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Models of MadnessReview - Models of Madness
Psychological, Social and Biological Approaches to Schizophrenia
by John Read, Loren R. Mosher and Richard P. Bentall (Editors)
Brunner-Routledge, 2004
Review by Tony O'Brien
Dec 22nd 2005 (Volume 9, Issue 51)

When an editor declares that a book does not attempt to be even handed or objective you know you're in for a bit of a ride. There's a disarming frankness about such an admission, but it leaves a reader wondering how far have the editors departed from objectivity in the interests of restoring 'balance' after 'a hundred years or more of [imbalance]'. The topic of this book is madness, or more correctly problems with the psychiatric model of madness, and some possible alternatives. Models of Madness is an ambitious title that raises expectations. The book delivers on its promise to provide an alternative to the medical model, although the content is of varying quality. The best chapters offer carefully thought out analysis; some of the others are irritatingly polemical. Still, you can't say you weren't warned. Models of Madness contains 24 chapters in three sections. The chapters are written by numerous authors, including the editors, John Read and Richard Bentnall, and the late Loren Mosher. There is something of a tradition of psychology literature critical of psychiatry and Models of Madness is consistent with that tradition, albeit that one of the authors, Mosher was a psychiatrist.

The three sections of the book explore, respectively, the illness model of schizophrenia, social and psychological approaches to madness, and evidence based psychosocial interventions. The range and number of authors means that the book is somewhat uneven, both in focus and quality. However the book is certainly thought-provoking. Clinicians working in mental health services, particularly those working within some sort of medical model, cannot read this book without facing some fundamental challenges to psychiatric orthodoxies.

As the title suggests, the main thrust of the book is directed at that standard psychiatric shibboleth, schizophrenia. There is no question that schizophrenia is a problematic concept, and Models of Madness wastes no time in declaring that 'schizophrenia is not an illness' before reviewing the substantial conceptual and empirical arguments against schizophrenia as a disease. This sort of criticism is made easier by those biological psychiatrists, and organizations such as the National Institute for Mental Health, who insist, against the weight of evidence, that schizophrenia is a brain disease of genetic origin. It is made even easier by those who acknowledge the problems with the biological model, but claim that that good old fallback 'further research' will inevitably identify the biological basis of schizophrenia. The second chapter sets out the threefold program of the book:

  1. Treatment for madness suppresses unacceptable behaviors thoughts and feelings in support of social norms;
  2. Treatments are frequently unhelpful and sometimes damaging and violent;
  3. Experts disguise their sociopolitical function and the damage caused by treatments by insisting that people with mental illness have personal defects.

The program is pursued inconsistently; although there are several returns to its central themes some contributors seem unaware of them. Having declared the above program, chapter two cites historical examples from East and West that support the idea of madness as a form of oppression. There is too little analysis to paint on such a wide canvas; a simply a stated position with some selectively interpreted historical references do not constitute an argument. The focus then shifts to the Inquisition and witchcraft which readers are invited to view as forerunners of modern psychiatry. This chapter is far from convincing. The scope is so broad that it is inevitably superficial, and it does not examine the historical emergence of psychiatry with any sophistication. Tuke, for example is presented as a medical apologist, and there is no discussion of his antagonism towards the medical management of madness. The critique of the Kraeplinian model however, presented in the following chapter, is more persuasive. It is a shame that the Foucaldian interpretations of the first chapter are not carried through to the second, as it is here that Foucalt's notion of discourse could have usefully been applied to the rising dominance of medicine. However John Read does a good enough job unassisted to show that psychiatric language involved an assertion of authority more than articulation of a theory or science of psychiatry. A brief chapter on psychiatry prior to and during the Nazi era argues that it is the biological theory of madness that legitimized eugenic treatment and mass murder. As the chapter shows, this period of German psychiatry has been little acknowledged by the psychiatric professions. But while there is a theme of oppression of the mentally ill, it is something of a stretch to cite this example in support of the authors' argument against the current biological model of schizophrenia.

The next chapter returns to the reliability and validity of 'schizophrenia', following the arguments of Boyle and others who have shown schizophrenia to be a problematic diagnostic category. The dimensional model Read argues for is better supported by evidence, and more sensitive to individuals' experiences of distress. The remaining chapters of this section cover various biological theories, heredity, and common treatments such as ECT and antipsychotic medication, ending with an analysis of the role of pharmaceutical companies in sponsoring research and promoting the role of drugs in psychiatric treatment. The latter chapter in particular makes compelling reading and raises serious ethical questions about the capacity of medicine to police itself.

The next section of the book explores psychosocial approaches; those models that consider developmental and psychological factors contributing to madness. A range of issues is discussed, including poverty, gender, trauma and stress. A standout chapter in this section is the contribution by Jim Geekie. Geekie's chapter uses grounded theory, linked to a Foucaldian analytical framework, to explore clients' interpretations of psychotic experiences. The chapter reports work in progress, but the findings are of interest because of the multiplicity of explanatory frameworks reported by participants. What Geekie's research shows is the ordinariness of many of the personal explanations for psychotic experiences. Geekie uses this evidence to argue for acknowledging people who experience psychosis as experts on that experience. This is not an abandonment of the professional responsibility to offer expertise; it is not even an abandonment of professional explanations. It can involve challenging individuals' explanations where these are proving unhelpful. But it is a recognition that clinicians need to work with people rather than impose views upon them. If it seems simple, that is because such straightforward arguments need increasingly to be articulated so that clinicians are reminded of the importance of listening to the person's story.

The final section of the book covers psychosocial interventions such as cognitive therapy, psychodynamic psychotherapy and family therapy. There is a final chapter from Loren Mosher on non-hospital non-drug intervention in first episode psychosis. This section reviews a range of research, as well as covering broader social issues and models of service delivery. The chapters are mixed, with some such as Johannssens' review of early intervention providing a descriptive overview of a range of programs across the world, and others such as Morrison's on cognitive interventions providing considerable detail on the use of cognitive interventions. There is also a range of views of the central concept of the book, schizophrenia. Morrison focuses on psychosis and discusses hallucinations and delusions separately, while Johannssen uses both 'psychosis' and 'schizophrenia' in discussing the various programs reviewed. Mosher returns to the program of the book, using his chapter on Soteria styled intervention to argue firmly against the medicalization of madness.

Although this is a somewhat uneven book there is enough material in it to offer a serious challenge to mental health clinicians to examine their conceptual models and to consider a range of alternative explanations for psychosis. If the book does not succeed in articulating a unified model of madness that is a small matter, as the more important task is to attend to the multiplicity of factors, social, personal and biological that need to be considered in any satisfactory framework. The strength of Models of Madness lies in the range of literature it brings together, in a generally accessible form, within a single volume. The book could have used a final chapter that drew its various strands together, and in particular returned to the program set out in chapter two. This is a book that is unlikely to win new adherents for its cause. That is a pity, because its less polemical chapters contain discussion and analysis that clinicians and others with an interest in madness would find both useful and informative.

 

© 2005 Tony O'Brien

 

Tony O'Brien is a lecturer in mental health nursing at the University of Auckland, New Zealand: a.obrien@auckland.ac.nz


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