'The Great Pretender' by Susanah Cahalan

Anyone who has an interest in mental illness, how it is diagnosed and treated, and especially an interest in society’s attitude to psychiatric practice will enjoy this book. It concerns the study published in Science in 1973 called “On being sane in insane places” by David Rosenhan, then professor of Psychology and Law at Stanford University. In summary this study purported to report on the fates of eight pseudo-patients who presented to psychiatric hospital. They reported hearing auditory hallucinations of a word such as “Thud” or a phrase such as “its hollow inside“. After this report, they behaved entirely normally without feigning any symptoms or exhibiting any unusual behaviour. The study reported that they were all admitted and diagnosed as mentally unwell (usually as having schizophrenia) and during weeks of admission given treatment for these conditions. The study suggested that psychiatrists could not distinguish between the sane and the insane, between health and mental illness.

This study shook psychiatry and mental health services to their core. At the time, following the work of the likes of Thomas Szasz (‘The Myth of Mental Illness’) and Erving Goffman (‘Asylums’), this seemed to give support and credence to the anti-psychiatry movement and provoked widespread, comprehensive and much needed change into the provision of in-patient psychiatric services. It was probably one of the prime drivers for the development of the DSM-III system of diagnosis which, at the time, helped address some of the major failings of psychiatric diagnosis.

I recall when I was a lecturer in psychological medicine referring to this study when lecturing to medical undergraduates, or psychiatric postgraduates, to try and inculcate a sense of shame that the profession was able to perform so poorly and fail our patients so badly.As a simple study with a blindingly obvious outcome it was very valuable.

However, it seems I may have been wrong. Without giving too much away this book looks into the study and checks the veracity of the reports. The author had a personal experience of psychiatric mis-diagnosis when she fell ill with autoimmune encephalitis and presented with psychotic symptoms. This kindled, in her, an interest in diagnostic accuracy and the interface between mental and physical illness and prompted her to look at this landmark study. Early in her research she noted significant defects in the study which she then started to explore. As the author follows clues, leading to the uncovering major flaws in the study, this book reads as easily as detective fiction. Although I suppose I should really class it as a true crime drama.

There is clear evidence that the ‘facts’ as reported are not the fact as they occurred. It is clear that some pseudo-patients actively feigned mental illness and threatened self-harm to capture the psychiatrists’ attention. The reports were also selectively reported so that positive or helpful experiences of psychiatric care were deliberately omitted from the published report. There is some, equivocal, evidence that Rosenhan was actively fraudulent in creating stories out of thin air to support his theories.

It is sad when our heroes turn out to have feet of clay. We feel duped when we discover the facts that were presented to us, and which we acted on, were misleading. However, many of the changes that followed this study were needed and one could argue that a “good lie” was more effective than many dry studies in forcing a change in the psychiatric services. I still hope that when people read the study they will think “how can we avoid problems like that ?“. However, a ‘good lie’ may prompt change but it is not a useful compass for what direction that change should take. We will all be glad to see that some of the bad practices are gone but this study did not help us see the positive aspects of “asylum” nor how we can preserve these. It lead us to throw the baby out with the bath water.

It is true that there are many less in-patient beds for patients with mental illness and that hospitals no longer degrade patients as they did. However, we now have many more psychiatric patients in prisons, nursing homes and general medical wards. Often the care here is poorer than that of the old institutions and I fear that the many mentally ill patients trapped in prisons are experiencing degrading and unpleasant treatment the equal of that in a seventies mental health hospital. In some senses we have just changed the nurse into a prison warder and the locked ward into a prison cell – the place and person may have changed but the crime hasn’t.

To improve the treatment of the mentally ill we need not only to understand mental illness better but also to understand better our own attitudes towards it. Although I will miss using this study in a ‘fire and brimstone’ talk about diagnostic accuracy I would (were I still teaching) have to be very cautious referring to it now. When we think we understand, but don’t, we are at the greatest risk of making mistakes. As this book reveals, even with good intentions, a prejudiced and dishonest look at the facts helps no-one in the long run.

Purple Prose?

Our present political life is seriously damaged. Many people are now looking for the centre having found that the main parties have migrated away from them to the edges. Life on the edge has damaged our mainstream parties. The Labour Party has become increasingly censorious and illiberal seeing a need for the state to increasingly intervene in the lives of us all. Further, following the principle of “my enemy’s enemy is my friend” it has developed nasty antisemitic traits in response to the problems in the middle east. The Tories on the right, on the other hand, have seen its perfectly correct support for freedom of speech and individual liberty used as a cover by racists and bigots (people less concerned with the right of free expression than pleased with the opportunity to say hateful and spiteful things under the cover of free speech). Neither of the main parties now are without problems and I am sure that many, like myself, find themselves politically homeless.

You can find the centre by going left from the right-hand side or by heading right from the left-hand side. However, the centre is distinct from both of its containing edges. I am not sure if these movements from the two sides will ever find the middle but it was in the hope that they may that I read the flowing two books over the last month or so. From the Left there is “Blue Labour: Forging a new politics” and on the right we have “Red Tory : How the left and right have broken Britain and how we can fix it“. I read these in that order, Blue then Red, although this is the reverse order in which they were published. There was five years between the books; Red Tory was published 2010 and Blue Labour in 2015 but despite this they tackle largely the same themes.

The similarity of the books is the most striking aspect; large aspects of either book could be transposed into the other with little upset whatsoever. Both are aware that the traditional working class has been abandoned by the main parties and we have a major problem of an large portion of our population in the post-industrial areas feeling alienated and ignored. They both also recognise the increasing disengagement of this group, who feel and behave as disenfranchised, and the danger that this poses to our society through the mechanism of populist parties from both extremes.

Both books see the need to review our approach to nationalism. Both feel patriotism and nationalism can act a valuable bulwark against the problems of globalisation. Both books promote the nation state and internationalism as the antidote to the excesses of global capitalism. On the left by limiting the powers of the state and corporations, and on the right by limiting the excesses of the market when corrupted by monopolies, cartels and state intervention. Both agree – ‘smaller is better’.

The fate of the family is prominent in both books and both are alarmed by the damage that has been done to it. Blue Labour views the family as a basic building block of society which is particularly important to the poor and working as it provides the best support and safety They bemoan the weakening of the family in pursuit of greater economic productivity and also express concerns that the traditions of mutual support and communalism which grew in the working class movements are declining (Trade unions, mutual societies, building societies, friendly societiesare all examples of working class organisations). The Red Tory also worries that these aspects of our society are changing, and fears that welfarism is replacing mutualism with the consequent risks of dependency and loss of autonomy.

Both books see the increasing inequality in our society as a major threat to our future. We are splitting into a society of “haves” and “owes”; the rich are becoming much richer and the poor are increasingly in debt. So even though we have more possessions it is hard to see that we are that much richer. As Red Tory reminded us of Belloc’s view :-

“For to own something on credit I not to own it at all, and since no security of tenure is available by rent, those who seek some primary foundation or asset in the world have little choice but to buy into a form of ownership that converts its possessor into a debtor”

Red Tory pp49

The housing bubble that first burst in 2008 has left most of us in debt and working to serve this. All members of the family now have to work in the market, there is no room or members to stay at home and care for others, and despite this increased work we are not wealthier. The cheap goods that capitalism generates a little but increasing debt wipes this out and adds to the growing inequality. This has worsened since the mid-70’s and the boom years of Thatcher and Blair :-

Little wonder then that the golden age for waged workers in the OECD was not in this recent allegedly great age of prosperity, but between 1945 and 1973, when they gained the greatest percentage share of GDP for their labour and enjoyed greater real purchasing power

Red Tory, pp 49

It is interesting to note that both books have strong religious influences. Blue Labour has a number of essays by prominent Christian thinkers and an introduction by Rowan Williams the prior Archbishop of Canterbury. Red Tory is written by an author who is an Anglican theologian as well as political theorist. There are shades of “distributionism“, in both books, as they try to find a path to more widely distribute assets between us all and steer a way between socialism and capitalism. There are perhaps modern echoes of the “Three Acres and a cow” proposed by G.K. Chesterton.

Both books are worth reading and I hope will have influence on their respective groups. I found the “Red Tory” more readable than “Blue Labour” as it was written by a single author and was consequently more consistent and coherent. But the ideas in both, on the need to curb increasing inequality, to promote society and constrain the state, and to use nations and locality to limit the influence of global capital, are well addressed in both books.

Serendipitous Arboreal Knowledge

You never know when good luck will find you. This week it appeared when I was standing aimlessly in the charity shop while my wife was looking at curtains. There seemed to be an enormous amount of inspection required to check these window hanging and my spirits were beginning to flag. I thought I had checked all the possible wares on display that might interest me. But I was wrong. Hiding in amongst all the paperbacks, concealed between the Lee Childs and the Judy Picoult’s, was a little gem : “Trees: Shown to Children” by C.E. Smith.

This little book, probably published around 1910 as far as I can determine, was one of the “Shown to children series”; a series of short educational works for children. Other works concerned ‘Beasts’, ‘The Seashore’ and ‘The Farm’. It is a simple book; each chapter is the description of a tree and these are accompanied by 32 colour pictures (by Janet Harvey Kelman) of the tree, its leaves, flowers and nuts.

The descriptions are wonderfully vivid and really make it very easy to identify tree types. The descriptions are followed by detailed information about the tree’s life cycle, its place in the local ecology and the uses of its produce and timber. Consider a little of description of the aspen below :-

But you will always know an Aspen tree by its leaves. These are never still unless when a storm is brooding and the air is perfectly calm; at all other times they shake and quiver incessantly, and you can hear the gentle rustle they make as each leaf rubs against its neighbour. In the Scottish Highlands the country people tell you that the Aspen trembles because at the Crucifixion the cross of Christ was made of Aspen, and the tree must always shudder at the cruel purpose it served.

In addition to evocative portrayals of the trees there are also passages which promote an interest and sympathy with nature. Any child (even one in his 60’s like me) will find pleasure from reading this.

And do you remember what secrets the trees told us as we lay under their shady branches on the hot midsummer days, while the leaves danced and flickered against the blue, blue sky? Can you tell what was the charm that held us like a dream in the falling dusk as we watched their heavy masses grow dark and gloomy against the silvery twilight sky ?

He had learned that the mystery of tree life is one with the mystery that underlies our own; that we share ths mystery with the sea, and the sun, and the stars,and that by this mystery of life the whole world is “bound with gold chains” of love “about the feet of God”

I hope I am wrong but I fear that books like this, heavy with information and lacking in action and adventure, will be found to be less interesting to young readers today. I have, instead, to hope that google and the internet will kindle their interest in the natural world and start them on their journey outside to look at the beauty of the world around them.

In any event, the child in me really enjoyed being shown these trees and this has certainly been the best 50p I have spent in a long time. I will certainly keep my eyes peeled for the other books in the series. And, as a further stroke of good fortune, my wife didn’t buy the curtains in the long run)

Something for (next to) nothing.

We were fortunate in that we lost our broadband and telephone service a couple of days ago. In the high winds a branch was blown off an ash tree and as it fell to earth it brought the fibre optic cable with it. This was fortunate as this was the only real damage we sustained in the gales. It could have been much worse; property could have been damaged, fences could have been breached or livestock harmed. All that did happen was that we lost some communication and our access to the Internet. It ha also be useful and instructive to discover how reliant we have become on the web and how much time I wasted with it.

The first thing I noticed the number of times I could not immediately Google the answer to multiple pointless questions. Was Ed Shearan in Game of Thrones? Is Baghdad bigger than Tehran? When did GK Chesterton die? I am in the habit of checking these as they arise. It is so quick and easy, a trivial task, that I never remember the answers I get and thus never become truly wiser. There were more important questions (Can goats eat Christmas trees?) but we were able to look these up in a reference book where there is a handy reference list(*) which will still be there should the electricity follow the Internet in deserting us. This was a minor annoyance and easily circumvented by more traditional sources of information.

The second thing that was missing was also information. I realised that I was receiving a great deal of my news through this medium. I world start each day reading the news in my bed on my mobile phone and often end the day in the same way. A newspaper, the radio and television not only sorted this problem but also gave me better quality news. It gave me a wider range of information and opinion that had not been filtered down to appeal to my biases and prejudices. This points to a news years resolution – I will wean myself away from reliance on the internet, and especially social media, for receiving my news.

The other things I realised was how much of a toy the internet is for me. I was not using my phone or computer as a tool but as a toy to amuse me. It was something to fritter time away. Rarely was my use actively constructive, usually is was simply as a diversion. I realised how hooked I was on this as it reminded me of when I stopped smoking. For months after my last cigarette I would find myself reaching into my pockets for cigarettes and a lighter. Now I was performing the same motions, patting my pockets, to check my phone rather than my next nicotine fix.

The most fortunate part of losing this distraction was the amount of time it liberated. Not just time spent in pointless activity, but it removed the diversionary attractions which often sideline plans.

I had a large amount of goat dung and bedding to deal with, which is never a fun task and one that can nearly always be postponed or sidelined. With the new free time I felt best to make some use of it. I gathered up some residual side cuts of timber, left over from the last time we were making planks, and decided to make some raised beds. The lining was made of old plastic feed bags and the preservative was two old tins found in the garage (Hence the two different colours). After a couple of days work and no special expenditure I had a couple of fuctioning vegetable beds. These may not look much now but wait until the summer when they start to be productive.

Two tone beds

I think I can say, quite definitely, that I was fortunate to lose the broadband connection. I now have beds, have used some rubbish and have formed a new year’s resolution. It is true that I am not up to date with what is happening with Kim Kardashian’s buttocks but I think I will survive this loss.

(*) They can, in moderation, indeed it can be a useful vitamin supplement.

Serotonin by Michel Houellebecq

I have not found a book so initially distasteful as this since I read Bret Easton Ellis’s “American Psycho“. I had to persevere at the beginning as much of the content was so unpleasant that it created a visceral emotional response. However, I am glad I persevered as, after a time, the satire of capitalism and consumerism was well worth reading. There are similarities between American Psycho and this book but Houellebecq’s satire is much more wide ranging and scathing. Rather than having an aspect of our society in its sights this book takes aim at the entirety of Western Culture.

This is a book about the end of our culture; a look at the end of a millennium that ‘had previously been known as Judeo-Christian’ and one that appears to be ‘one millennium too many, in the way that boxers have one fight too many’. This is a book about a culture which has lost its sense of love and purpose and has been left only with its desires and the consequential emptiness that this brings.

The narrator, of this story, has little that makes life worth living and only survives, after a fashion, by taking antidepressants to try and keep his brain biochemistry in the range where life is tolerable. He has lost love, both personal erotic love and also agape: the positives of life are absent. Similarly the negatives of life are no longer felt. He knows (intellectually) many things are wrong but he cannot feel appropriate anger or disgust. This is truly a nihilistic story. This is the story of a man, and a culture, who have huge gaping holes at the centre of their being which no amount of sex, pornography, eating or violence can fill. They are left with suicide as the rational options.

Despite these themes the book is well written and at times beautifully lyrical. It is also often very, very funny. A black desperate humour runs through this tale. This may be a problem to some readers as the author’s misanthropy and disgust with our cultural changes is very well described and it can be difficult to see, in back and white, just how debased some aspects of our lives have become. Many will find this story too excessive and gruesome, however, if you can stomach it, then it is a worthwhile read. Indeed, by the end, of this torrent of sadness and depravity the narrator, and reader, discover that only love and self-sacrifice really matter.