Archive for the ‘Books Films Television’ Category

Science Tales review

Wednesday, May 30th, 2012

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.

Psychiatry in Dissent revisited

Wednesday, May 23rd, 2012

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.

Shock Head Soul

Sunday, May 20th, 2012

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.

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

Friday, April 27th, 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 (there’s a free copy on Scribd here, which I don’t supposed he’s very happy about) 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

Can incarceration be thought of as disease?

Thursday, April 19th, 2012

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.

Interview with writer Will Self part 2

Monday, April 16th, 2012

Will Self interview by Prof Femi Oyebode (part 1 with me found here) in November 2010

WS: I’ve been very interested in the psychiatric profession and though out my fiction and my nonfiction and have written on visions related to psychiatry, so in a way when it comes to reading to you I’m presented with an embarrassment of riches. So I’m going to confine myself to my latest book, available in all good bookshops at the seductive price of £17.99. No one, not even the most exalted mental health professionals would see this for a second as being in any way analogous to £18 but will see it as significantly cheaper. It’s called Walking to Hollywood and it’s a sort of fictionalized memoir which in itself arouses some interesting questions about relationships between mental states and what philosophers call ontology, the nature of reality in a wider sense.

Just by way of an introduction to a couple of short readings, as it’s a fictionalized memoir and the ‘I’ in the fictionalized text and me are the same person.

(Reading – I’ve not transcribed this for copyright reasons, but extracts are legitimately  available here and here)

FO: Thank you very much for that Will. One of the intriguing things about that reading was how it is both fiction and autobiography, and I was wondering how far the fiction had in it ‘real life’.

WS: Well my grandfather was a relentless autodidactic who, whist working as civil servant gained eight degrees by studying during his daily train commute to London. He did write a thesis called ‘The Divine Indwelling’, which was an attempt to reconcile Existentialism, Christianity and Western science. That’s true.

I was prescribed those drugs; I did decide not to take them and tied a knot in the bag and threw them on top of a shelf. Indeed they were up there until I wrote that passage, when I finally got them down and disposed of them in a suitably irresponsible fashion.

FO: And Dr Busner?

WS: Dr Busner doesn’t really exist but is a character who exists in a number of my different narratives. He’s a consultant psychiatrist in a place called Health hospital which doesn’t exist either, although it’s quite easy to guess which hospital it might be modelled on. He doesn’t exist, but he acquires an existence by being present in different narratives appearing in my novels and short stories; I think that gives him perhaps a greater level of reality than a lot of fictional characters.

He’s based to some parts on R D Laing and the anti-psychiatrists of the 1960s. I was very influenced by books like Thomas Szasz’s the Myth of mental illness and Laing’s The Divided Self and most specifically by Szasz’s concept of the ‘therapeutic state’ and the idea of the psychiatric profession being responsible in our culture for policing behaviour in ways that perhaps neither the profession itself nor the wider society are actively aware of. He’s also based in some other aspects on the neurologist Oliver Sacks as well as people I’ve known over the years. Busner is a way for me to examine in fictional terms the role of the psychiatrist in our culture and what the psychiatrist represents. He’s described in one of my books as a kind of almost religious figure, almost like some kind of shaman or witch doctor.

FO: Can I draw you out a little bit about the question of characterisation. One of the things I find wonderful in your writing is the way in which you create these very strong characters. They could easily be in plays and I was thinking of Ibsen, for example, saying that when he is writing a play, he thinks during the first draft that he knows his characters like he might someone he has met once. When he writes the second draft he feels like he’s spent a month with them on his farm. Then when he writes the third draft, he thinks that he knows him as well as he knows his friends.

With characters like Shiva Mukti and Zac Busner, how do you create them? Because they do feel real. I know they are fiction, but there is a sense in which you feel that they are real.

WS: Shiva Mukti is a protagonist in a novella I wrote called Dr Mukti. The second protagonist in that novella is Dr Zac Busner and these two psychiatrists find themselves engaged in a duel – or at any rate Shiva Mukti thinks they are engaged in a duel – where they attack each other using psychotic patients as weapons, whom they send to each other for diagnoses, with the knowledge that having appended falsities in the case notes, their colleague may well make a mistake in terms of diagnosis and then reap the consequences which could potentially be fatal. It’s in many ways an engaging – or non-engaging – fantasia, but it’s based in reality like of a lot of what I write.

It’s interesting that you should pick on Shiva Mukti as a character. I don’t think of myself as a writer of character in particular at all. I would say that he’s probably one of the few characters I’ve created who has a more or less conventional depth psychology. I don’t know how many of you here today read much fiction. There are certain assumptions in naturalistic fiction about how and what you can convey in prose narrative of individual psychology.

What you said Femi about Ibsen, though he’s a playwright, applies to what conventional writers of fiction at times do. I’m not a naturalisitic writer and the reason I think that most people, if they read a lot of fiction, find characters in fiction believable as people is because they have constructed their own persona from reading fiction. In other words I think it’s a self-fulfilling prophecy. However in that particular novella I needed a character to contrast with Zac Busner. We never really know Dr Busner in Dr Mukti except through Shiva Mukti’s perception and it becomes clear, without giving too much away, that Shiva Mukti is himself mentally ill. I needed him to have that kind of naturalistic humanity in that way. And how did I construct the character? I think that all fictional characters are kind of ‘us’. They are usually based on a number of people the writer knows, their characteristics cut up and sewn together into some sort of Frankensteinian figure.

FO: There’s a theme in your work where psychiatrists, I suppose through their patients, themselves have pathology in them. That’s quite an interesting way in which you’ve got the patients in the asylum but you’ve also created the similar problems in the psychiatrists I was wondering why you were doing that?

WS: Well, in terms of iatrogenic disease, psychiatry is well ahead of the pack. The phrase in the pharmaceutical industry I believe now is ‘conditioned branding’ whereby a certain psychiatric pathology is devised or defined in order to provide a market for a certain neuropharmaceutical product. That is an iatrogenic disease. This is going on all the time and it goes on more in psychiatry than arguably in any other branch of medicine. So in seeking to establish that the psychiatrists themselves are afflicted with a pathology I’m making a comment on the iatrogenic propensity of psychiatry itself. Primarily my use of psychiatry is supposed to establish what psychiatry is doing in our society which neither its practitioners nor the wider society may be aware of and then to satirise it.

Question from floor: You mentioned about Zac Busner that he can be a tool for exploring the role of psychiatrists in society today and their ‘policing’ of social behaviour, but what should be the role of psychiatrists be in society today?

WS: That’s a very interesting question. I started off at some point saying that when I was a young man I was very much influenced by RD Laing’s writings and very much viewed psychosis as a radical lifestyle choice. And then as a result of that I put my money where my mouth was and found myself living in my own version of Laing’s Kingsley Hall with a group of psychotic outpatients in a mental hospital and rapidly reached the understanding that in fact psychosis is not a lifestyle choice at all, it’s a mental illness. So don’t get me wrong. I’m not one of those people who say that there shouldn’t be psychiatrists or that mental illness doesn’t exist, I know it does. I think the job of psychiatrists is to treat mental illness, pure and simple. Far be it from me to tell you your job in its practical application but I think that the criteria used and the way in which we understand what mental illness is is in question. And nor do I think that the psychiatric profession necessarily are the worst offenders of the problem we have in understanding what mental illness is. If you’ll forgive the extended pun, there’s a folie à deux between the wider society and the psychiatric profession in regard to that and that’s where the problem is and where I think the confusion sets in.

Let’s not forget that this is an evolving thing. In the 1950’s and 60’s there were 120 000 people in this country in total institutions in one kind or another. So we have changed in our attitudes and we continue to change our attitudes. I don’t want to demonize the psychiatric profession because in a way you get loaded with society’s dirty work. But put simply psychiatry’s job is to treat mental illness, nothing more and nothing less.

Question from floor: Critiques about medicalisation of normal life leave psychiatrists between a rock and hard place and in our culture. On the one hand we are criticized if we are paternalistic. On the other hand if we don’t attempt to define the diseases we treat then patients are given the ‘keys to the shop’, which also has its problems. Where do we draw the line?

WS: There have been some colossal howlers within living memory in your profession. There are many many thousands of people with extra-pyramidal side effects who were classed as catatonic schizophrenics and held in total institutions for many years. Nobody is responsible for that except for paternalistic psychiatrists.

You could argue that medical science had not advanced far enough for the diagnosis to be made, that’s not actually true. You could also argue that society wished for a total institution programme to exist. I’m not sure. Of course when you come to people who are, to use probably an expression that is outmoded in the profession, engaged in inadequate reality testing and to actually hand over to them the keys to their own sins on the face of it is an absolutely mad thing to be doing. But on the other hand I’m very concerned and have been concerned throughout my writing career with kinds of collusion that particularly affect who are placed in positions of professional expertise. I don’t think that the psychiatric profession is by any means unique in this but I do think that all professions need to be very alive to these tendencies. The tendencies to create forms of arcane knowledge that are not accessible to lay people and to hide behind that. In as much as I agree with you that there is a real difference of kind between serious mental illness and what could be regarded epiphenomenal forms of that: neuroses of various kinds. I think again there is an unconscious collusion between the profession and the wider society to allow the profession to police that boundary.

Question from floor: Medicine generally is responsible for some ‘real howlers’ in the past – and psychiatry as well – and will continue to do so to a large extent because of the relationship we have with society as doctors. One of the problems is that the brain should be an organ that gets diseased as well, it shouldn’t be protected but it’s not the liver and it’s not the kidneys, it’s who we are, it’s our very essence, it’s the human condition. We all find it a problem when it goes wrong and I think one of the bigger problems is that none of us, especially lay persons, are clear about what constitutes a mental illness and what constitutes the rough and tumble of normal life and we in a sense sup with the devil on that one because there are some psychiatrists who are willing to go down that route and profess to make comments about all sorts of human endeavours, activities and behaviours as if they’re psychiatric conditions. If you ask a cardiologist on something that’s got nothing about cardiology he’ll say ‘I can’t answer that as a professional, but I’ll answer it as a lay person’. But many psychiatrists are unwilling to do that and they medicalize all of human behaviour. My concern with psychiatry is around the areas of depravation of liberty and the perceptions of dangerousness which is primarily driven by the public and by commentators. Those are the areas that worry me because that determines how we work.

WS: Yes I would agree with where you paint the problem. Interestingly that’s another aspect of my psychiatrist Zac Busner; he’s a kind of media doctor. So that is exactly what I was satirizing. But it’s easy to understand as well why, that of all things psychiatry is seen to be the right profession to be doing that. Here you are, the people qualified in science but you’re treating not of the brain but of the mind, so you seem to represent the interface between the mechanistic, physical explanation of the world and whatever other meanings we wish to ascribe to our existence. So it’s very easy to understand that if one of your kind goes to the dark side it’s going to be that much more dangerous than it might be for a cardiologist or a podiatrist.

The other thing that I’ve been most concerned is about, and I’ve written about a lot in my fiction, is the impact of neuropharmacology. That concerns me a great deal. I don’t necessarily think – and I’m aware that I’m in a room full of psychiatrists and I’m not looking to make a swift exit out the back – that psychiatrists are the worst offenders in terms of what we described as ‘conditioned branding’, I actually think that the foot soldiers in that tendency are General Practitioners. And also what can you do when we have now reached the situation where the public collectively now know how to approach a dispensing doctor in such a way as to solicit an anxiolytic medication of some kind or another? I think we need to maintain a very critical view of all of this, and I think the profession in and of itself, and maybe goaded on by people like me, needs to be involved in a continuous and evolving discourse.

Question from floor: I think that it’s interesting the shift you made from writing fiction where you can be in control of your characters and be quite sheltered to then a fictionized memoir in which you leave yourself open and reveal a lot about yourself, but still retain the power to change whatever elements you like because it’s fictionalized. I just wondered what made you choose to do that? And I think it’s interesting given what Ruby Wax was saying before, talking about stigma, and making herself a poster person for mental illness. She said that she didn’t volunteer to be a face for Time for Change.

WS: What pathology does Ruby Wax cleave to? I only ask this as a point of information.

Floor: She was talking about her experience of bipolar disorder.

WS: Bipolar, that’s a corker isn’t it? There was a very good article in the London Review of books’ last issue on bipolar disorder. I mean again following on from what you were saying: this idea that there are, these quite dangerous people from the profession who adopt this role of medicalizing conditions that are just part of the hurley-burley of life. The celebrity authorities are equally dangerous for almost exactly the same reason. One thinks immediately of Alastair Campbell as I do – on waking – with the feeling of deep and numbing rage – or indeed Stephen Fry who can make me feel quite nauseous at almost any hour of the day. People who witting – or not – are doing exactly the same thing, they are placing expectations on you as a profession that you will be able to provide some sort of pill for every ill.

I’m not really answering your question because the answer is inadvertent in a sense. I wanted to write about various things and I found I couldn’t write about them within the established rubric of factuality. So, like a lot of things I write it was a form as on-the-job experimentation using my own psyche as the test bed. So I didn’t set out to reveal or not reveal particular things about myself. It’s actually on the public record anyway some of the things I’ve said about my own history of either what you might call ‘mental illness’ or of being diagnosed with mental illness. I’ve written about it and spoken about it before, so that wasn’t why I choose to use myself as the protagonist.

There’s a connection with a film I recently saw called Hancock. It’s about a superhero living in modern LA, and there were some scenes in that, as there are in quite a lot of contemporary Hollywood films, I thought were psychotic, that they were like people’s experience of psychosis must be. They had a sense of great believability and you could suspend disbelief in them but in fact what was happening in these scenes was suspension of all kinds of natural laws and so on and so forth. So it was an interesting exercise to write from a protagonist’s point of view about experiencing that. So as mental health professionals next time you see one of these extravagant CGI sequences in a Hollywood blockbuster try and think about it as really happening and what that might be like and then snapping back to reality. That might be quite a good way into the mental states of some of your patients. And of course that’s something one can only do fictionally.

FO: I wanted to finish with one or two words. Will Self’s writing is absolutely incredible and I think we ended on what is quite so important about his writing from a psychiatrist’s point of view. Of course he’s commenting on the world we inhabit, on a day to day basis, as psychiatrists and commenting on the hospital environment, commenting on people’s emotional experiences and commenting how people might depart from their sense of reality that we all take for granted.

But he does something else we haven’t talked about today which is that he bends language so that he to express the world that he’s created for that particular story, or for that particular novel. And of course as psychiatrists we also have a day to day contact with patients who use language in an awkward, novel, original kind of a way. So I think there’s a lot to learn from what Will Self does and it’s been marvelous listening to him talk with his exposition and also for him to challenge us in his usual subtle way.

Art of psychiatry: Richard Dadd

Saturday, February 18th, 2012

Richard Dadd (1 August 1817 – 7 January 1886) was an English painter of the Victorian era. Following a long tour of the Middle East in the early 1840s he succumbed to a schizophrenia-type illness, following which he murdered his father and fled to France where he attacked another traveller. After his return to England he spent over forty years in the Bethlem and Broadmoor, during which period most of the works for which he is best known were created.

Dadd’s painting The Fairy Feller’s Master Stroke is featured on the cover of a recent British Journal of Psychiatry. Nicholas Tromans, a Senior Lecturer at London’s Kingston University, is widely published on the subject of 19th century art and is author of Richard Dadd: the Artist and the Asylum. He came to talk to The art of psychiatry society (with which I am involved) about Dadd’s life and mental illness:

AoP: As a young man, how did Dadd go about establishing himself as a painter in London?

NT: It seems that Richard owed a great deal to his father, who had been a high-street chemist in Kent but who, when Richard was a teenager, took over a gilding business in central London which must have had many professional artists among its clients. Dadd’s own beginnings as a professional artist were really entirely conventional. He became a student at the Royal Academy (virtually next door to his father’s shop) and made studies after the sculptures at the British Museum. He appears to have been extraordinarily self-confident, and was soon sending his pictures to exhibitions in London and in places like Birmingham and Manchester. He managed to attract the patronage of both London aristocrats and the self-made men of the industrial cities – as well as the support of some influential critics. By the time he left for his tour of the East in 1842 he was one of the risng stars of the London art scene.

AoP: What do we know about how and why he killed his father?

NT: Towards the end of his tour of the Mediterranean, in the Spring of 1843, Richard began to suffer from delusions – that there were people trying to harm him, perhaps that he could see the devil in human forms. Many of those who had known him were worried by his unusual behaviour after his return to London, and his father consulted a psychiatrist at St Luke’s – Alexander Sutherland – who recommended hospitalisation. Possibly in response to this suggestion, Richard carefully planned a knife attack on his father, which succeeded in killing him. Richard was soon afterwards arrested and eventually sent to Bethlem Hospital in Lambeth. Later Dadd explained that the killing had been required of him by the Ancient Egyptian god of the dead, Osiris, and that although Richard approved of the destruction of the imposter who claimed to be his father, he was in effect only an instrument in the hands of the deity. It was a fantastic delusion, but one in keeping with Richard’s larger set of beliefs about the continuing truth and relevance of the philosophies of ancient cultures.

AoP: What do we know about how he was as a patient?

With regard to his time at Bethlem (1844-64) – not a lot. There are really only two entries in his casenotes, and the first of these dates from as late as 1854. This entry describes how violent Dadd was considered when first admitted, and how he would suddenly strike another patient without provocation (and then immediately apologise). The formal designation of ‘dangerous’ was applied to Dadd even during the last years of his time at Bethlem. I infer from the lack of detail in the notes, however, that he was by and large not an especially troublesome patient – not one who required strategies to manage. That he painted ambitious pictures for the two senior managers of Bethlem – paintings which he worked on for years – suggests some kind of relationship between patient and staff, although certainly not an uncomplicatedly collaborative one.

AoP: Why was he transferred to Broadmoor?

Dadd was admitted to Bethlem as a Criminal Lunatic – someone too unwell to be punished for a crime, or (from the 1840s) one too unwell to stand trial at all. This meant being placed in a special wing of the hospital in very cramped, minimally furnished, high-security conditions. It was obvious to the authorities that something needed to be done with this novel legal category of prisoner/patient, and a dedicated new hospital was made possible by an Act of Parliament in the early 1860s. This was to be Broadmoor near Reading, to which Dadd was transferred along with his fellow male Criminal Lunatics, in 1864, and where he died and is buried. There were those – among them the Superintendent of Bethlem – who feared that gathering together these cases out in the countryside would produce “a bastile of lunacy”, feared and resented by the public. These critics were to be proved at least partly right, but for Dadd the change brought improvements. By any common-sense criteria of well-being, his life got better: he was able to see more, to move about more; he took an interest in cricket and chess; and the range of media in which he himself worked expanded.

AoP: How has Dadd’s legacy been regarded after his death?

Dadd’s meticulous watercolours never entirely went off the radar of the art market. Collectors were able to buy them as they left Bethlem and Broadmoor by one route or another. The V&A and the British Museum both acquired watercolours by Dadd while he was still living at Broadmoor. But after his death there were really only a series of false starts when it came to retrieving his biography and reconstructing his oeuvre. Various people had a go, but there was just too little to go on. Things changed only in the 1960s when the Fairy Feller arrived at the Tate and when Bethlem acquired a dynamic and imaginative archivist who was in a position to become Dadd’s first proper biographer. This all coincided of course with the passionate debates generated by the so-called anti-psychiatry movement, and Dadd – in the guise of heroic ‘survivor’ of the Victorian asylum – seemed suddenly of acute cultural significance. Interest in him has calmed down since. As I say in the preface to my own book on Dadd, I have not tried to resurrect him as a hero of any kind: I have tried to understand him as a wonderful artist – one of the most exciting of the Victorian age in my opinion – who happened to spend his career in unusual circumstances.

AoP: Despite his situation, Dadd’s pictures seem untouched by the content of his delusion and he never addressed asylum life in paint. Can you reflect on this?”

Well, “sane” Victorian artists rarely painted the streets on which they lived, or pictures which sought to sum up their philosophies of history. They were typically more interested in the same kinds of things on which Dadd remained fixed, that is, the topography of exotic places filtered through the memory, portraits, and illustrations to literature. Dadd had never been a Realist — on the contrary he was from the start of his career a painter of poetic imagination. And in any case, one reason for spending so much time thinking back, visually, over his time abroad in the early 1840s must surely have been a need to escape from the very limited environment in which he had to live.

AoP: And where can interested people see Dadd’s stuff?

NT: Not a lot of oil paintings in public collections (the watercolours can only be shown periodically of course because of their vulnerability to light).

The Scottish National Portrait Gallery have Dadd’s wonderful portrait of Dr. Alexander Morison:

Tate Britain Dadd collection

And just last year, the Harris Museum and Art Gallery in Preston acquired the early fairy subject Puck which had been in a Preston collection in the nineteenth century

The best place to head is however Bethlem Hospital itself where a substantial number of Dadd’s works can be seen in a context which helps make sense of them.

A small collection of Richard Dadd’s paintings is being exhibited Feb – April 2012 in the Bethlem Hospital museum – details.

Links:

Richard Dadd: The artist and the asylum on Amazon.co.uk

This clip of a Richard Dadd painting being discovered on Antiques Roadshow is worth a watch (starts at 4:24)

Tate channel: Richard Dadd the artist and the asylum (recommended)

Wikipedia

Richard Dadd: Masterpieces of the asylum Independent 2011

Richard Dadd: Madness and Beauty Telegraph 2008

Review of Artist and the asylum:
Guardian A S Byatt September 2011
Telegraph Nicholas Shakespeare July 2011

RSM Global health and human rights film club: Living in emergency

Tuesday, September 13th, 2011

Buy from Amazon.com

The RSM’s Global health and human rights film club launched on 8 September 2011 with a screening of director Mark Hopkins’ Living in Emergency.

Filmed in the war-zones of Liberia and Congo it follows four volunteer doctors providing emergency care under the aegis of Doctors Without Borders/Médecins Sans Frontières (MSF).   The film’s urgent title is borne out by its content.   The doctors work in chaotic overcrowded clinics, there is limited diagnostic equipment and often they have sole responsibility for the lives of all the patients they treat. 

The stress of this situation runs through every frame and every line of dialogue.  “The demand is pretty much infinite” says Dr Christopher Brasher.  “It’s just a matter of choosing what you can do”.  The film shows that the inadequacy of what MSF’s doctors can offer is in direct contrast to the enormity of the task with which they are faced. 

Brasher, a veteran of several conflicts, wants out but wonders where he should now call home.  American surgeon Tom Krueger works in Monrovia’s only emergency hospital and is on his first assignment, having grown disillusioned with the contribution he could make at home.  He appears to cope the best, but struggles to live with his inevitable mistakes. 

Davinder Gill, 26 years old and working in remote bush, is overwhelmed and exhausted by his responsibilities.  His irascibility makes him the most compelling character, his frustrations leaving him unguarded in front of the camera.  Perhaps inevitably Chiara Lepora, the head of the Liberia mission, compares him to Conrad’s Kurtz, driven mad by the insanity that surrounds him.    Like the majority of MSF doctors who never make it beyond one 9 month mission, Gill is unlikely to volunteer for a second time.

When conflicts end, healthcare needs remain and the film sensitively shows how difficult it is to leave.  Also here are the gore, personal conflicts, and difficult compromises that day to day MSF work entails.  This is no recruitment film for MSF, but a forceful character study of people close to their emotional limit. 

It’s a shame that couldn’t have gone a bit deeper, as its subjects’ back stories remain untouched.  A more serious omission is total lack of any local viewpoint on MSF interventions or volunteers.  Without this, their suffering becomes a mere backdrop for the disillusionment of Western idealists.

Living in Emergency press page for further reviews

Also published on BMJ blogs

Trouble in mind – review

Sunday, September 11th, 2011

Amazon.co.uk link / Amazon.com link

I was asked to review this book for the British Journal of Psychiatry.  For various reasons I wrote two different reviews of which this is the first; the second will appear in the journal and anyone keen can compare the viewpoints for subtle differences.

 

When critics state that psychiatry lacks both a firm logical foundation and a grounding in psychology and neurobiology, Prof MacKinnon thinks that they have a point.  In addition he considers that psychiatrists have no clear concept of ‘the mind’, the organ we treat.  This is in contrast to other medical specialties; whilst a psychiatrist would struggle to explain what ‘mood’ is for, a renal physician could easily relate the dysfunction of a diseased kidney to its proper physiological function. 

It is these failings that Trouble in Mind seeks to address.  The unorthodoxy of its approach is to build up, from first principles, a functional model of the mind (‘a function of brain’) and to place psychiatric problems within this working system.  With the brain’s shape and structure as a starting point, three further levels of increasingly complex cerebral activity are examined in detail.  At each level adaptive function is linked to the dysfunction seen in mental disorder

Trouble in mind threatens to be a classic of non-mainstream psychiatric thinking.  It has a novel approach that makes intuitive sense.  MacKinnon’s influences are clear.  McHugh and Slavney have been colleagues, and he cites their classic The Perspectives of Psychiatry (amazon.co.uk / amazon.com) several times.  As an ‘introduction’ it is cunningly aimed at trainees who may be open-minded enough to pick up and run with its ideas.  But alas it ultimately fails to deliver. 

The concluding chapter ‘psychiatric mind’ is problematic.  This is dedicated to the treatment of mental illness as a problem of the adaptive mental functioning the book describes.  As the book’s crucial denouement one might expect this chapter worthy of detail but curiously it is only twenty pages long and MacKinnon’s argument is left underdeveloped and unfinished.  The reader is left without adequate guidance as to how a disciple of these insights might integrate them into everyday practice and research. 

Perhaps a second edition could address this shortfall.  I hope so, as MacKinnon has a good point to make, a clear command of his subject and this book is well written and never dull.

Book website

 

Smile or Die/Bright sided by Barbara Ehrenreich

Monday, August 22nd, 2011

(Smile or Die -  UK edition / Bright Sided - US edition buy at Amazon.com)

Smile or Die is social critic and author Barbara Ehrenreich’s examination of the stronghold that positive thinking has on America.

She first encounters this close-up when diagnosed with breast cancer.  She is encouraged to be positive about her condition, almost to the point of considering it a gift allowing spiritual growth.  Rather than embrace this way of thinking, she finds it sinister, and the pink ribbon she is offered infantilizing. 

Looking further afield, Ehrenreich finds that the notion that positive thoughts lead to positive outcomes is pervasive.  She can find no scientific evidence for this, but regardless the notion has become the basis for several best selling books, including The Secret.  The threat is, Ehrenreich writes, that if you do not think positively then you will not thrive.

Ehrenreich says that positive thinking has also percolated into the work sphere.  She identifies this as a source of social control.  People who are laid off are told this is an ‘opportunity’.  This then feeds into the current American paradigm whereby misfortune is never the fault of the system, but rather in an individual for not thinking positively enough.  How could social inequality be important if you can become rich simply by thinking about it?

The solution?  Ehrenreich would like to see herself as a realist, not someone who champions despair.  Instead we should try to see the world as it really is. 

By a stroke of luck that’s what I’ve been trying to do for many years. 

 

Links

Guardian review 9 January 2010

BMJ review 18 December 2009

RSA animate video

 Interview on R4 Start the week 11 January 2010