Figure 1.
Richard P Bentall
Allen Lane, £25, pp 640 ISBN 0 713 99249 2
Rating: ★★★
My first close contact with a clinical psychologist was when I was a new consultant, intent on fostering a multidisciplinary approach, during my first ward round. Nervously I pumped up the team spirit in the assembled crowd. In truth, I hadn't a clue what I was going to do. The psychologist looked stern and impenetrable. He took to contradicting everything I said. Desperately I would agree with him, only he would then change his point, saying that I had not understood. We went round like this for a while. I nodded and smiled and adopted what I hoped was not threatening body posture. Eventually I entreated him to spend some time with the patient. Anything to help move things on. I received a barrage of reasons as to why this was clearly not an appropriate case for him to take on. It was then that the penny dropped. He was more interested in being right than being helpful.
Of course, I have since worked with very friendly psychologists but it was with trepidation that I approached this book. The author wants us to be crystal clear that he is not a psychiatrist. He is a clinical psychologist. He stops short of saying that these are of two separate biological species but I had the feeling he might believe this. Anyway, I can now report that "flooding" (massive exposure to an anxiety provoking situation) really works. I actually began to enjoy the experience.
The book sets out to do three things. Firstly, to blow the lid on the limitations of the classifications currently employed in psychiatric practice, in particular the Diagnostic and Statistical Manual, now in its fourth version (DSM IV). This full scale attack on inadequate disease entities and their historic origins will not necessarily shock and awe. Perhaps in the ivory towers there is real honour at stake, but in everyday practice I have encountered only a healthy awareness of the limitations of the DSM. That said, this is a furious, well written, and thoroughly enjoyable assault.
Secondly, we are led around a maze of past and present psycho-socio-biological observations, and these are woven into a theory of sorts. It may be a little laborious but there is a lot here that is worth understanding. That the observations are often limited and the theory a little stretched is no great disappointment. This is an impressive review of literature, enthusiastically presented.
Thirdly, the author wants us to know some of his personal story, why explaining madness is important to him. The ever present distraction, though, is that intense sense of professional rivalry, almost palpable. In the glossary I learnt that "because doctors have a long history of telling other health professionals what to do, they are usually the leaders of multidisciplinary psychiatric teams." It threw some light on my encounter with that first clinical psychologist. In retrospect I am just glad that he didn't boo and hiss at me. The explanation of madness offered here—"essentially, though not exclusively, a cognitive framework for understanding symptoms, rather than disease entities, as variants of normal mental processes"—is supposed to make us more humane, tearing down the walls between madness and sanity.
Explanations of madness will continue to provide insight as well as mislead. But as long as all the explanations of madness just add up to a very small piece of a very large pie, in the real world at least, we have to remember the importance of being helpful rather than right.
Or perhaps I could explain it better like this. Madness is like being at the wheel of a car that you don't know how to drive on the streets of an unfamiliar city. A psychologist is someone who will look under the bonnet to show you how the bits and pieces seem to connect. A psychotherapist is someone who can point out the traffic jams but may also lose you down a dark narrow street where you end up in a ditch. Psychiatrists are like those men in tow trucks. They can fill the tank with chemicals, they can pull you out of the ditch and sometimes the conversation in the cab on the way home can be surprisingly enjoyable. And they love to turn on those flashing lights...