While a lot of criticism of psychiatry's approach has recently come from within the profession itself, stopping short of criticizing psychiatry itself, Bentall, a psychologist, and a Professor at Bangor University in the UK, takes on psychiatry for its failure to improve the mental health of nations since its entry into the world of intervention. Bentall is part of the antipsychiatry movement whose first major players, Cooper, Laing, Szasz were themselves disillusioned psychiatrists, although their reasons and styles were different. This does not mean he is against psychiatry: like Miller and others he is merely questioning the way it all works. Or rather, doesn't.
He sets about explaining himself, and then showing how in various studies, being treated, or not treated with medication once the diagnosis of schizophrenia has been made, doesn't really make much difference, and in fact, modestly better outcomes may be seen in patients who are not treated medically, especially in non-western lands. Whilst the defenders of modern psychiatry, such as Shorter, might have proclaimed a really good outcome, Bentall quietly sets about showing that it is a false claim, and largely one manipulated by Pharma. This is not his first show and tell, his first work, Madness Explained, was well received, lengthy and hugely referenced, defensively so, and proceeded to win a book prize from the British Psychological Society.
This is a shorter work, but he is no less meticulous and cautious. After his introduction, he sets out to explain how a limited view of mental illness as a biological illness with biological solutions came to dominate the modern industry. He does not immediately voice his opinion about the nosological categorization of mental illness or of compacting human suffering, as he is not keen to opine: rather, he simply shows research that makes the point that various authors or lobbyists for one opinion or another embark on research that is flawed, or manipulated to propose and maintain a singular approach as the most sane one, despite the resultant cold or ineffective treatments that emerge. He contrasts these against the truer forms of medical intervention, namely in medical illnesses such as cancer, which have shown startling improvements in the general health and longevity of patients, versus the neutral outcomes in psychiatry as a biomedical science. One has to recall the devastating evidence of the STAR-D and CATIE studies in antidepressants and antipsychotics, which show that all is not what it seems when it is claimed that there are more and more effective treatments for what is classed mental illness today: there is no convincing evidence for this. Older studies using older drugs long ago found that the warmth of the relationship in psychiatry really mattered and made the medication approach more palatable and efficacious.
More than 100 years ago, Adolf Meyer founded what is now known as the Meyerian Psychobiological approach, a forerunner of the biopsychosocial approach being pondered on today. Unlike the warm and shy Meyer, Kraepelin would emerge the role model for psychiatry, cold, obsessional and aloof in personality. He rejected Freud as too subjective, and instead molded himself on Wundt, his teacher.
No sooner had asylums come to be, then doctors were noted by their patients to be aloof, cold, judgmental: with asylums, came coercion to stay and be treated, as well as a flood of letters from those penned in there, complaining about the awfulness of being there and the implausibility of being judged as sane in any way when all that was focused on was any sign of a lapse in mentation. Dr Henry Cotton was a great beginning in the USA, operating on patients in a systematic way, beginning with teeth, then tonsils, and moving on to other organs, with 45% of his patients likely to die from sepsis: a bizarre interpretation of medical orientated mental health treatment, later on followed by lobotomies and leucotomies which continued for decades, and ECT, which continues today.
As Dr Walter Freeman noted at the time, after doing hundreds of leucotomies, about a quarter of his patients were left with the intellectual capacity of a household pet, but "we are quite happy about these folks…" (p39).
Bentall then further tracks history through the asylum era until its end, namely as a result of the advent of psychotropic medications, mostly discovered by accident when searching for antihistamine effects etc, as was chlorpromazine. However, Bentall asserts that it was probably a more political and pragmatic approach to mental health care that ended the asylum era, rather than the benefits of the drug advances, which in retrospect he argues, did not achieve that much.
But by the mid '60's and on into the '70's, spurred by the philosophies of the times as much as by Cooper, Laing and Szasz. The split that emerged between medical and non-medical mental health professionals began to widen, and fuelled the emergence of biological psychiatry and the neo-Kraepelinian revolution, with dopamine and serotonin hypothesis dominating, even if the evidence for both was indirect and flawed.
In any event, psychiatry was to become the dominant force, and psychotherapy regarded as an adjunct if anything at all. As the next chapter illustrates however, this is not necessarily based on reliability or the clarity of the attempt at a categorical nosology in the DSM or ICD approaches to diagnosis. He presents the arguments that began to emerge that the conditions listed are neither categorical nor easily able to distinguish between normal and not, as well as being subject to a range of variables that later authors have brought forward, bedeviling attempts at a clear psychiatric science. The lack of a clear causative chain is also a problem that the classification systems have not substantially addressed.
Therefore, the idea that psychiatric disorders are genetic is worthy of question, even if it were taken as axiomatic across recent years. They are however not, as Bentall points out, and recent studies of monozygotic twins in Schizophrenia show a less than 1 in 4 risk for one twin when the other has a diagnosis of schizophrenia: a weak genetic effect which means genes influence, but in a small way, and in the words of Nobel Prize winner Kandel, genes need an environmental playground. Whilst genes may play a role in one in four psychosis, early life experiences that are stressful in the extreme create a 15- fold incidence in psychosis in affected adults in a dose-dependent way. Bentall further discusses insecure attachment, emotional expression, helplessness, vague communication and other features of families where mental illness is present.
Another myth to be debunked by Bentall is that mental illnesses are brain diseases. Summarizing, Bentall is contending that a signs and symptoms approach, rather than a complaints approach, is not yielding any better results than a 100 years ago for patients with a mental illness.
Bentall then embarks on a detailed analysis of whether the double blind and placebo controlled trials into drugs designed for depression and psychosis can be trusted, and yield effect treatments. Most readers will be aware of the CATIE and STAR-D trials, and their troubling results, and that of the controversy around the very real placebo effects and the value of a warm relationship and this as a context for prescription of medication. One of his more disturbing allegations is that confirming Harris' observations in early detection and treatment of psychosis: the main effect is due apparently to the warmth and zeal of the investigators, not the medication, and such early gains such as decreased negative symptoms and incidence of suicide diminish when the patient moves on to conventional treatment services years later. Certainly some studies have shown that withholding medication does not harm at all. At best, the value of the drugs is sadly shown to be contentious. Much quoted studies, such as those comparing clozapine to chlorpromazine, are shown to be flawed in their methodology, including skewed dosages, and short follow up times, amongst others.
The obvious question then is, is psychotherapy effective for severe mental illness presentations? The Smith and Glass study springs to mind, with effect sizes of 0.80 meaning that 80% of those without therapy fare worse than those who receive it, and more importantly, it doesn't matter what therapy one receives, not in that study. Therapeutic alliance thus has a powerful influence, namely, the warmth of the relationship. As a result of the studies emerging from SoCrates and the Layard report, the IAPT program in the UK and the NICE guidelines have answered this question with a Yes, and made CBT from professionals and paraprofessionals a major part of the National Health Service delivery system for significant mental illnesses.
In the closing chapter, he muses about the psychosocial recovery movement, and about what type of psychiatry we as consumers might want. After all, one might have to accept that the increase in human lifespan is not really the result of treatment, but of modern sewage, inoculation, better nutrition when we are young, health policy, primary prevention and so on. Despite the health of nations not having declined, there is recent evidence, on the pages of the British Psychological Society that awarded Bentall his award for his previous book, that the incidence of permanent disability has increased, and that much of it is mental illness, and untreated well if at all. Worse, the 30-40 year olds, I am told at DMEC in the USA, are now consuming more disability money than any other age group at any other time. All is not well.
Bentall is no lightweight, and despite not being part of the British or American psychiatry establishment, is clearly very well informed and able to provide what I can clearly see are mildly skewed, but very cogent arguments that the establishment cannot truly unseat. There is too much that they themselves acknowledge is correct and damning. It is not that much that psychiatry as a profession is fraudulent, but many of the top name in psychiatry have been brought to task in the USA for less than sanitary practice in stepping to the beat of big Pharma, and pocketing large sums of money along the way, leading to questions by Senate committees and Congress, and their being banned from publishing for years. Hundreds of them. It's a tainted profession, and Pharma's deep pockets are to blame, but then again: Pharm were basing their drug investigations on criteria for mental illnesses that no one agrees are good enough, let alone perfect, not even the ex-head of the NIMH, and the DSM V appears to be equally flawed and not likely to respond to Steve Hyman's pleas for a neuroscience informed text.
So the wave of criticism is headed for tsunami, and Tsunami Bental is not a raging activist wave, just a much shorter version of his original, with new information, and a dogged determinism to effect change and add his voice to a really significant and informed critique of psychiatric practice and the reliance on drug-placebo filibusters, that just don't address the nature of human suffering.
It's a must read for everyone who professes a role in mental health, and readable by just about everyone.
© 2009 Roy Sugarman
Note: This book has been published in the UK under the title Doctoring the Mind: Why Psychiatric Treatments Fail.
Roy Sugarman, PhD, Director of Applied Neuroscience, Human Performance Institute, Sydney