Mood induction procedures


As a teenager I spent hours in my room listening to arch-miserabilist pop band the Smiths.  I felt they really understood my teenage angst, and my love for them withstands even David Cameron’s unrepentant fandom and Morrissey’s regular and unsavory announcements.

We spend a lot of time and money trying to feel good, but there is also a pleasure in the melancholy that listening to every Smiths’ song played back to back can engender.  Alongside teenagers, researchers use various experimental methods for inducing mood states.  These are often used in studies which aim to investigate the correlation between mood and neurological function.


Self referential statements

One of the first mood induction procedures was the Velten Mood Induction Procedure.  Subjects read aloud self-referent statements, which progress from the relatively neutral to those associated with either a negative or positive mood.

Example of questions – this site suggests that the Velten mood induction procedure should be used as a form of “guided meditation”.



Music can arouse deep emotions in the listener.  The majority of studies use classical music, but a wide variety of musical pieces is used to experimentally induce mood states.  This paper (update 2018 – broken link) lists music used in forty-one music mood induction procedure studies.  The authors find that most musical pieces are used in one study only, but find twelve studies that use Delibes Coppélia to induce happy or elated moods.  No mention of the Smiths.

It’s probably best to ban your teenage children from listening to Stravinski’s Firebird suite.  Played at 80 dB, as one study used this to provoke anger.

Movie clips

Habitual cinema-blubbers will not be surprised that requesting participants to watch movie clips is a common way to manipulate moods experimentally.

In a 2008 study positive mood was induced by participants watching a 10 minute excerpt from a British comedy series (the actual series itself is not identified alas – Monty Python?). Neutral mood induction involved an excerpt from a nature documentary, and negative mood was brought about by an excerpt from a film about dying from cancer.

According the many authors film and music based mood induction is the most effective.


Critical feedback.

Another technique is to use verbal feedback. This 2008 (update 2018 – broken link) study asked participants to complete a series of anagrams and then report their answers through an intercom system. To induce a negative mood state they received insults in return.

After the 4th anagram, the experimenter said: “Look, I can barely hear you. I need you to speak louder please.” After the 8th anagram, the experimenter said in a louder and more frustrated voice: “Hey, I still need you to speak louder.” After the 12th anagram, the experimenter said in a very frustrated voice: “Look, this is the third time I’ve had to say this! Can’t you follow directions? Speak louder!

Forming mental images/autobiographical recall.

This approach can use emotionally charged sentences, with subjects asked to try and experience the affective state they would feel if the situation were real.

“Imagine that you just won the lottery and you will have all the money you could ever want” (paper) (update 2018 – broken link)

(These lottery winners are in the lucky situation of not having to use their imagination).

In a similar approach (update 2018 – broken link) participants were instructed to write a short essay about an event they experienced that provoked specific feelings such as anger or sadness.

Combining methods and effectiveness

The most effective mood induction procedures may combine two procedures in the belief that multiple interactions contribute additively to mood.   One type of induction occupies the foreground attention, whilst the other forms the background atmosphere.  So, for example the Velten mood induction procedure has been combined with music mood induction.

The effectiveness of mood induction procedures is questioned by some authors, who dispute whether they can produce moods of sufficient intensity.  Another debate concerns whether the results of experiments using mood induction result from the expectations that the protocol induces in participants, rather than because of the induced mood per se (demand characteristics).

Sponsored by Inexika, creator of iMoodJournal – mood tracking application for iPhone and Android

Photo credit


17 June 2018 reviewed – some of the links to papers are broken – sorry.


“Detoxification” or “detox” is a word that is put to many (related) uses.  When used in a psychiatric sense its use refers to “the process of withdrawing a person from an addictive substance in a safe and effective manner” (Cambell’s Psychiatric Dictionary).  Detoxification can also refer to the treatment of poisoning.

When referring to the treatment of addictive substances detox is used variously to mean the treatment of a withdrawal syndrome, the experiencing of a withdrawal syndrome or the treatment of an acute drug overdose.

Talk of “detoxing” is also beloved of alternative practitioners, the idea being that because of modern lifestyles or diets the body accumulates various toxins.  With the aim of attaining health and equanimity these require periodic purging by (say) yoga, cold showers, or holding crystals etc.  As the liver and kidneys work full time removing toxins from the human body, neither the mechanisms by which these interventions work nor their efficacy is established.  (This is not to say that eating healthily and exercise are not noble pursuits).

Detoxification of addictive substances involves cessation of drug intake cross tapered with medication to address withdrawal effects.  In this sense “detoxification” is a misleading term as – beyond stopping taking a toxic substance – the process does not include the removal of body toxins.  Depending on factors like the drug of misuse, habitual daily intake and the severity of the withdrawal syndrome, medical detoxification can take place either in the community, or in a rehabilitation clinic.

Withdrawal from alcohol is probably the most common detoxification requiring medical intervention.  Prolonged periods of heavy alcohol use can lead to physiological dependence and abrupt withdrawal from alcohol can be fatal.  Alcohol acts as a central nervous system depressant.  Because of this, chronic heavy use leads to GABAA receptor desensitization and a reduction in receptor numbers.  If alcohol is abruptly stopped then the nervous system suffers from uncontrolled synapse firing, which can result in anxiety, life threatening seizures, and delirium tremensBenzodiazapines are the most commonly used drugs to reduce alcohol withdrawal symptoms.  Severe withdrawal is also seen with GHB and sedative-hypnotics also produce a withdrawal syndrome similar to that of alcohol.

Other withdrawal syndromes can be less severe, but nevertheless act as a barrier to cessation.  Opiates withdrawals resemble a flu-like illness, and directly life-threatening symptoms are not caused.  Methadone acts on the same receptors as heroin and is used to reduce withdrawals.  Stimulant (cocaine, amphetamine) withdrawal following heavy use can resemble a severe depressive illness and a number of medications such as dopamine agonists can be administered.

Further information

Drug detoxification Wikipedia

Alcohol detoxification wikipedia


Photo credit

(June 2018 reviewed – broken links removed)


The term “schizophrenia” was coined by Swiss psychiatrist Eugen Bleuler in 1908.  With the term’s introduction, Bleuer ultimately replaced ‘dementia praecox‘, a term first used by Arnold Pick (of Pick’s disease) to categorize a similar disorder (or group of disorders).  The essence of schizophrenia as described by Bleuler is the ‘loosening of the associations’ between personality, thinking, memory and perception.  Dementia praecox has a different focus, describing patients having a global disruption of perceptual and cognitive processes (dementia) together with early onset (praecox).  I’ve written about different conceptions of schizophrenia in the past.

The word “schizophrenia” derives from Greek roots and translates approximately as “splitting of the mind”.  It is often written that, because of this, schizophrenia is misconstrued to mean having a split or multiple personality.  Otherwise known as ‘dissociative identity disorder‘ a ‘split personality’ is where a person has two or more distinct identities or personalities alternatively in control of his or her behaviour.  I’m not absolutely convinced this disorder exists in a straightforward sense but anyway, our current understanding of schizophrenia is that it’s nothing like that at all.

“Starbucks is a schizophrenic brand”

This brings me to the point I wish to make.  For affected people, and their families, schizophrenia can be pretty devastating.  But rather than simply used to refer to this, “schizophrenic” is also used quite commonly to mean “inconsistent and contradictory”.  Here’s an example from Radio 4’s Today programme and another from the Guardian.  Today’s presenter, Evan Davies, doesn’t hesitate at talk of Starbucks as a “schizophrenic brand”.  “Irish” used to be used in quite a similar way, but I doubt Davies could have let talk of Starbucks as an “Irish brand” pass without reproof.  “Schizophrenic” used in this way is a misappropriation, and one which perpetuates misunderstanding and disparages a vulnerable group of people.  I don’t know why it remains so acceptable.



Inquiry into the schizophrenia label has published on whether we should use the term ‘schizophrenia’ at all

I haven’t read it, but this book – American Madness: the rise and fall of dementia praecox – looks v. interesting.  It charts how DP lost out to schizophrenia in the nosology ‘arms race’.



(June 2018 review – Evan Davies now presents Newsnight; I don’t know if he still uses ‘schizophrenic’ in the above sense.

Science Tales review

I’ve just read Science Tales, Darryl Cunningham’s second book.  Cunningham was interviewed on this blog in August 2010.  I’m a big fan of his work, so this isn’t an entirely unbiased review.

Cunningham’s first book, Psychiatric Tales, was about his time working on psychiatric in-patient wards: the experiences he had and the people he met.  The tales are arranged as black and white strips, with a striking and unembellished drawing style.  Words accompany the pictures only sparingly, but are thoughtful and often quite wise.

Science Tales adopts much the same approach.  Cunningham’s artistic technique is recognizably similar, although here strips are in colour and Cunningham liberally uses photographs alongside his line drawings.  The focus is upon scientific ‘lies, hoaxes and scams’ – a broad remit – in one chapter Cunningham patient debunks moon landing conspiracies, another addresses climate change deniers.  The claims of homeopaths, chiropractors and champions of intelligent design are also patiently dismantled.  The chapter about Andrew Wakefield and MMR is particularly good.

‘Science denial’ – the book’s final chapter – is about some people’s willingness to dismiss scientific theory.  This can be a dangerous position, as Thabo Mbeki demonstrated when his denial that HIV causes AIDS prevented thousands of HIV-positive mothers receiving anti-retroviral drugs.  I have a sense that Cunningham really doesn’t get such people; I don’t either, although I’m rather more sympathetic.   I suspect that Cunningham is more of a positivist than me.

From looking at Cunningham’s blog, he’s moving onto history for his next ‘Tales’ book.  I hope he’ll return to science in the future.  Having now dispatched some of the most prominent science hoaxes, I’d like to see where a more esoteric selection might take him.

(June 2018 review – no changes all links working)

Interview: substance misuse and addiction psychiatrist Henrietta Bowden-Jones

This was first published in the Student BMJ


A consultant psychiatrist working in the field of substance misuse and addiction, Dr Bowden-Jones was born and grew up in Italy where she studied medicine at Pavia University. She went on to train as a psychiatrist on the Charing Cross and Imperial College rotation in London. After her psychiatric training, she obtained a doctorate of medicine in neurosciences at Imperial.

She is the founder and director of the National Problem Gambling Clinic, the first and only NHS clinic for problem gamblers. Until recently she also ran an inpatient ward for alcohol and drug detoxification. She is an honorary senior lecturer in the division of neurosciences at Imperial College and is the Royal College of Psychiatrists’ spokeswoman on problem gambling.

What attracted you to psychiatry?

I first decided to become a psychiatrist when I was seven. Everyone laughs at the reason. I was an avid reader of the Peanuts cartoons; a character called Lucy has a stall with a sign that says “The psychiatrist is in” and the other characters go and ask for advice on how to sort out their problems. She was my role model, as she was energetic and optimistic.

During my childhood in Italy there was an epidemic of heroin addiction among the middle class population. The question of what would drive someone to destroy their life with drugs or alcohol was one of the early drivers for my interest in addiction psychiatry.

How did you become interested in problem gambling?

This began while I was studying for a medical doctorate at Imperial. I was undertaking research on the ventromedial prefrontal cortex of the brain of alcohol dependent subjects. I was using computerised neuropsychological tests, one of these was the Cambridge Gamble Task. I noticed that some of the subjects performed extremely badly and this led me to read up about the neuronal pathways involved in pathological gambling. The more I read, the more fascinating the topic became to me. I’m not a gambler and never have been. But from an intellectual, and then later, a human perspective, gambling really grabbed my attention.

What evidence is there that gambling is a disease?

Pathological gambling is recognised in both the ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th Revision) and in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) manuals. It has a prevalence of 0.9% in the 2010 British Gambling Prevalence Survey. There are hundreds of thousands of people out there in need of treatment. Research is still in its early stages compared with that of other addictions and we still need to clarify the neurobiological basis of the disease.

What is the natural history of a gambling problem? How does it progress?

There isn’t really a “typical” patient, but many of our patients start gambling when they are very young; they often report starting around the age of eight or nine. This could be playing cards with grandparents or being taken to the races.

By their early teens, some patients are spending their lunch and bus money on gambling and return from school on foot without having eaten. Some give up university or lose their home because they have spent their money on gambling. Relationships also suffer because a person spends so much time thinking about or actually gambling that he neglects others.

What sort of symptoms do people with problem gambling display?

By the time people seek help they’re usually quite desperate. Their mood can be extremely low. They can also be gambling on a daily basis with a compulsion to seek out places to gamble.

Patients often gamble excessively to the exclusion of other activities. Some don’t show up for work after a night gambling. Others become suicidal after incurring debts. Pathological gambling mirrors the presentation of other addictions and will be moved to addictive disorders in the DSM V from its current position as an impulse control disorder.

How are problem gamblers treated?

Research shows that the best outcomes are achieved using cognitive behavioural therapy (CBT) both individually and in a group setting. So this is what we provide at the clinic. We put most people in group CBT. The ones with serious psychiatric comorbidities receive individual treatment using the same steps, and all are offered family therapy and money management advice.

At present there are no medications that have a specific licence for the treatment of problem gambling, but we plan to trial naltrexone in the near future.

Is the internet changing gambling habits?

The internet allows people to gamble at all hours and for as long as they want. The availability of gambling online makes it hard for someone to resist because of the ubiquity of the world wide web. People lose track of the time and money they’re spending on gambling and it’s easier for people to hide their addiction.

By the time they come to us patients have often sold their computer and they are living hand to mouth. They’re still gambling but they tend to go to the bookies and queue up to play on slot machines.

Are there any changes you’d recommend to gambling laws in the UK or internationally?

We need to protect young people from the temptations of gambling and from starting early. Young people are currently allowed to play on some slot machines, but from a neurobiological perspective, this could be priming their brains and making them more sensitive to monetary rewards in later life.

It is our national duty to make problem gambling fall under the care of high quality NHS services and to treat it as a public health issue in view of the preventive work that needs to take place.

What advice do you have for those interested in psychiatry?

I would certainly recommend a career in psychiatry. The rewards as a human being and as a doctor, when you help people love life again after having seen them suicidal or psychotic, are great.

I love my work in addictions psychiatry. You have to be optimistic as you know some patients will relapse into their substance misuse or alcoholism, and there are challenges of keeping patients well with relapse prevention and medication. However, there are plenty of interesting research opportunities in addictions psychiatry, which is still young compared with many other medical ones.

The Royal College of Psychiatrists is keen to support students who want to pursue a career in addictions. We also have bursaries and essay prizes for students. Further details can be found at

Life extension: “Moral obligation” or “a disaster for humanity and the planet?”

Is medical control of human aging a worthy goal?

Despite the moisturisers you can buy it is impossible to reverse the damage of aging and very few of us will live to anywhere near the theoretical maximum of human age, estimated to be 125. Yet some people think the first person who will live substantially longer than this is alive today.

Aubrey de Grey is one of them.  He was recently speaking at a debate at the Oxford University Scientific Society, for the motion “This house wants to defeat aging entirely.”  De Grey is the chief scientific officer of the SENS foundation and a cheer leader for bringing aging under medical control.  “This is no longer a radical heretical idea” he says; for de Grey defeating aging is at the heart what medicine is about. And when we treat aging, longevity is a welcome side effect.

Methods to extend human lifespan are speculative and de Grey’s ideas are controversial. Calorie restriction is shown to increase the lifespan of several species, including rodents and fish, but there is no evidence that this will translate to humans. Nanomedicine is a futuristic strategy, with constant corporeal repair provided by microscopic robots. Another proposal is for cloning to generate cells, body parts, or even entire replacement bodies.

De Grey is bullish about the future and the emergence of new technologies “if you tried to predict the rate of improvement in the Atlantic crossing by looking at ocean going liners you’d have been wrong” he says.  Another of his proposals is of a “human longevity escape velocity” which supposes that initial life extension therapies will only grant a modest life extension. This extra lifespan will see a recipient through until the development of more advanced therapies. In this way the first person to live to 150 might also be first person to live to 1000.

I find this reasonably persuasive. Colin Blakemore, professor of neuroscience at Oxford University, does not.  He was speaking against de Grey.  “Utterly unrealistic” is how he describes de Grey’s proposals and says that to defeat aging an “incredible range of age related disorders would have to be defeated.” He thinks that talk such as de Grey’s is a distraction from the real work of medical research.

Blakemore also says that the emergence of technology that will substantially prolong human life will be a “disaster for humanity and the planet.”

I agree.  I don’t think that it’s inherently unethical to seek to extend human lifespan.  It may actually be immoral not to do so as it denies future generations the chance of extended lives.  Diseases of old age (which is most of them) kill 50 million people a year old worldwide and these will be preventable deaths like any other.

But I am worried about the consequences.  Even the prophets of life extension such as de Grey concede that, without a drop in birth rate, problems of rising population will become even more acute.  We will need to choose between living longer and having children, as doing both will be catastrophic.

As for my profession, I fear the emergence of life extending technology will divide the medical world.  At present many doctors do not consider aging to be a “disease,” and it is therefore a questionable target for our attentions.  Despite this objection, many doctors’ careers do not focus on acquired disease but on treating the consequences of age related decay. Either way, once we are able to arrest aging, life extension will be the only show in town.

Population explosion and doctors’ objections aside, how else would living to 150, 300, or 1000 affect us and our societies? There are many potential pitfalls. Progress in many spheres—scientific, political, commercial—happens when its opponents die.  Life extension will profoundly affect power structures as death will no longer serve as the ultimate solution to entrenched authority. If life extension were to be restricted to a wealthy few then this will further exacerbate our already deep social divisions.

Perhaps most fundamentally, without a sense of urgency, what sense will we make of our lives?  Will longer lifespan allow us to live all the lives we want, or will boredom overtake us leading to widespread demoralization? Maybe with so many more years to lose we will all become more careful with our bodies, reflective in our relations, and optimistic in our outlook.

First published on BMJ Blogs

(reviewed June 2018 – link updated)

Psychiatry in Dissent revisited

Influential when it was published during the 1970s, how relevant is Anthony Clare’s Psychiatry in Dissent today?  We discussed this book last night at the Maudsley book group, and were joined by Prof Robin Murray, and friend and colleague of Clare.

Clare, a clever and urbane Irishman, was one of the first to take on the arguments of ‘anti-psychiatrists’ such as Thomas Szasz and R. D. Laing.  Although Clare was still in psychiatric training when Dissent was published he found himself propelled into the limelight as a spokesman for the profession.  This was something that Prof Murray said caused some resentment at the time, not least because Dissent is, in places, quite critical of contemporary senior psychiatrists.

After the passage of years the book is notable for both what it does and doesn’t include.  The first two chapters of the book are perhaps the strongest.  They explain the concept of psychiatric illness and the process of diagnosis, both of which have undergone little change.  Also still relevant is Clare’s critique of the Rosenhan experiment .  This is an interesting, but methodologically flawed, study.  Controversy was raging about it in the mid-70s and its results are still cited uncritically today.

There’s no mention of ADHD, PTSD or bipolar spectrum – these didn’t ‘exist’ then.   A similar book written today would need to address controversy of the efficacy of SSRI antidepressants.  There is a chapter on psychosurgery, something of a non-topic now, and already on its way out during the 1970s.  The 40s, 50s and 60s had seen lobotomy used for a wide range of presentations from schizophrenia to migraine.

The final chapter “Contemporary psychiatry” is notable in that in many respects it echoes many of the problems of psychiatry today, as if nothing has changed: poor recruitment to the specialty and under provision of services.

Towards the end of his life Clare talked about updating Dissent, but a heart attack intervened.  It would be nice to have a contemporary critique of psychiatric practice aimed at the layman – a modern Psychiatry in Dissent is sorely required today.


(reviewed June 2018 – broken link removed)

Shock Head Soul

At a recent Art of Psychiatry meeting we held a screening of the film Shock Head Soul which is about the experiences of Paul Schreber who, at the turn of the 20th century published a famous account of his experiences of (what others saw as) mental disorder.  Afterwards Helen Taylor-Robinson (psychoanalyst and fellow of the Institute of Psychoanalysis London) and Clive Robinson (psychiatrist) talked about their work on the film, with which they were both involved.

They’ve kindly answered some questions for this website which give a flavour of the film’s subject matter and themes.

FP: Can you tell us about the film and how it tells Schreber’s story?

HTR & CR: The film is an imaginative drama documentary based on the German judge Daniel Paul Schreber’s Memoirs of my Nervous Illness (1903). The film is in narrative form, set in the period of the late nineteenth, early twentieth century. It depicts the key episodes of Schreber’s illness, his admission into care and treatment, and his subsequent release by the courts, after his plea on his own behalf (through the Memoirs) to be allowed his freedom, even though he continues to be unwell.

Alongside the narrative, and woven into it, are sections of commentary brought to bear on important questions regarding Schreber and his condition, which several experts from the fields of present day psychiatry, neuro psychiatry, psychoanalysis, the arts and film history contribute to the debate about mental illness and its treatment and care. These experts are dressed in 19th century costume as if they were part of Schreber’s time, though they comment with the expertise of today. This blurring of time past with time present was a deliberate choice in making the film, in order to provide consistency with the way in which the various forms used in the film (documentary, animation, drama) are allowed to ‘bleed’ one into the other. This echoes an aspect of DP Schreber’s experience, where ‘reality’, ‘imagination’, and ‘delusion’ blend, interweave and collide and he struggles to make sense of it all. It also felt important to position the ‘expert’ commentators of today as somewhat in the same position as the experts of the late nineteenth/early twentieth century. That is, they are attempting to provide explanations, and suggest treatments based on the level of knowledge and understanding available. Our twenty first century knowledge may be more advanced in some respects, but it does not give us a definitive understanding, or a solution to many of the problems faced by Schreber, his family or the psychiatrists involved in his care. What we knew in the past about mental illness, its effects, and the most appropriate way of behaving towards someone like DP Schreber, may today appear to be better informed, may overlap with or may differ from then, but it continues to pose open and problematic questions.

Sections of the film also use animation to depict some aspects of Schreber’s delusional systems. Again the aim is to represent some aspects of the alternative reality experienced by someone in his situation and the suffering of those immersed in powerful internal processes. The viewer is subject to these ‘creations’ to some extent, as is Schreber. These animations form the basis of a separate art installation that has been staged alongside special screenings of SHS. The literal reality of these works of the imagination, conceived from the Memoirs by Simon Pummell the director, serves again to give weight and credence to the experience Schreber underwent.

Thus, the whole film is a complex interweaving of all these modes of communication with the viewer to try and engage affectively with Schreber’s circumstances—his detailed highly articulated personal autobiographical account of his visions/delusions and what he took them to represent. As a multi media work, Shock Head Soul, is a visual testament to the man and his belief system, a strange tableau of madness, and our responses to it, re-imagined.

FP: How did you come to be involved?

HTR: As a psychoanalyst (HTR) I had worked with Simon Pummel the film’s director some time ago when a film animation symposium was organized at the National Film Theatre where I commented with others (including Professor Ian Christie who also appears as an expert in SHS) on Simon’s work and that of another film animator Ruth Lingford. I have had an interest in the relationship of psychoanalysis to the arts over many years, and in particular to film, since the inception, in 2001, of The European Psychoanalysis and Film Festival (EPFF) that is held biennially at BAFTA by the British Psychoanalytic Society and to which I, and fellow psychoanalysts, film makers, performers and academics and have regularly contributed.

Simon got in touch about this project of his, something he has wanted to do for many years and together we worked, initially, the two of us, on the idea of the film, the background research for it, the seeking of funding and the working on several screenplays to completion, and I brought in my colleagues, including my husband, Clive Robinson, a Consultant in general psychiatry, and I prepared the questions with Simon for them to answer on screen. I am described as developing the concept of the film with Simon its director. We really enjoyed filming the interviews on screen with Simon and his crew—and then Simon shot the narrative with his actors, developed the animation and the art installation and the film went to the Venice Film Festival and the London Film Festival (2011) and the Rotterdam Film Festival (2012) and it continues its festival tour to the Czech Republic and Australia and then the UK this autumn.

I, and my husband and our colleagues have really enjoyed working in quite a different way on this film project, learning slowly what was wanted, and I have felt privileged to be asked to be involved. Psychoanalysts, despite Freud’s (among others) case study of Schreber which is part of our training and development, do not usually work with the floridly mentally ill, and they certainly do not (usually) become part of the creation of a film process—certainly not one as complex and, in my view, as original as this one!

FP: How is the Schreber case relevant today?

HTR & CR: Probably very few young trainee psychiatrists will read a first hand account of being as unwell mentally as DP Schreber is. Many psychoanalysts will only have read Freud’s commentary on Schreber, not his own memoirs, which this film is about. Sociologists, philosophers, professors of cultural studies, and others with political motives have focused on Schreber’s document, to make the case for a given aspect of interest to them, which Schreber’s story allows for—lends itself to one could say. Artists and writers, also, and those studying the religious aspects of Schreber’s delusional system, have something to say about this multi faceted document of madness—because there is so much first hand graphic detailed writing about an incomprehensibly mad experience that has very little apparent connection to our so called reality. To be with Schreber and try to follow him in his labyrinthine world is to submit to a very disturbing process. Yet Schreber makes his highly controlled vision available, powerful and immediate, even if, largely, ‘deadly’ to be in.

For most psychiatrists, and others in mental health services who spend time with seriously unwell people in their clinics or on the wards, many aspects of DP Schreber’s experience and behaviour will seem familiar. However, this kind of protracted and persistent monologue of madness is much less likely to occur nowadays, and his ability to represent his world in such an organized albeit complex fashion is far more unusual. In the twenty first century it would be extremely rare for someone to have Schreber’s type of experience without receiving very active interventions and treatment; at the very least the reasoning world would be much more likely to interrupt the experience continually and therefore dilute and diminish its power. Schreber’s story—in his memoirs—is unadulterated and horrifying, yet he is able to present it, and explain it, and account for it, on his own unquestioned terms. It allows all of us to try to imagine what it is like to be continually in the grip of something we usually have no access to whatever. This in itself is educative. But it also highlights the richness of our own less mad world and the riches of a different kind–that of Schreber’s. Should we not try to see such a different ‘other’ reality and discuss and debate and try to understand what we can from it?

In a sense independent of the actual content of his experience, once Schreber becomes unwell, the impact of the change in his behaviour on those around him, his changed position in the wider society, the question as to whether society has any right to interfere, where to treat him, whether to force treatment upon him, and when to allow him his liberty are as pertinent now as at the end of the nineteenth century.

FP: Which is most important, Schreber’s memoirs or Freud’s interpretation?

HTR & CR: As the film, SHS, points out all of us engaging with this subject of Schreber, are engaging with a text, not with a person and his experiences in situ, and we have no access to the actual events Schreber writes of—we have only his account. And Freud when he came to study the published Memoirs of Schreber, was doing so under the influence of Jung who was exploring the psychoses, and with a remit to further develop psychoanalytic ideas in relation to the psychoses, and to continue to refine his theories of psychic structures, to go on building his metapsychology. For Freud, without Schreber in the room to discuss all this with, in the give and take of an analytic process, as he states, his study is a severely limited kind of exploration—a nonclinical one—a theoretical one at a particular point in his own, that is, Freud’s, growth.

As to whose document, Schreber’s or Freud’s is most important, one can only answer from the perspective of the model of mind one is currently using to look at either. For psychoanalysts, like myself (HTR), we are reading and learning about a stage in psychoanalytic development—learning about the workings of paranoia, of grandiosity, of narcissism, of projection and repression, and Freud is an eloquent teacher, even if these ideas do not fit Schreber perhaps so well today, when we psychoanalysts have taken our discipline further. But the Schreber case by Freud is a piece of the history of psychoanalytic development, and, as such, is important reading for us. Inflected by reading Schreber’s memoirs themselves I would say—as John Steiner in his paper on Schreber does—(he uses Schreber’s writings AND Freud’s to go forward with his ideas drawn from psychoanalytic thinking of today)– the student psychoanalyst of the present, or indeed any other serious student of the mind, may judge and evaluate Freud’s work and that of Schreber’s together.

For those interested in other models of the mind, in literary, philosophical, political, social or indeed psychiatric frames of reference, Schreber’s memoirs are primary, Freud’s secondary. Overall Schreber’s testament as a statement about what it is to be human and suffer in this way is highly and disturbingly original—in that sense it has import beyond Freud’s case study. For psychiatrists the text of DP Schreber provides the working document of someone struggling with all his intellectual powers, with all the structure provided by his legal training and with his very considerable personal strength, to make sense of his experience and the meaning of his life.

FP: How was the film’s title decided on?

HTR: One of the features of this film was the interest in Schreber’s father, Moritz Schreber who was an educationalist who developed ideas and practical equipment for the controlling and rearing of children in Germany—he was held in very high esteem and his methods and equipment were tried out on his son and were very popular indeed throughout the land. They may appear barbaric in conception and application to our eyes—and yet at the time were acceptable ways of trying to manage the impulses and primitive behaviours of young children. As well as attempts to control the body, the control of conduct and morality was disseminated by such very popular children’s illustrative books like Strewwelpeter,(by Dr Heinrich Hoffmann) which means ‘shock headed peter’ in which a boy is denigrated for leaving his hair and his nails to grow long and dirty—these are cautionary tales with vivid words and pictures– to frighten or shame a child into obedience, cleanliness, tidiness, and more.

Although one of the views of Schreber is that a lot of the content of his delusions may owe something to his father’s physical treatment of him, for his own good as it were, the question of its arising directly from this environmental impingement is another matter. Did Schreber senior bring about Schreber junior’s psychotic breakdown? This is speculation as we now know more of the likely organic sources of the psychoses rather than as a result of external forces. But ofcourse those external forces come into play in the psyche’s use of them as the illness develops.

So it was thought that the popular children’s book (quoted directly in SHS where a child’s thumbs are cut off for thumbsucking—and this rhyme Schreber repeats to himself in his padded cell –with a reference to his castration there in isolation and further withdrawal from others) could have its title adapted and that Schreber could be seen as the outcast or naughty boy, Strewwelpeter, with not just his body or his conduct treated with unenlightened methods, but also his soul itself—subjected to physical and intellectual methods of care within German psychiatry and its institutions. The use of this widely known text, Strewwelpeter, thus adapted, is an intended symbol—one of many compressed poetic references the film uses to tell its’ tale. In addition,, the term ‘soul murder’ is coined by Schreber (Chap 2 of the Memoirs) to refer at length to the means by which, in Schreber’s view, his soul, and that of others, at different times and for different purposes, was procured and possessed by ‘another’ in order, among other things, to prolong life for that soul at the expense of the ‘stolen’ one—to which terrible things were also required to be done.

FP: What has been the reaction to your film?

HTR& CR: I think we have been pleased that the unusual subject matter and its complex treatment has won attention, raised questions, moved and saddened audiences and overall held and engaged them. At the Venice Film Festival the question was put as to whether we feared this film would actively make people feel mad. It seems to me a question to ask—but it has not been the usual response. We hope it reflects on madness rather than engendering it—but of course it depends on the viewers and film is a very powerful medium—it is a powerful introject, to use a technical term, and it needs working on and shaping after the experience, but it is also a powerful provoker of projections—and things are attributed to it that come from the viewers rather than the film itself necessarily.

Usually people have said, in question and answer sessions after the screenings, how serious and dignified a picture it is of mental illness, those with a serious mental illness have said it felt like the most authentic account of what it is like to be ill in this way, others have been perplexed and have felt the film gives no clear or straightforward answers, and yet as those behind its creation would argue, this is a good not a bad thing—the film certainly bears viewing several times. It may be that paradoxes rather than simple yes or no answers are there to be found in the film if it can be digested slowly. And people have also said how surprising it is that such an amalgam of forms and structures and methods of film making have come together successfully into one.

We do hope that with screenings and discussions and dissemination of the ideas around Schreber, —whose work is such a complex one in its own right–that Shock Head Soul a kind of testament to the art (skill) of the insane will take off for the viewers, get challenged, debated, questioned and hopefully enjoyed also, and come to have a life of its own and a proper place in the genre of truly experimental film.


(June 2018 review – broken link fixed)

Review of ‘The Greatest Silence: Rape in Congo’ screened at the RSM Global Health film club 28 March 2012

The author Philip Gourevitch once wrote: “Oh Congo, what a wreck. It hurts to look and listen. It hurts to turn away”. Exploited and misruled for much of its modern history, this country has spent more than a decade in a state of semi-permanent civil war.  5.4m people have died, mostly from disease and starvation, and Congo’s abundant mineral resources bring nothing but the worst kind of exploitation.

Directed in 2006 by Lisa F Jackson, and shown recently at the RSM’s global health film club, The Greatest Silence: Rape in the Congo concerns a further tragic facet of this conflict: the systematic rape of Congolese women.  “Rape” is actually a rather mild term for the violations suffered.  Many of the women subsequently require surgery for fistulas, having been deliberately mutilated and 30% will be HIV positive.  This gender violence is not a consequence of the war, but a key mechanism in its execution: both as a demonstration of power and a form of social control.  Raped women are likely to be abandoned by their partners and ostracised by their communities; children born as a result of rapes carry their own stigma.  Jackson has a connection with this subject that no one would wish on themselves: she was gang-raped herself in 1976, an experience she shares with the women she interviews.

Filming takes place in South Kivu province, 3572sqkm and 141000 in population.  It is part of the ‘red zone’ and has known incessant fighting during the conflict.  Healthcare services are often poorly equipped and serving the area are twenty-seven health centres and Panzi hospital.  The gynaecologist there, Denis Mukwege, works eighteen hour days repairing severely damaged genitalia.  Some of the women may also be doubly incontinent and require multiple operations.

During and after the screening, this question is with me: who are these men who commit these acts, and how can they act in this way?  I refuse to believe that Congolese people are any different to any of the rest of us, but some of their number act in ways that are cruel and barbaric beyond expression.  In the film, and with rather more disregard for her personal safety than I can muster, Jackson ventures into the bush and meets some of them.  From behind scarves and dark glasses they admit their crimes, but otherwise give little away.

Perhaps their casually brandished weaponry reveals more.  During the post screening discussion one of the panellists explains that many of the soldiers will have joined the militia in their early teens.  Initiations whereby they will have killed their families and raped their own mothers are not uncommon.  With a weak central government, Congo is unable to protect its citizens and the brutalisation of its people stretches back several centuries.  This is a thoughtful and powerful film, and I hope that someday the Congolese will be able to make films of their own.

Books about Congo:

Dancing in the glory of monsters: The collapse of Congo and the great war of Africa – Jason Stearns is interesting and comprehensive

Blood River – Tim Butcher.  Butcher sets off to navigate the Congo river and reports on what has become of the DRC

The state of Africa – Martin Meredith.  A riveting history of Africa post independence.

This also published on BMJ blogs


(June 2018 review – broken link removed)

Can incarceration be thought of as disease?

This review by me in the BMJ

It’s fashionable to treat social problems as if they were diseases. Stephen Ginn reflects on a book that considers an epidemiological solution to the huge and rapidly rising prison population in the United States

Among its many marvels, some things about the United States of America are stubbornly unfathomable. The persistent, widespread opposition to socialised medicine is one of them. And despite a murder rate impressive for all the wrong reasons, US gun laws remain unreformed.

Add to this America’s prisons. This is not an area in which the United Kingdom basks in glory, but the American dedication to incarcerating its citizens remains without rival. “If this population had their own city, it would be the second largest in the country,” dryly remarks author Ernest Drucker.

The numbers tell the story: of a population of 310 million, 7.3 million people are under the control of the US criminal justice system. Of these, 2.3 million are imprisoned, 800 000 are on parole, and 4.2 million are on probation. The US has 5% of the world’s people but 25% of its prisoners. This section of the US population grew fivefold between 1970 and 2009.

Drucker, an epidemiologist, sees this increase as a plague and amenable to examination using the tools of his trade. Although imprisonment is not usually considered a disease, this framing isn’t meant to be metaphorical. The American fondness for imprisoning its citizens meets all the key criteria for an epidemic: its growth rate is rapid, its scale large, and it shows self sustaining properties.

During London’s 1854 outbreak of cholera, John Snow’s insight famously led to the removal of the handle of the Broad Street water pump. Soho’s residents could no longer drink its contaminated water. What is the pump filling America’s prisons, and is it possible for the handle to be removed? Drucker shows how in one state­­—New York—the rate of incarceration clearly surged from the 1970s. This coincides with the introduction of the state’s so called Rockefeller drug laws: punitive legislation introduced in response to a rise in heroin use in the 1960s. These laws made it possible for those caught in possession of even small amounts of illegal drugs to receive the same sentences as imposed for violent crime. Similar legislation would be enacted throughout the country.

Most of New York City’s prison population comes from just six neighbourhoods. This echoes the distribution of deaths on the Titanic, which reveal the rigid social structure of the Edwardian era. On the Titanic, those in the highest social class were more than twice as likely to survive as those in the lowest social class. In New York some areas are plunged into near anarchy by the so called war on drugs being waged on their streets, while others are almost untouched.

Incarceration also causes disability, just like disease, and is passed on to future generations, just like disease. The children of families where a member is incarcerated have a lower life expectancy and are six to seven times more likely to go to prison themselves.

The notion of applying an analysis to social problems that is more conventionally used to understand disease has gained recent cultural currency. The Interrupters, a 2011 feature length documentary, focused on CeaseFire, a Chicago antiviolence programme that deploys street workers as mediators between factions during incipient street conflict. It was founded by Gary Slutkin, another US epidemiologist, who considers violence to be primarily a public health issue. Slutkin has publicly encouraged David Cameron to adopt CeaseFire’s approach in London.

Something must be done about prisons, but is this the way ahead? Labelling people as victims of a plague has never been a good way to rehabilitate them back into society. No matter how neatly it may fit a disease model, bringing epidemiological theory to bear on the problem of prisons reframes that problem as something dispassionate and treatable, when in fact it is intensely political. Drug laws may be America’s prison pump but behind those laws lies the willingness of lawmakers and politicians to treat marginalised groups and their problems within a punitive criminal justice framework. If drug laws are reformed then opprobrium for other misdemeanours may take their place. Some US schools now use police to enforce school discipline, for example, and increasing numbers of children are being convicted via this route.

This criticism is unacknowledged by Drucker, but to his credit, the public health response he offers to high levels of incarceration is more radical than might be expected. It’s no surprise that he writes that, as primary prevention, drug laws like the Rockefeller laws have to go. Secondary prevention involves prison reform. But as tertiary prevention, and to address the “great task of healing to be done on both sides of crime and punishment,” he proposes a programme of restorative justice in a shape of a formal peace process, not unlike South Africa’s Truth and Reconciliation Commission.

In a time when public inquiries are not in short supply, it’s easy to be cynical about such a suggestion, as it is about Drucker’s approach in general. But this book is accessible and persuasive. Prisons on both sides of the Atlantic represent an immense waste of human potential and financial resources. The questions of what to do about them need to be asked more often. This analysis has much relevance beyond US borders; British incarceration rates are lower, but the UK has one of the highest rates of imprisonment in Europe. Successive recent governments have presided over a steadily increasing UK prison population that has doubled in 20 years.


(June 2018 review – Ceasefire is now known as ‘Cure Violence’ it seems)