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

This review by me in the BMJ

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.

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.

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

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

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 -  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

Buy on Amazon.com

Anna Minton’s book, Ground Control, is about the relatively recent phenomenon of the privatization of public space in the UK.  In city centres, what might once have been public space is now privately owned and managed.  Although seldom noticed, this provides a very different culture and environment; certain behaviours and people are encouraged whilst others are seen as undesirable and excluded. 

Minton traces this trend back to the 1980s, when London’s Canary Wharf and Broadgate centre were built.  Since then private ownership has become a template for all new city developments.  Similarly, most new houses are now built as gated developments.  Although the perception is that only the wealthy live in these high-security environments, in fact it is equally prevalent in social housing. 

The result, Minton argues, is a more divided and security conscious population and environment.  Paradoxically, she writes, increased security actually makes us feel less secure, as security is as much an emotional and physical state. 

One of her conclusions is that this pervasive fear over safety is linked to overall population well-being.  Levels of UK unhappiness have been reported to be twice those of continental Europe and Minton writes that this is due to their stronger civic life where the ‘architecture of fear is the exception to the rule’. 

Minton’s book is interesting, and it remains timely as her ideas can now be reread in light of the recent UK-wide civil disturbances.  Whilst I do find her overall conclusions somewhat speculative, she illuminates an issue that is rarely acknowledged or discussed.

Ground Control synopsis

Anna Minton on Start the Week R4 (she’s the last guest)

Anna Minton website

The London River Park: place for the people or a private playground? Observer 13 November 2011

Published in 20-27 August BMJ

How does the biggest trial unit in Europe balance the individual needs of hundreds of patient volunteers with the demands of participation in studies of treatment? Stephen Ginn reflects on a two part radio documentary

Of all maladies, few so occupy human fears and efforts as cancer. This is not without justification because many of us will eventually receive this diagnosis. For an individual, cancer brings uncertainty about the future and places strains on close relationships. In many cases the disease will progress and be accompanied by failing health and prolonged treatment. Western societies, which venerate youth and are on uneasy terms with death and decay, provide little preparation for a terminal diagnosis.

The complexity of the disease is perhaps why cancer and its treatments are imbued with metaphor. Although many nuanced concepts are understood in more familiar terms, cancer is unusually well suited to be described in this way. The martial metaphor is the most common. A patient (a soldier) fights cancer (the enemy) with chemical, biological, and nuclear “weapons.” Another metaphor is that of a journey. This is more applicable when thinking of cancer as a chronic disease, where the trajectory through life is diverted, leading to new goals and redefined definitions of progress.

Responses to cancer are the subject of Behind the Scenes at the Christie, a two part BBC Radio 5 documentary. Based in Manchester, the Christie is the largest cancer treatment centre in Europe, treating 40 000 patients a year. It is also the largest early phase clinical trials unit in the world, and at any one time 200 treatment trials are taking place.

In the programme, presenter Geoff Bird interviews the patients, doctors, and nurses who take part in the Christie’s trials. Although there is a lot of interesting factual content, the exploration is primarily emotional as Bird focuses on the motivations and challenges that face the patient volunteers and staff. What emerges is a portrait of an institution with a clear sense of mission, and touching emotional portrayals of patients.

It is a remarkable thing to take part in an early clinical trial of a cancer treatment. The sacrifice is substantial because participants undertake to spend a substantial slice of their remaining life span in clinics, and to be given potentially harmful treatments from which they are unlikely to benefit. Yet their contribution is essential; all cancer drugs currently in use have started life as trial treatments.

The challenge for the Christie’s staff is to ensure that patients feel valued while maintaining the rigour of their trials. Managing patient expectations is also vital because there are no “magic bullet” treatments (another metaphor). A common complaint from trial participants is that they dislike the possibility of being placed in a study control arm. I was interested to learn that different types of cancer bring their own challenges. Patients with lung cancer experience a lack of sympathy as a result of the perception that they are responsible for their own condition. Progress in breast cancer is slow because current treatments are fairly effective, and ethical approval for a trial is hard to obtain. Brain research has a lack of funding; patients with this cancer are often too disabled to fundraise.

Bird’s style is gentle and empathic, and the interviews that result are moving. His discussions with his patient subjects rarely venture far beyond their condition and relationship with the Christie, yet we also learn much about their lives and families. It is clear how much cancer becomes part of patients’ lives and how vital family support is to their recovery.

The motivation for a patient to take part in a trial with such a low chance of success is not what you might immediately expect. Some patients are holding out for a cure, but the narrative that Bird elicits is that participation in the Christie’s trials has lent them renewed purpose. In many cases trial inclusion affords them the opportunity to redirect the narrative of their lives from that of victim to pioneer.

Which metaphor best suits the Christie and its trials as portrayed in these programmes? With the martial metaphor the Christie could be an “experimental weapons division.” Bird may agree with this because he describes one patient as acting with “a quiet heroism.” Finding new sources of strength and purpose is more consistent with cancer as a journey. One story of transformation after treatment at the Christie is almost magical. Richard Jackson’s metastatic melanoma, which was advancing rapidly, disappeared after treatment with ipilimumab.

The approach of thinking about cancer in terms of metaphors has its limitations, and likewise this documentary leaves some stories untold. Patients for whom trials hold no appeal are mentioned only in passing. Similarly, the programme only occasionally profiles patients for whom treatments have failed. Bird’s interviewees are largely positive in their outlook, despite their prognosis, no doubt in part because of the practicalities of recruitment of interviewees and the requirement for reasonably upbeat radio, I wonder to what extent they feel obliged to behave in this way, a situation recently criticised by Barbara Ehrenreich in her book Smile or Die.

Of course no two hours of radio can do justice to a subject as complex as cancer treatment, and omissions are inevitable. These quibbles aside, Behind the Scenes at the Christie intelligently covers essential and unsung sacrifice.

BBC page

Amazon.co.uk link / Amazon.com link

Epileptic is a memoir of childhood and disease, and also tackles the dreams and fantasies of emerging maturity.  When Pierre’s brother, Jean-Christophe, develops epilepsy age 11, his family is profound affected.  In a search for a cure his parents seek the advice of all manner of alternative therapists, mediums and communities; but alas any improvement is often short lived.  Pierre seeks solace in drawing elaborate battle scenes and as an adult becomes the acclaimed cartoonist David B.  In contrast the adult Jean-Christophe becomes demoralised and distant, his life dominated by the side effects of his medication and his still constant seizures.  Central to the book, the relationship between Pierre and Jean-Christophe remains complicated.