition of the insanity defence. He believed that those judged mentally ill should be treated equally and held accountable for their actions (i.e. psychotic individuals should have the right to refuse treatment and be sent to prison if they break the law, even when demonstrably unwell). He often drew on hysteria as his model of mental illness (probably reflecting his experience as a psychoanalyst in New York), which has limited the power of his case. It has been suggested that his extreme libertarian standpoint and opposition to compulsion stemmed from his experiences under Soviet occupation. He is regularly quoted by the Church of Scientology in their opposition to state run and coercive psychiatry.
Michel Foucault was a French philosopher who believed that the concept of mental illness was an aberration of the post-Enlightenment age. He objected to the classification of identities, arguing that the existence of madness did not entail the identity of madman. His book Madness and Civilisation challenged the very basis of psychiatric practice and cast it as repressive and controlling (rather than curing and liberating). His work had enormous influence in Continental Europe (most evident in Basaglia’s reforms in Italy). However, his writing is dense and difficult to absorb and he is more often quoted than read.
The most accessible and influential of the anti-psychiatrists was R. D. Laing. A Glaswegian psychoanalyst with a brilliant mind and lucid prose style, he turned the psychiatric world upside down with a series of best-selling books. An original and impulsive man, his views changed throughout his career and like Freud he didn’t feel the need to acknowledge these radical changes or explain them. His first, and most influential book, was The Divided Self: An Existential Study in Sanity and Madness (1960). He called his position ‘existential phenomenology’ (don’t ask!) and proposed that the delusional thinking of the schizophrenia patient was simply a different take on the world. He argued that this could be challenging but it was essentially creative and, with enough imagination and moral courage, could be understood. However, these different worldviews threaten our security so we seek to deny them by imposing a diagnosis and ‘pathologizing’ them.
9. Michel Foucault (1926–84): French philosopher who criticized psychiatry as a repressive social force legitimizing the abuse of power
The book is filled with vivid descriptions of patients Laing had treated, accompanied with the most moving and imaginative interpretations of their dilemma. The impression given of psychosis by The Divided Self was of a tormented and rather heroic individual communicating vivid, authentic experiences, only to be met with a cowardly and mean-spirited rejection from society. Although he did
10. R. D. Laing (1927–1989): the most influential and iconic of the antipsychiatrists of the 1960s and 1970s
11. The remains of the psychiatry department in Tokyo – students burnt it down after R. D. Laing’s lecture in 1969
not deny the suffering, his was essentially a romantic view of madness which (paradoxically) increased recruitment into psychiatry at the same time that it attacked it. Like Szasz, Laing never called himself an anti-psychiatrist (a term coined by his colleague David Cooper in 1967), and continued to practise, albeit in unorthodox ways.
Laing’s second ‘phase’ was his belief that families contributed to schizophrenia by denying the emerging identity of their child. Sanity, Madness and the Family: Families of Schizophrenics, with Aaron Esterson, cast schizophrenia as a response to repressive and rejecting parenting. The film inspired by it (Family Life, 1971) struck an international chord. Laing’s third phase was inspired by his extensive experimentation with LSD, so common at that time. The Politics of Experience and the Bird of Paradise, published in 1967, conceived of psychosis as a psychedelic voyage of discovery in which the boundaries of perception were widened, and consciousness expanded.
Laing was an improbable candidate for such an influential role. He started his psychiatric career as an army psychiatrist. His personal life was turbulent, with several marriages and many children. As a lecturer he ranged from the inspirational to the frankly intoxicated and unintelligible. His ability to galvanize anti-establishment feeling was so powerful that after a lecture to the student body in Tokyo in 1972 they went off and burnt down the department of psychiatry! He remained a radical until his death, aged 62, surprising all who knew him by collapsing while engaged in the outrageously bourgeois activity of playing tennis on the French Riviera.
Anti-psychiatry in the 21st century
The contradictions inherent in psychiatry which generated the anti-psychiatry movement in the 1960s and 1970s have not gone away. Mind and brain, freedom and coercion, the right to be different (perhaps even the duty to be different), nature and nurture remain live issues. Many (though by no means all) ex-patient groups have become militantly anti-psychiatric, often referring to themselves as ‘survivors’ rather than patients, clients, or service users. In Germany and Holland the state contributes to hostels and crash pads for individuals who have ‘escaped’ routine mental health services. The most high-profile anti-psychiatry group is probably the Church of Scientology. While much of their focus is on controversial treatments such as brain surgery and ECT (Chapter 6), they are critical of the whole endeavour. They would argue that we should avoid artificial and technological approaches to human suffering and seek alternative personal routes to relief.
Overall, however, there is now much less concerted opposition to psychiatry as a discipline. This may, in part, be due to a somewhat exaggerated faith in the rapid expansion of ‘biological’ explanations and an optimism that genetic and genomic advances will soon render the whole issue academic. However, while there is less conceptual opposition to psychiatry, there is no shortage of disquiet about various aspects of its practice. We turn to these now in Chapter 6.