Madness Explained
RICHARD BENTALL
Madness Explained
Psychosis and Human Nature
ALLEN LANE
an imprint of
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ALLEN LANE
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First published 2003
1
Copyright © Richard Bentall, 2003
The moral right of the author has been asserted
All rights reserved. Without limiting the rights under copyright
reserved above, no part of this publication may be reproduced, stored in
or introduced into a retrieval system, or transmitted, in any form or by any
means (electronic, mechanical, photocopying, recording or otherwise),
without the prior written permission of both the copyright owner
and the above publisher of this book
The Acknowledgements on page x
constitute an extension of this copyright page
ISBN: 978-0-14-190932-5
For my family
Aisling
Keeva and Fintan
Everyone is much more simply human than otherwise.
Harry Stack Sullivan,
The Interpersonal Theory of Psychiatry
Contents
Acknowledgements
Foreword by Professor Aaron Beck
Author’s Preface
Part One The Origins of our Misunderstandings about Madness
1 Emil Kraepelin’s Big Idea
The origins of modern psychiatric theory
2 After Kraepelin
How the standard approach to psychiatric classification evolved
3 The Great Classification Crisis
How it was discovered that the standard system was scientifically meaningless
4 Fool’s Gold
Why psychiatric diagnoses do not work
5 The Boundaries of Madness
Why there is no boundary between sanity and madness
6 Them and Us
Modern psychiatry as a cultural system
Part Two A Better Picture of the Soul
7 The Significance of Biology
Psychosis, the brain and the concept of ‘disease’
8 Mental Life and Human Nature
Madness and the social brain
9 Madness and Emotion
Human emotions and the negative symptoms of psychosis
Part Three Some Madnesses Explained
10 Depression and the Pathology of Self
Core psychological processes that are important in severe mental illness
11 A Colourful Malady
The psychology of mania
12 Abnormal Attitudes
The psychology of delusional beliefs
13 On the Paranoid World View
Towards a unified theory of depression, mania and paranoia
14 The Illusion of Reality
The psychology of hallucinations
15 The Language of Madness
The communication difficulties of psychotic patients
Part Four Causes and their Effects
16 Things are Much More Complex than they Seem
The instability of psychosis, and the solution to the riddle of psychiatric classification
17 From the Cradletothe Clinic
Psychosis considered from a developmental perspective
18 The Trials of Life
How life experiences shape madness
19 Madness and Society
Some implications of post-Kraepelinian psychopathology
Appendix A Glossary of Technical and Scientific Terms
Notes
Index
Acknowledgements
Verse
p. 118: Extract from ‘We and They’ by Rudyard Kipling reproduced by permission of A. P. Watt Ltd on behalf of the National Trust for Places of Historical Interest or Natural Beauty. p. 465: Extract from ‘This be the Verse’ by Philip Larkin reproduced by permission of Faber & Faber Ltd, on behalf of the estate of Philip Larkin.
Figures and tables
Table 3.1: Reprinted by permission of Oxford University Press. Table 3.4: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition. American Psychiatric Association. Table 3.5: Reprinted by permission of Cambridge University Press. Figure 4.1: From Manic-Depressive Illness by Fredrick K. Goodwin and Kay R. Jamison © 1990 by Oxford University Press, Inc. Used by permission of Oxford University Press Inc. Figure 4.2: Reprinted by permission of Cambridge University Press. Figure 6.1: Reprinted by permission of Cambridge University Press. Figure 7.1: Reprinted by permission of Elsevier Science. Figure 7.2: Copyright © 2001 by Oxford University Press, Inc. Used by permission of Oxford University Press, Inc. Figure 7.3: From In Search of Madness: Schizophrenia and Neuroscience by R. W. Heinrichs, copyright © 2001 by Oxford University Press, Inc. Used by permission of Oxford University Press, Inc. Figure 9.1: Copyright©Addison Wesley Longman Limited 1996, reprinted by permission of Pearson Education Limited. Figure 10.1: Copyright © 1999 by American Psychological Association. Adapted with permission. Figure 11.1: From Manic-Depressive Illness by Fredrick K. Goodwin and Kay R. Jamison, copyright © 1990 by Oxford University Press, Inc. Used by permission of Oxford University Press, Inc. Figure 11.3: Copyright © 1999 by American Psychological Association. Adapted with permission. Figure 12.3: Reproduced by permission of Taylor & Francis. Figure 13.1: Reproduced with permission from the British Journal of Medical Psychology, copyright © The British Psychological Society. Figure 14.1: Reproduced with permission from the British Journal of Medical Psychology, copyright © The British Psychological Society. Figure 14.2: Reprinted by permission of Carol Donner. Figure 14.3: Copyright© 2000 by American Psychological Association. Reprinted with permission. Figure 14.4: Copyright © 2000 by American Psychological Association. Reprinted with permission. Figure 15.1: Reprinted by permission of Loris Lesynski. Figure 18.1: Copyright © Sage. Reprinted by permission of Sage Publications.
While every effort has been made to contact copyright holders, the author and publisher are happy to rectify any errors or omissions in subsequent editions.
Foreword by Professor Aaron Beck
As we move into the twenty-first century, a radical shift in the way many of us look at severe mental disorders has been taking place. Irrespective of the label – whether schizophrenia, psychosis or severe mental disease – a new humanizing trend is observable. In contrast to the more mechanistic framing of schizophrenia in terms of abnormal brain chemistry or anatomical lesions, the new approach views the patient as a whole person troubled by apparently baffling problems, but also having the resources for ameliorating these problems. This New Look can be contrasted with the prevailing biological paradigm with its emphasis on the disordered neurochemistry and anatomical defects and especially the perception of the patient as a passive recipient of the treatment. Although the laboratory tests, brain scans, and
post-mortem studies have advanced our understanding of the neurological substrate and provided a variety of new medications, the distancing of the mental patient from the rest of humanity has persisted.
The more recent work spearheaded by Richard Bentall has brought the patient back into the mainstream of humanity. He and his co-workers have been able to demonstrate that the apparently mysterious, incomprehensible symptoms of the mentally ill are actually extensions of what many of us experience every day. The rather arcane extreme beliefs manifested by the patients can be seen to be on a continuum with ideas of the population at large. Beliefs in mind-reading, clairvoyance and alien possession are especially common in young people and a surprisingly large percentage of the population believe that they have received communications from God, the Devil and aliens. The ‘bizarre’ thinking of the severely disturbed patient represents an extract of these common notions. These beliefs, however, become a problem when they come to dominate the patients’ thinking and especially their interpretations of their experiences. By analysing these beliefs within the framework of human nature and mainstream psychology, we can begin to make sense out of them. Further, the so-called ‘negative symptoms’ can be understood as a natural detachment from a stressful environment. By disengaging, the patients attempt to shut out those stimuli that activate their delusions and hallucinations. Part of the withdrawal also represents a ‘giving up’ produced by the profound demoralization over others’ having given up on them.
Concurrent with the ground-breaking work of Bentall and his team, there has been an upsurge of interest in cognitive therapy of schizophrenia, with a number of successful attempts to ameliorate the patients’ psychotic symptoms already published. The new approach, inspired in part by Bentall’s work, views patients as agents in their own change, rather than passive recipients of the treatments that are administered to them. Further, the ‘normalizing rationale’ derived from Bentall’s formulations provides a basic construct by which patients can understand and cope with their distressing, unusual experiences.
As the leader in the investigations of the psychology of psychosis, Bentall is uniquely qualified to explain this new approach and make it available not only to readers of scholarly journals, but also to a much broader audience. His approach demystifies psychosis and restores the patient to a proper place with the rest of humankind. By reversing the dehumanizing trend, he makes it possible to relate to the afflicted individuals as though they are just like the rest of us, although ostensibly quite different. The book is of particular interest to anybody who is curious about human nature and its vicissitudes. It will be of a special interest to those individuals who suffer from these mental disturbances or are related to such individuals or are professionals who treat them.
Like the legendary Theseus winding his way through the Labyrinth, Bentall has in his personal and private life encountered many obstacles and taken many twists and turns. As he faced and solved one problem, he was confronted with another, then another, which he proceeded to resolve. Like Theseus, he has endeavoured to slay the monster – mental illness – and in this volume he shows how he has trapped it, if not finished it off.
Author’s Preface
In this book have I tried to tell three stories. First, I have tried to trace the history of our current understandings of serious mental illness and to show that these understandings are fatally flawed. Second, I have attempted to draw together recent research to suggest a radically different way of thinking about the most severe types of mental disorder, known as the psychoses. Finally, I have tried to tell a fraction of my personal story, about how I came to conduct research on delusions and hallucinations, and how the ideas outlined in these pages have come together in my mind. I have tried to write these stories in a straightforward way that will be accessible to non-specialists and lay people, because I believe that the way we think about psychiatric problems should be important to everybody, given that most people have some acquaintance with these problems, either through direct experience or by observing the suffering of a close relative or friend. At the same time, I have tried to be thorough enough in my treatment of the various issues to satisfy both my sympathetic colleagues and my critics from within psychiatry and clinical psychology. Inevitably, balancing the needs of these two quite different audiences has been difficult. The extent to which I have succeeded can only be judged by my readers.
The most important of the three stories is undoubtedly the second. I believe that many psychologists and psychiatrists can sense that a new way of thinking about psychiatric disorders is emerging, but few willhavehadtheopportunitytotrytogathertogetherthemanydifferent strands of research that are contributing to this shift in thinking. Over the four years that it has taken me to assemble the relevant evidence I have found myself exploring surprising avenues, such as, for example, developmental psychology, medical anthropology, the new molecular genetics, developmental neurobiology and ideas from the branch of mathematics known as non-linear dynamics. These explorations have confirmed a view I have held for many years: that psychosis shines a particularly penetrating light on ordinary human functioning. Indeed, I do not think it is an exaggeration to say that the study of psychosis amounts to the study of human nature.
Of course, in many of the areas that I have explored I remain an amateur. Inevitably, there are gaps. One virtue ofwritinga book rather than an academic paper is that it is possible to speculate. However, the price of speculation may well be that I have got some things wrong. This is very much an unfinished project. For example, for completeness it would have been good to have included something about anxiety and obsessional thinking, thereby bringing the psychoses and the neuroses within a single framework. I think it is quite easy to see how this could be accomplished. However, to do so would take fifty extra pages and at least another year, so this part of the project will have to wait until another time.
I have said something about my personal story because I believe that it is important to recognize that science, and especially the scientific study of abnormal mental states, is a human activity. Scientists, like ordinary folk and psychiatric patients, are flawed, emotional and excitable human beings who are sometimes wise and sometimes stupid, sometimes lovable and sometimes bloody irritating. By talking about my own experiences, both positive and negative, I have attempted to highlight an important theme of this book, which is the vanishingly small difference between the ‘us’ who are sane and the ‘them’ who are not. At a recent conference I was introduced as ‘Someone who has done more than most to move the dividing line between sanity and madness’, which I think was a compliment. In any case, in these pages I have tried to demonstrate that the differences between those who are diagnosed as suffering from a psychiatric disorder and those who are not amounts to not very much. This is an important insight because of its implications for psychiatric care. As I hope to demonstrate in a later publication, the dreadful state of our psychiatric services is not only a consequence of muddled thinking about the nature of psychiatric disorders, but also a consequence of the way in which psychiatric patients have been denied a voice by being treated as irrational and dangerous, like wild animals in a zoo.
A word to my critics from within the mental health professions. Commentators on my work (you know who you are) have very occasionally dismissed my ideas as ‘angry’, anti-biological, a rehash of old ideas from the sixties, ‘a politically motivated anti-psychiatric rant’ (to quote an extremely unhappy member of the audience at a conference where I spoke) or Szaszian (readers who are unfamiliar with long-running arguments about the nature of madness will know, by the seventh chapter of the book, what this latter epithet means, and that its application to me is inaccurate). Perhaps I have been angry on occasions; certainly this seems to be an appropriate response to the way in which psychiatric patients are often dehumanized by a system that purports to care for them. However, the rest is false. Because I believe that these impressions arise from a superficial acquaintance with my work I
will give unsympathetic readers of this volume an important clue: you will not be able to understand the approach I am advocating without reading the fourth part of the book, in which I attempt to show how an approach which is based on symptoms, and which therefore appears to be fragmented, can be welded together into a coherent whole.
Writing this book has been an interesting journey, during which there have been several important distractions, including my migration along the M62 from the University of Liverpool to the University of Manchester and, much more importantly, the birth of my two children Keeva and Fintan. In developing the ideas herein, I have been influenced by many people, but above all by the talented Ph.D. and D. Clin.Psychol. students it has been my privilege to supervise over the last fifteen years. One of the best-kept secrets in science is that most successful academic reputations are built onthe backs of hard-working postgraduates, and my career is no exception to this rule. For their contributions to my thinking about the psychoses, I single out (in alphabetical order): Kim Bowen-Jones, Jennie Day, Gill Haddock, Sue Kaney, Peter Kinderman, Peter Rankin, Rebecca Swarbrick, Sara Tai and Heather Young, all of whom have since moved on to greater things. Current postgraduates who continue to keep me on my toes, and who constantly feed me ideas, include Paul French, Paul Hammersley, Becca Knowles, Peter Simpson, Joanna Teuton and Justin Thomas. Numerous collaborators who have supported and encouraged me, while tolerating my dreadful time-keeping and other idiosyncrasies, include David Healy, David Kingdon, Shôn Lewis, Tony Morrison, Richard Morriss, David Pilgrim, Anne Rogers, Jan Scott, Nick Tarrier and Doug Turkington. I would also like to thank Tim Beck, whose recent interest in the work carried out by myself and colleagues in Britain has been an important source of encouragement. Despite his abrupt departure from the British clinical psychology community a few years ago, it would be wrong not to mention Peter Slade, who strongly supported me during the early years of my career. I should also mention Don Evans and Martin Evans who ran the famous MA course in philosophy applied to health care at Swansea in the late 1980s; I hope that parts of this book show that their efforts were not entirely wasted.
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