Inglis contends that the BMJ’s print run and thus carbon footprint can be reduced by a combination of increased reader sharing of print issues and greater embrace of digital distribution.
The whole picture is less straightforward. The BMJ is a commercial publication, albeit not an aggressively capitalist one, and it must pay its way. Part of its funding comes from print advertising, and advertisers remain reluctant to pay for online and iPad advertisements. Were the BMJ to make the transition to an online only publication, with most printed copies communally read in institutions, its business could prove unsustainable. “So what?” some might say, but unexamined healthcare is also wasteful inefficient healthcare.
The idea that a move from printed to digital distribution will automatically lower the BMJ’s carbon footprint is not a foregone conclusion. At least one comparison of the environmental impact of print, online, and tablet based consumption has been attempted and comes out only hesitantly for tablets.
A comparison of print and digital distribution must include all stages. A digital journal is free from the physical print and distribution costs of a print journal but data storage—“cloud computing”—and device manufacture/disposal must be considered. Greenpeace’s recent report on cloud computing data centres voices concern that many rely on “cheap but dirty” coal power stations.
Ultimately many factors determining an electronic journal’s environmental impact are down to reader behaviour. The fewer tablets, laptops, and smart phones we buy the lower our carbon footprint. Yet most of us own several devices with overlapping functionality, which we regularly replace. Few of us switch them off as often as we should.
Competing interests: SG is employed by the BMJ as editorial registrar.
It’s widely accepted that individuals can be disturbed or troubled of mind. What is controversial is how we should understand this.
Asides psychiatrists, many professional disciplines work and research in the field of mental disorder. Each discipline approaches the subject from their own viewpoint, using their own conceptual model to explain what they find before them.
Alas there is no single model that has complete explanatory power. To fully understand an individual’s difficulties it is often necessary to borrow from several. This would be the favoured approach from an eclectic practitioner. In practice it’s easy to favour a pet model which most closely fits one’s world view and defend this against those supported by others.
The on-going debate about the merits of drug treatments versus talking therapy can be viewed as a clash of models: biological versus psychodynamic/cognitive.
The disease or biological model
This model holds that any dysfunction that effects mental functioning can be regarded as ‘disease’ in a similar way to dysfunction that affects other parts of the body.
In the disease model, a disorder affecting mental functioning is assumed to be a consequence of physical and chemical changes which take place primarily in the brain. Just like any other disease a mental disease can be recognised by specific and consistent signs, symptoms and test results. These distinguish it from other diseases.
Psychiatrists who adhere to the disease model are often referred to as ‘biological psychiatrists’ (as in ‘he’s very biological’).
With a biological approach comes a preference for physical treatment methods, primarily drugs, but also ECT.
This model best applies to schizophrenia.
The psychodynamic model
The central tenet of the psychodynamic model is that a patient’s feelings have led to problematic thinking and behaviour. These feelings may be unknown to the patient and have formed during critical times in their life, due to interpersonal relationships.
These unknown (or unconscious) feelings are uncovered during therapy. Therapy can take place over a large number of sessions and over a time period of a year and beyond.
During therapy a relationship builds up between therapist and patient. The emotions that the patient attaches to the therapist are collectively known as ‘transference’, and those the therapist attaches to the patient collectively as ‘counter transference’. By understanding these feelings a patient may gain an understanding that they can take with them to future relationships.
This model is applied broadly, but has limited applicability to the most severe mental disorders.
The behavioural model
The behavioural model understands mental dysfunction in terms theory emerging from experimental psychology.
Symptoms, as understood by the behavioural model, are a patient’s behaviour. This behaviour has come about by a process of learning, or conditioning. Most learning is useful as it helps us to adapt to our environment, for example by learning new skills. However some learning is maladaptive and behaviour therapy aims to reverse this learning (counter conditioning).
This model best applies to phobias.
The cognitive model
The cognitive model understands mental disorder as being a result of errors or biases in thinking. Our view of the world is determined by our thinking, and dysfunctional thinking can lead to mental disorder. Therefore to correct mental disorder, what is necessary is a change in thinking.
This model will be familiar to anyone who has trained or undergone cognitive behavioural therapy (CBT). CBT aims to identify and correct ‘errors’ in thinking. In this way, unlike psychodynamic therapy, it takes little interest in a patient’s past.
This model is widely used, but classically applies to depression and anxiety.
The social model.
The social model regards social forces as the most important determinants of mental disorder. The social model takes a broader view of psychiatric disorder than any other model. It regards a patient’s environment and their behaviour as being intrinsically linked.
In some ways it is like the psychodynamic model, which also sees patients as molded by external events. However whereas the psychodynamic model sees mental disorder as highly personalized and its determinants not immediately recognizable, the social model sees mental disorder as based on general theories of groups and caused by observable environmental factors.
For someone who develops persistent depression following the death of a close relative :
“This can be perceived in several ways by psychiatrists. One sees the depression as a pathological event that is directly due to the biochemical changes occurring in the brain of someone who is predisposed to pathological depression through an accident of illness. Another sees the depression as a reactivation of unresolved childhood conflicts over an early loss. Another regards the depression as part of the normal mourning process that has got out of control because the person’s thoughts become fixed in a negative set which sees everything in the most pessimistic light. Yet others conclude that the mourning response has been exaggerated primarily by society or see it as an abnormal form of learning which is no longer appropriate for the situation but is receiving encouragement from some quarter (positive reinforcement)”
Identifying mental illness in historical figures is a favourite hobby of psychiatric sleuths. Particular scrutiny has been paid to the lives of painter Vincent van Gogh and composer Robert Schumann. Both spent time in asylums, but their correct diagnoses remain in dispute. Similarly, descriptions of symptoms of mental disorder have been identified in creative works dating as far back as Shakespeare in the 16th and 17th centuries and the playwright Sophocles in ancient Greece.
Until recently depiction of mental disorders in comics (also known as graphic novels) has attracted less interest. This may be because of their historic association with younger readers, but comics are now read by people of all ages and are gaining more attention, particularly in healthcare. Long running series such as Batman have multiple characters who display symptoms of mental disorder, and works such as Couch Fiction and Psychiatric Tales have storylines specifically about mental health issues.
Looking at the psychopathology of comic book characters is an interesting diagnostic challenge and also a newly used approach to medical education. A comic book convention earlier this year was held to educate the public about psychiatric conditions. Various comics were studied, with Batman being heavily scrutinised.
Mental illness is ubiquitous in Batman’s Gotham city. “Over the years, the stories of the Batman comics have been intensely psychological,” says psychologist, writer, and visiting senior research fellow at the Institute of Psychiatry, Vaughan Bell.
The longevity and popularity of Batman comics and films make it one of the best known representations of mental illness. Arkham Asylum, Gotham’s sanatorium for the “criminally insane,” towers both literally and metaphorically over the city. Many of Batman’s adversaries have either escaped from there, or are destined to return there.
In Batman, “the fictional explanations of what causes madness tend to be particularly detailed,” says Dr Bell. The disorders often bear little relation to those seen in clinical practice, however. In Batman comics “two main themes are used to explain the development of madness,” says Dr Bell. “The influence of trauma and the pursuit of forbidden knowledge.”
The personas of Batman and his arch enemy the Joker are both trauma-induced. Batman’s crusade against crime begins with witnessing the death of his parents. The Joker becomes a villain when, as told in The Killing Joke, he falls into a toxic river shortly after the death of his wife.
Batman’s response to his traumatic experience is to become a masked vigilante. Objectively this is unusual behaviour, but not in Gotham city, where spandex-clad criminals are the norm. In contrast, the Joker is unable to show such a “mature” response and turns to crime. Both can be considered madness owing to trauma.
On the other hand, it is those who seek to know who also suffer. For example, being a psychiatrist in Gotham city’s Arkham Asylum is a particular “risk factor” for mental ill health. “A remarkable number of Arkham inmates are former psychiatrists who have been driven to madness as a result of their work as investigators of the human mind,” says Dr Bell. “Rarely are psychiatrists, psychologists, or neuroscientists portrayed as anything except figures of fear.”
Harley Quinn is an example of a disturbed psychiatrist, although her presentation has little resemblance to an established psychiatric disorder.
Quinn, originally Dr Harleen Quinzel, is an Arkham psychiatric intern who becomes fascinated with the Joker and offers to psychoanalyse him. During treatment, the Joker’s influence causes her to abandon her previous life and personality. She falls in love with him and helps him escape on several occasions.
“In the real world we don’t necessarily see someone either becoming a hero or a villain following a single traumatic event,” says Dr Bender, questioning the verisimilitude of the back stories of Batman and the Joker.
Dr Bender also says that the term “criminally insane,” although liberally used in the Batman stories, is not a term that is used either legally or in psychiatry.
Batman storylines often combine syndromes, and sometimes the use of terminology is just plain incorrect.
“The Joker is the character who is most commonly referred to as ‘psychotic’,” says Dr Kambam, “but in over 70 years of stories you’d be hard pressed to find evidence of actual psychosis depicted.” Classically, the definition of psychosis is a mental state seen in serious mental disorders such as schizophrenia, when a patient has disorganised behaviour and thinking.
“What the Joker actually displays more of is psychopathic traits,” says Dr Kambam. Psychopathic traits include manipulativeness and a lack of empathy.
Drs Bender, Kambam and Pozios are using the depictions of mental states in Batman as a way to talk to the general public about psychiatric disorders. The histories of comic book characters are well known and, unlike other public figures, can be discussed without fear of impropriety.
Pioneering this form of medical education, they held a seminar at Comic Con, a large comic convention held in San Diego in July 2011.
“We looked at whether the character of Bruce Wayne [Batman] displays any symptoms of post-traumatic stress disorder (PTSD) in the film Batman Begins,” says Dr Pozios. During the seminar they explored the nature of PTSD and the challenges in making a diagnosis. They felt that Batman had symptoms of PTSD but does not meet the full diagnostic criteria.
Audience questions also provided an opportunity to correct misperceptions. One audience question was, “If Batman doesn’t have PTSD then is it better to say that he has schizophrenia?” This refers to the common misunderstanding that schizophrenia means split personality.
“That’s not correct,” says Dr Bender, “schizophrenia is a psychotic illness.” PTSD is an anxiety disorder.
Beyond the bat cave
Many other comic book characters are amenable to psychiatric scrutiny. Could we diagnose the Hulk with an impulse control disorder? And how has Superman been affected by being the last survivor of his planet?
Mental disorder is also depicted in characters who are not superheroes. “The examination of mental illness in comic form goes well beyond that seen in genre comics,” says Ian Williams, a general practitioner and comics artist. “Batman comics primarily aim to entertain, and their interest in mental disorder is second to this. Other more thoughtful works address the subtleties of mental disorder directly, and aim for a more realistic depiction,” says Dr Williams. “Comics are able to convey an immediate visceral understanding in a way that conventional texts cannot.”
“The handling of mental disorder is particularly effective in The Long Road Home by G B Trudeau,” says Dr Williams.
G B Trudeau draws the well known newspaper comic strip Doonesbury. In The Long Road Home he examines the life of a Doonesbury character following active duty in Iraq.
“The comic documents how the character’s life changes after he loses a limb traumatically,” says Dr Williams. “The author spent time in rehabilitation centres in order to make the approach more realistic.” The character develops PTSD, becomes withdrawn, and has constant flashbacks.
Another comic, Depresso, by Brick, examines depression. “The visual metaphors in Depresso are very powerful,” says Dr Williams. “Especially when he likens depression to being entombed in wet shrinking concrete.”
Brick’s approach to doctors is interesting. “Brick takes a deliberately provocative point of view to his medical care,” says Dr Williams. “He is by nature suspicious, and this influences his view of the psychiatrists who treat him.”
Dr Williams also recommends Psychiatric Tales. This is a collection of 11 strips about psychiatric illness, which was published to acclaim in 2010. Its author, Darryl Cunningham, worked as a healthcare assistant on psychiatric wards and also had his own problems with mental illness.
“Psychiatric Tales is patient centred and humane as Cunningham has experienced mental illness from both sides,” says Dr Williams. “Despite the seriousness of the subject he has a light touch and the book is funny and informative.”
Comics are very accessible as they are quick and easy to read. Their ability to juxtapose image and text means that they are a rich medium for both storytelling and documenting.
Established comics such as Batman have featured mental disorder for many years. Although the characters’ disorders in Batman often display a high degree of artistic licence, they can still be used as a teaching aid and may engage an audience who would otherwise lack interest.
Non-fiction comics such as Psychiatric Tales are often more realistic and can provide us with valuable insights into the lives of psychiatric patients.
The first salvo in the Guardian’s recently published series of articles on academic publishing was delivered by veteran agitator George Monbiot. Journals publish government funded research, written and often edited for free by academics says Monbiot. “But to see it, we must pay again, and through the nose” he says.
The monopolist practices of academic publishers make Walmart ‘look like a corner shop’ and Rupert Murdoch ‘look like a socialist’ he continues.
In a second article Ben Goldacre writes of Aaron Swartz, a digital activist. Swartz is accused of downloading academic papers on a grand scale, intending to make them available for free on file sharing sites such as Pirate Bay. Goldacre writes that in some respects this is a remarkable tale of “Robin Hood behaviour”.
Thirdly David Colquhoun writes of the enormous pressure on academics to publish research papers. He says this has lead to a proliferation of journals and a shortage of qualified peer reviewers. As a result the quality of published research has nosedived. “The only people who benefit from the intense pressure to publish are those in the publishing industry” he writes.
Profits for some academic publishers certainly are healthy. Monbiot reports that Elsevier made £724m on revenues of £2bn during the last financial year. This is a profit margin of about 40%. Can this be justified?
In the past Reed Elsevier has defended their profits on the basis of their skilled staff, their support to authors and peer review panels, and their complex typesetting and distribution costs.
“We believe the publisher adds relatively little value to the publishing process. We are not attempting to dismiss what 7,000 people at REL do for a living. We are simply observing that if the process really were as complex, costly and value-added as the publishers protest that it is, 40% margins wouldn’t be available.”
The industry does face major challenges. Libraries are struggling to pay escalating subscription prices and electronic distribution of papers is making the established business model redundant.
Open access is an alternative paradigm, where authors pay a publishing fee to make journal articles are free for anyone to access.
In 2008 the BMJ formally became an open access journal and all BMJ research articles are free to access immediately upon publication.Authors are asked to pay a publication fee per accepted research article if their research grant covered open access publication fees.Other ‘added value’ articles, such as clinical reviews or editorials, require a subscription.In addition to the BMJ, BMJ Open is an online only open access journal also owned by the BMJ group.
A further option is self archiving, where freely accessible copies of an article are placed on the web.In his article Colquhoun favours a variety of this approach with peer review provided through anonymous reader comments.
With ten daily national newspapers, the UK has one of the most competitive newspaper markets in the world. Since the 1980s sales have fallen but innovative business models are emerging which may have lessons for academic publishing.
The Guardian has long championed a comprehensive free online presence. Although its website does provide a substantial income from advertising, the newspaper remains unprofitable and is famously underwritten by the less sophisticated Autotrader, a trading magazine for used vehicles, also owned by the Scott Trust.
By contrast the Times does not allow any of its articles to be read online for free. When introduced this move lead to a drastic drop in online traffic. Whist dismaying to columnists, News Corp may not be concerned about this drop as occasional visitors tend to ignore ads and add little value. The Times has concentrated on maximizing business from loyal readers; the site is awash with advertisements for tie-ins such as wine clubs and holidays.
The Daily Mail has the world’s second biggest newspaper website, with 35m unique visitors per month. Unlike the alarmist print edition, the online Mail focuses on the fashion choices of attractive female celebrities.
Innovation is not restricted to online approaches. The Evening Standard print edition is now entirely free, and its circulation has doubled. Distribution costs have also fallen. The paper is handed out at Underground stations and each issue is read multiple times as abandoned copies are moved around London by Tube. It’s still not in profit, but its losses have halved.
The Independent’s approach is arguably the most experimental. It has introduced an abridged version called ‘i’, which is distributed alongside the full newspaper. The greater combined distribution of these two offerings makes selling advertising easier.
The approaches of UK newspapers indicate that new business models for academic publishing can include both print and online innovation. Approaches such as those of the Mail may of course not be compatible with the brand values of academic journals. Allowing increased free access will appease critics such as Monbiot and augment readership, but may not encourage loyalty. A closed model, like that of the Times, prevents bloggers linking to the research they discuss, potentially decreasing a paper’s impact.
It will be dangerous for academic publishers to do nothing. In his article Goldacre suggests a grubby compromise may emerge. Journals will stay afloat financially due to institutional subscriptions, whilst individuals will avoid excessive per article charges by downloading articles they wish to see from semi-legal content sharing sites. I expect that this is not a situation most publishers would welcome. “These are very interesting times for information” he writes. I agree.
(June 2018 review – things have moved on quite a bit since I wrote this, although academic publishing is still going strong. The Guardian no longer owns Auto Trader. The Independent Newspaper became online only in 2016. Aaron Swartz committed suicide in 2013 aged 26. Sci-hub allows academic papers to be accessed without a paywall and in 2015 was prosecuted by Elsevier. )
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.
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) 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.
Metaphors are widely used by both healthcare professionals and lay people when talking about matters of health. Despite this their role is largely unrecognised. This is a shame, I feel, as they can have a powerful effect on the practice of medicine and the experience of illness.
A metaphor is a way of understanding and experiencing one kind of thing in terms of another. Many complex concepts are understood in this way and they are integral to the way we understand things.
The essayist Susan Sontag was one of the first to identify the widespread use of metaphor in relation to certain diseases. She wrote Illness as Metaphor whilst being treated for breast cancer and visited the topic again in 1988 with AIDS and its metaphors.
Sontag argued that metaphors attach themselves to certain diseases and these metaphors exert influence on patient and public attitudes. With both HIV and cancer Sontag argued that metaphors introduced an unhelpful emotional dimension when a more detached scientific approach was required.
Two main sorts of metaphors have been suggested. “Biomilitary” metaphors represent disease and the body’s response to it in terms of “attack” and “defence.” By contrast with “bioinformationist” metaphors the body, in both health and disease, is seen as a communication system with “receptors,” “transmitters” etc.
Particular diseases attract metaphorical description more readily than others. Biomilitary metaphors are pervasive in discussions of cancer. By contrast heart disease is discussed almost exclusively in terms of the mechanical metaphor of plumbing.
Arguably metaphors don’t merely describe similarities; they create them. As well as illuminating they can also conceal. It can be hard to think of cancer in a way that is not biomilitary, but wars honour battles which can make the transition to hospice care problematic. Mechanical metaphors for heart disease are also limited as they hold no place for lifestyle modification. I don’t agree with Sontag that metaphor should be eliminated from the discussion of medical illness. In fact I don’t actually believe that it would be possible to talk about disease without them. But they have a hidden power that should be understood.
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.