Filed under: Books
Date for next book club is Tuesday September 11th 2012 at 6pm, IoP, room to be confirmed.
Here are Amazon links – please use to support the book club
Filed under: Books
Influential when it was published during the 1970s, how relevant is Anthony Clare’s Psychiatry in Dissent today? We discussed this book last night at the Maudsley book group, and were joined by Prof Robin Murray, and friend and colleague of Clare.
Clare, a clever and urbane Irishman, was one of the first to take on the arguments of ‘anti-psychiatrists’ such as Thomas Szasz and R. D. Laing. Although Clare was still in psychiatric training when Dissent was published he found himself propelled into the limelight as a spokesman for the profession. This was something that Prof Murray said caused some resentment at the time, not least because Dissent is, in places, quite critical of contemporary senior psychiatrists.
After the passage of years the book is notable for both what it does and doesn’t include. The first two chapters of the book are perhaps the strongest. They explain the concept of psychiatric illness and the process of diagnosis, both of which have undergone little change. Also still relevant is Clare’s critique of the Rosenhan experiment . This is an interesting, but methodologically flawed, study. Controversy was raging about it in the mid-70s and its results are still cited uncritically today.
There’s no mention of ADHD, PTSD or bipolar spectrum – these didn’t ‘exist’ then. A similar book written today would need to address controversy of the efficacy of SSRI antidepressants. There is a chapter on psychosurgery, something of a non-topic now, and already on its way out during the 1970s. The 40s, 50s and 60s had seen lobotomy used for a wide range of presentations from schizophrenia to migraine.
The final chapter “Contemporary psychiatry” is notable in that in many respects it echoes many of the problems of psychiatry today, as if nothing has changed: poor recruitment to the specialty and under provision of services.
Towards the end of his life Clare talked about updating Dissent, but a heart attack intervened. It would be nice to have a contemporary critique of psychiatric practice aimed at the layman – a modern Psychiatry in Dissent is sorely required today.
Filed under: Books
One year ago I decided to start a book group. Bang on trend for 2011 eh? However, this wasn’t any old book group, this one had decidedly high falutin’ aims. With psychiatric training focusing increasingly on competencies and MRCPsych requirements, there seems little time left for learning about concepts critical to the development and history of psychiatry and related fields e.g. psychoanalysis, psychology, philosophy, sociology, anthropology, neuroscience etc… Such disciplines can be hard to access for the uninitiated and a medical training doesn’t help much to furnish one with the necessary critical tools to appraise, say, a philosophy of mind book however relevant it might be to psychiatry. Thus Reading the Mind was born; unashamedly educational and aimed at psychiatric trainees wanting a little bit more.
Our first book was The Divided Self by R D Laing (1960) a seminal work by a key figure in the anti-psychiatry movement critiquing the biological model of schizophrenia. Here Laing reworks psychosis as an understandable response to intolerable pressures placed on the patient by society and the family. This was followed by Notes Upon a Case of Obsessional Neurosis by Sigmund Freud (Rat Man) (1909), a great introductory text to Freud’s core concepts of psychopathology, particularly neurosis, and an exemplar case history on the descriptive phenomenology of OCD. Next, we discussed Consciousness Explained by Daniel Dennett (1994), an influential and contemporary philosophical critique of the paradigm we use to think about consciousness outlining the foundation for his own theory of consciousness. Opening Skinner’s Box by Lauren Slater (2004) provided the group with a run-through of the ten most important psychological experiments of the 20th Century and in doing so provided a crash-course in the recent history of Psychology. We then read The Loss of Sadness by Allan Horowitz and Jerome Wakefield (2007) a devastating critique of the current concept of depression within psychiatric nosology; Illness as Metaphor by Susan Sontag (1978) a brilliant essay on the dangers of reducing illness to metaphor and the pervasive effect on doctor, patient and society; Winnicott by Adam Phillips (1998) a welcome introduction to his life, work and key concepts, and finally, The Mask of Sanity by Hervey Cleckley (1941,1982) a seminal study on the psychopath. Grounded in case studies, it profiles and refines the concept of the psychopath, and was used heavily by Robert Hare in developing his PCL checklist.
Our next meeting is on Tuesday 22nd May and we’ll be discussing Anthony Clare’s Psychiatry in Dissent (1980). Unfortunately, due to our funding, Reading the Mind is only open to Maudsley trainees. However if you’re interested in starting a similar book group then please get in touch.
Dr Lisa Conlan, ST6 General Adult Psychiatry, SLAM.
Filed under: Books
There’s an interesting programme just broadcast on BBC Radio 4: Writing Madness
From the BBC website:
“Vivienne Parry takes her diagnoses of literary heroines into the 20th century and the age of Freud, the Great War and the explosion of the ‘sciences of the mind’ focusing on three great works of fiction, mixing contemporary psychiatric and literary insight.
How did modern literary and psychiatric ideas meet and how did each shape the other? Do these heroines show literature of the period to be a critical – and even emancipating – force…or is fiction really medicine’s stooge? Novels on the couch include Scott Fitzgerald’s Tender is the Night and Virginia Woolf’s Mrs Dalloway….interestingly with both novels there’s a tendency to base the heroines on real people – Nicole Diver is based on the case history of Fitzgerald’s own wife Zelda, whereas Woolf’s Mrs.Dalloway comes very close in literary terms to what Freud calls ‘self-analysis’ – one difference is that Woolf sometimes believed ‘madness’ was necessary to be creative, while Scott Fitzgerald depicted it as disastrous drain on creativity (ie. his). And both novels have the dynamic and lucrative new industry of psychotherapy in their sights. Vivienne compares fiction in the age of Freud to literary ideas of mental health in the Victorian age and in Dickens specifically, using Great Expectations’ Miss Havisham as a case study.
Contributors include psychotherapist and essayist Adam Philips, leading psychiatrist Simon Wessely, cultural historian Lisa Appignanesi and Chris Thompson, psychiatrist and medical director of The Priory”
The programme is broadcast again on March 31 at 2330 and is also currently available on iPlayer.
Picture via Wikipedia
Richard Dadd (1 August 1817 – 7 January 1886) was an English painter of the Victorian era. Following a long tour of the Middle East in the early 1840s he succumbed to a schizophrenia-type illness, following which he murdered his father and fled to France where he attacked another traveller. After his return to England he spent over forty years in the Bethlem and Broadmoor, during which period most of the works for which he is best known were created.
Dadd’s painting The Fairy Feller’s Master Stroke is featured on the cover of a recent British Journal of Psychiatry. Nicholas Tromans, a Senior Lecturer at London’s Kingston University, is widely published on the subject of 19th century art and is author of Richard Dadd: the Artist and the Asylum. He came to talk to us about Dadd’s life and mental illness:
AoP: As a young man, how did Dadd go about establishing himself as a painter in London?
NT: It seems that Richard owed a great deal to his father, who had been a high-street chemist in Kent but who, when Richard was a teenager, took over a gilding business in central London which must have had many professional artists among its clients. Dadd’s own beginnings as a professional artist were really entirely conventional. He became a student at the Royal Academy (virtually next door to his father’s shop) and made studies after the sculptures at the British Museum. He appears to have been extraordinarily self-confident, and was soon sending his pictures to exhibitions in London and in places like Birmingham and Manchester. He managed to attract the patronage of both London aristocrats and the self-made men of the industrial cities – as well as the support of some influential critics. By the time he left for his tour of the East in 1842 he was one of the risng stars of the London art scene.
AoP: What do we know about how and why he killed his father?
NT: Towards the end of his tour of the Mediterranean, in the Spring of 1843, Richard began to suffer from delusions – that there were people trying to harm him, perhaps that he could see the devil in human forms. Many of those who had known him were worried by his unusual behaviour after his return to London, and his father consulted a psychiatrist at St Luke’s – Alexander Sutherland – who recommended hospitalisation. Possibly in response to this suggestion, Richard carefully planned a knife attack on his father, which succeeded in killing him. Richard was soon afterwards arrested and eventually sent to Bethlem Hospital in Lambeth. Later Dadd explained that the killing had been required of him by the Ancient Egyptian god of the dead, Osiris, and that although Richard approved of the destruction of the imposter who claimed to be his father, he was in effect only an instrument in the hands of the deity. It was a fantastic delusion, but one in keeping with Richard’s larger set of beliefs about the continuing truth and relevance of the philosophies of ancient cultures.
AoP: What do we know about how he was as a patient?
With regard to his time at Bethlem (1844-64) – not a lot. There are really only two entries in his casenotes, and the first of these dates from as late as 1854. This entry describes how violent Dadd was considered when first admitted, and how he would suddenly strike another patient without provocation (and then immediately apologise). The formal designation of ‘dangerous’ was applied to Dadd even during the last years of his time at Bethlem. I infer from the lack of detail in the notes, however, that he was by and large not an especially troublesome patient – not one who required strategies to manage. That he painted ambitious pictures for the two senior managers of Bethlem – paintings which he worked on for years – suggests some kind of relationship between patient and staff, although certainly not an uncomplicatedly collaborative one.
AoP: Why was he transferred to Broadmoor?
Dadd was admitted to Bethlem as a Criminal Lunatic – someone too unwell to be punished for a crime, or (from the 1840s) one too unwell to stand trial at all. This meant being placed in a special wing of the hospital in very cramped, minimally furnished, high-security conditions. It was obvious to the authorities that something needed to be done with this novel legal category of prisoner/patient, and a dedicated new hospital was made possible by an Act of Parliament in the early 1860s. This was to be Broadmoor near Reading, to which Dadd was transferred along with his fellow male Criminal Lunatics, in 1864, and where he died and is buried. There were those – among them the Superintendent of Bethlem – who feared that gathering together these cases out in the countryside would produce “a bastile of lunacy”, feared and resented by the public. These critics were to be proved at least partly right, but for Dadd the change brought improvements. By any common-sense criteria of well-being, his life got better: he was able to see more, to move about more; he took an interest in cricket and chess; and the range of media in which he himself worked expanded.
AoP: How has Dadd’s legacy been regarded after his death?
Dadd’s meticulous watercolours never entirely went off the radar of the art market. Collectors were able to buy them as they left Bethlem and Broadmoor by one route or another. The V&A and the British Museum both acquired watercolours by Dadd while he was still living at Broadmoor. But after his death there were really only a series of false starts when it came to retrieving his biography and reconstructing his oeuvre. Various people had a go, but there was just too little to go on. Things changed only in the 1960s when the Fairy Feller arrived at the Tate and when Bethlem acquired a dynamic and imaginative archivist who was in a position to become Dadd’s first proper biographer. This all coincided of course with the passionate debates generated by the so-called anti-psychiatry movement, and Dadd – in the guise of heroic ‘survivor’ of the Victorian asylum – seemed suddenly of acute cultural significance. Interest in him has calmed down since. As I say in the preface to my own book on Dadd, I have not tried to resurrect him as a hero of any kind: I have tried to understand him as a wonderful artist – one of the most exciting of the Victorian age in my opinion – who happened to spend his career in unusual circumstances.
AoP: Despite his situation, Dadd’s pictures seem untouched by the content of his delusion and he never addressed asylum life in paint. Can you reflect on this?”
Well, “sane” Victorian artists rarely painted the streets on which they lived, or pictures which sought to sum up their philosophies of history. They were typically more interested in the same kinds of things on which Dadd remained fixed, that is, the topography of exotic places filtered through the memory, portraits, and illustrations to literature. Dadd had never been a Realist — on the contrary he was from the start of his career a painter of poetic imagination. And in any case, one reason for spending so much time thinking back, visually, over his time abroad in the early 1840s must surely have been a need to escape from the very limited environment in which he had to live.
AoP: And where can interested people see Dadd’s stuff?
NT: Not a lot of oil paintings in public collections (the watercolours can only be shown periodically of course because of their vulnerability to light).
The Scottish National Portrait Gallery have Dadd’s wonderful portrait of Dr. Alexander Morison:
Tate Britain Dadd collection
And just last year, the Harris Museum and Art Gallery in Preston acquired the early fairy subject Puck which had been in a Preston collection in the nineteenth century
The best place to head is however Bethlem Hospital itself where a substantial number of Dadd’s works can be seen in a context which helps make sense of them.
A small collection of Richard Dadd’s paintings is being exhibited Feb – April 2012 in the Bethlem Hospital museum – details.
This clip of a Richard Dadd painting being discovered on Antiques Roadshow is worth a watch (starts at 4:24)
Richard Dadd: Masterpieces of the asylum Independent 2011
Richard Dadd: Madness and Beauty Telegraph 2008
And so to philosophy… We dived in headfirst and found the waters, well, rather murky. Consciousness Explained is Daniel Dennett’s 1991 book on the most difficult conundrum facing philosophy and science today – the phenomenon of consciousness.
As a group, we started by thinking a bit about this. How would you study it? How would you define it? Hang on, what actually is it? The more we thought about it, the more difficult it seemed. Thankfully, despite our guest expert falling ill on the day of the event, we had a great turn out to make (ahem) light work of this weighty topic.
Consciousness Explained is divided into three parts. Dennett uses the first section to outline his project, method and goals. Here he introduces ‘heterophenomenology’, his ‘neutral’ method aimed at getting clear on what the phenomena that need to be explained actually are. The second part develops his model of consciousness, the ‘Multiple Drafts Model’, which he contrasts with the ‘Cartesian Theatre’ which it is so hard to think oneself out of. This is presented as an empirical theory, drawing on evidence from evolutionary theory as well as Artificial Intelligence, neuroscience and cognitive psychology. The third and final part focuses on the philosophical challenges that consciousness poses in the form of some entertaining thought experiments.
Dennett aims to ‘break the spell’ of our way of thinking about consciousness which makes consciousness seem unexplainable. He does this by providing an alternative way of thinking – an alternative set of metaphors. Few people would claim to be Cartesian dualists – to believe that the mind is made of a completely different kind of stuff than the body – yet we seem to fall into the trap of imagining consciousness as something that is played out in the brain for another observer in the brain: as if the light waves that impinge on our retinas are transduced into neural signals only to be transduced again for our real selves to ‘see’. This manifests as much in scientific as lay thinking about consciousness. His alternative metaphor is the ‘Multiple Draft’: the self exists rather as a scientific paper exists – circulating in multiple drafts – with no final, authoritative version.
Discussion focused on the book and its wider implications e.g. the mind/brain divide, the implications of materialism, is consciousness an epiphenomenon? (we thought not), is there a social definition of consciousness as opposed to individual? (we got stuck on that one!), whether Dennett believes in free will or not? (yes he does). Artificial intelligence and Turing’s famous Test came up, – a machine indistinguishable from a human being. Could a robot have a mind? What about philosophical zombies? Zombies are similar to us in appearances and behaviour but, supposedly, lack subjective conscious experience. Sadly, the zombie discussion didn’t go very far as the group were sceptical (probably rightly) about the contribution that fantasy zombies could make. It did, however, lead us to the one of the key difficulties: qualia. Qualia are the subjective ‘feel of things’, what it’s like to feel pain, to smell fresh coffee. Labelled elsewhere as ‘the hard problem of consciousness’, how can these be explained? Dennett attempts to show how the whole way of thinking in these terms is a ‘mess’, ‘best walked away from’.
Philosophy often uses thought experiments (such as zombies) to help with complex problems like this. So we thought we’d give that a go with Frank Jackson’s famous thought experiment Mary’s room. Mary is a sci-fi colour expert in the future kept in a black and white room for her whole life. Mary has never seen colour although is world expert on colour red (she knows everything! Refraction, chemical components, wave-length, subjective reports from others). One day she is released, she steps outside and sees a red-rose. Does she learn something new about the colour red? Intuitively, you might think yes. Not our group, hardcore materialist Maudsley Trainees that they are! A straw poll saw ‘no’ as the majority – albeit a narrow majority – view. They were quite happy to do away with qualia but still felt that Dennett hadn’t fully convinced them with his theory.
Well-written, witty, direct and peppered with useful footnotes and anecdotes, Explaining Consciousness was, nonetheless, an ambitious and challenging book and choice for our group. The grand project of the book and the value of philosophy in shaping ideas and questions for modern scientific exploration of consciousness were widely remarked on. The study of subjective conscious experience and the ideas of what the mind may be seemed so relevant to our practice that we wondered why the MRCPsych Course hadn’t touched upon it. Consciousness is an area the book group will return to.
The next meeting of Reading the Mind will be on Tuesday 20th September at 6pm in Seminar Room 2, Institute of Psychiatry. We will be reading Opening Skinner’s Box by Lauren Slater – an interesting run through ten of the 20th century’s most relevant psychological experiments. See you there!
Dr Lisa Conlan, ST6 Psychiatry Trainee and Simon Harrison, ST4 Psychiatry Trainee
“Flight Fantastic” by Lorraine Nicholson
Emerging from the darkenened caverns of the mind
To embrace a light so directional and bright.
A chrysalis once, a butterfly now,
Wings unfolded, taking flight.
A flight not of escape but of liberation.
Brave New World.
What a day, what a night, what a life!
Experiencing a spiritual rebirth,
Breathing a passionate air into my lungs once again,
Like a stiff, bracing breeze energizing the soul.
Life is in my eyes once again.
The window on the soul expresses the happiness within.
A childish enthusiasm fills all my days now.
Reawakened, impassioned and wide-eyed as I go out into the world once more.
The freedom of flight is mine now
To land at will wherever fancy takes me
To touch the lives of fellow creative souls
And deliver the message of beauty
In this oft dark world in which we live.
The flight of the butterfly is one to relish.
Spread your gossamer wings and fly….
Lorraine Nicholson is the author of “The Journey Home” a collection of poetry, artwork & photography which tackles the theme of recovery from severe depression. Lorraine has kindly agreed to be interviewed by AoP blog. Her website is http://www.hope4recovery.co.uk
Can you tell us how you came to produce this book?
Like recovery it has evolved and taken shape over a period of 5 years. Back in 2006 the seed of the idea of publishing was sown during a 6 week solo exhibition I was offered showing my photography and emerging poetry which I called “A Carnival of Colour”. I used the opportunity to challenge the stigma which surrounds mental illness by going to the local press and having information up about the background to the exhibition being the visual expression of recovery from severe depression. It opened floodgates for people with similar experiences to open up to me in the gallery which was an eye-opener for me as I realised how common it is.
Subsequently in early 2007 I sent my work to several publishing houses without success. Ironically it was through a 2 month relapse in hospital in 2008 that I began to read recovery poems to fellow patients by way of peer support. One of the patients was somebody whose father was in the printing trade and on discharge we met up and he offered to put the money up to have it printed and published. It was a dream come true to share in order to help others.
How does this book fit into your story?
The first two years of my illness 2002-4 when I was in denial and giving services the runaround I got to the stage that all I did was walk long distances and then when my weight dropped to 5 stones and I was in bed all the time the last thing on my mind was creative expression. There was emptiness, desolation within and numbness, no feelings, no response to anything around me be it music, art, people. All I craved in illness was isolation and darkness.
On discharge from hospital the second time in 2005 words started coming to me thick and fast, expressing strong emotions firstly of regaining my joy in seeing colour, experiencing light and feeling alive within. My first poem had the title “Flight Fantastic” and takes the metaphor of a butterfly emerging from its cocoon and taking flight. My prolific writings helped me to make sense out of the trauma and allowed me to reframe experiences. Over the course of 3 years I was slowly able to return to the extreme pain and vulnerability and express illness in a powerful way which often shocked me to the core.
In short this book is my story.
You talk of your depressive illness giving you a second chance – can you tell us more about this?
Depressive illness as a second chance.
Severe depression for me represented something majorly wrong with and in my life which needed addressing and changing.
It was a time to ask myself the big questions in life around who am I and why am I here? Depression was the stop sign that forced me to search for and discover these answers for myself so I could move on and stay well. I realised over the course of time that I had up to that point been living life for everyone else but me.
I see, in retrospect, that illness such as this was, for me personally, an opportunity to reassess and find balance and fulfilment, so that what initially felt like a curse, being in prison for a crime I did not commit, became, in the fullness of time, the greatest blessing of my life.
There are many references to the theme of rebirth in my book. One poem, in fact, is called RENAISSANCE woman. The identity I had suppressed for years yearning to be an artist, was surfacing in a very emotive way. It could no longer be kept underground. It was gasping for air and a chance to flourish.
Now that my needs are being addressed by going to art school as a mature student, I am managing to stay well.
You’re now at art school. Where you an artist before your depression?
Since the age I could hold a pencil and before I was always keen to express things visually, having a strong visual response to the world around me.
It was something within me right from birth. Pre school age I would sit and draw everything in the room on the back of a napkin at a coffee morning with my mother. It was my main source of fulfilment and it continued right through to my teens with painting, drawing, making things out of wood/metal and then at 15 I was handed my Dad’s old analogue camera and began to photograph the world around me.
Then the academic world got in the way and art was regarded as a “nice hobby” but ” get a proper job” by the school. I had the academic ability to go to university and there studied modern languages but still took History of Fine Art as an outside subject.However, the writing was on the wall and after 3 years of success academically I failed to get my Honours degree in my final year dropping out at Christmas two consecutive years with stress and depression.
Yes I was very much the essential artist before suffering major depression at 40.
You said that you would never have thought of writing poetry before your depression – why do you think that you were inspired towards poetry as part of your recovery?
I didn’t feel as much inspired to write poetry, which, incidentally I never felt drawn to before I became ill, rather compelled to write poetry. It was a need not a choice and proved very cathartic . I didn’t choose it. It chose me and I have heard poetry described as the language of suffering. Words bagan to surface after the catatonic state of severe depression, like lava from a dormant volcano.
After long periods of non-communication and self isolation words put me in touch with the sense of self that had been absent for years. I began to feel emotion again after the numbness of depression.Floodgates opened and I could express and attempt to make sense of the trauma I had been through. It was a huge release.
Do you still write?
I no longer write poetry which, to me, demonstrates its need at that time in my life which is no longer a need. My main channel now is art and photography.
Which artists/poets do you find inspirational?
Of course there are many artists and poets who have suffered depression in their lives or major adversity like Van Gogh, Munch and Frida Kahlo. For colour alone Matisse is my favourite and in 2009 I was in the tiny chapel at Vence he designed the interior of. The vibrant colours of blue and yellow streaming through the stained glass windows onto the marble altar suddenly had me in floods of tears but of joy not anguish as I was unable in the depths of depression to feel colour or have any emotional response to what i take pleasure in normally.
As far as poetry goes I love the work of Robert Frost.What he writes speaks to me. As far as contemporary poets go, Kenneth Steven’s work evokes a visceral response in me.
You identify depression as being connected to identity loss – can you explain? Do you see this book as part of regaining that identity?
Many of my poems are related to this theme. “Labelled Lost and Found” being one of them. As much as a loss of identity in more focused terms it is related to a loss of soul for me.
I have emerged with far greater self awareness than ever before.
I now know who I am and what I am here to do.
For all my adult life I had suppressed my truth, my authenticity to “get the proper job” and to please others all at the expense of my soul’s truth. The art was an aside, an evening class here and there, a hobby, no more. I was bored, empty, hugely unfulfilled. Life was an existence.
Recovery for me has been a search, a seeking out of truths, a going deeper to explore, a PHD in self-awareness. A clarity is there which was a haze before.
My Book “The Journey Home” is an affirmation of my artistic identity. It is my unique signature on the world’s surface.
At the back of your book you thank the professionals who helped you recover – what did you find the most helpful?
The therapeutic relationship has been of huge significance to me wherein an approach is taken which is totally driven by the belief that recovery is possible.
Asking me to take the lead once I have been deemed ready to has been the very root. They have handed me back the responsibility for the future direction of my own life and invested in the development of my strengths, empowering me to be all I can be through active listening to my needs and goals.
They have allowed me to take positive risks which is the very kernel of personal growth and self-determination.
They have shown complete faith in my abilities.
Such consistency of support and encouragement to move forward in my life and go beyond the person I was before, has had an enormous impact on my self belief. The foundation of their approach is humanitarian-driven and stems from a genuine desire to care holistically and promote self determination, ultimately aiming to make themselves redundant in my care.
The recovery approach for me consists of a “way of being” with people at every stage from crisis through every ongoing step. It is an intuitive “felt” response to the way you are feeling at any given time. “Tuning in” to the person’s wavelength shows wisdom based on understanding what is needed at the time. The tone of voice, body language, choice of words, hopeful attitude makes all the difference to our outlook. Being surrounded by people who feel positive about you and believe in you undoubtedly boosts confidence but there is a right time for every word and gesture. Knowing when to step in and prevent and when to stand back and allow are crucial skills which will impact on people’s chances of recovery.
Recovery is not a buzz word. It is an ethos, a philosophy, an approach to life and caring.
Filed under: Books
Reading the Mind. The Maudsley Book Group.
I have long had it in mind to start a book group dedicated to reading seminal works in, and related to, the field of psychiatry. After a chance meeting with Simon Harrison and Carol Kan, I finally decided to do something about it! Thus Reading the Mind was born, as was our small committee. The premise was simple really; psychiatry is a complex discipline, firmly a branch of medicine but interwoven with psychology, neuroscience, psychoanalysis, philosophy, sociology, anthropology and many more. The culture of reading widely around these subjects has somehow become more difficult for trainees to access. With so many areas to cover, where do you start? Well that’s exactly the sort of itch the book group aims to scratch.
The first meeting of Reading the Mind was held on Tuesday 29th March at the Institute of Psychiatry in seminar room 2. Our first book was R D Laing – The Divided Self. Seminal certainly but, admittedly, a difficult read. Professor Tony David kindly came along to help us make sense of it. The Divided Self was Laing’s first book, written at the tender age of 28, setting out his theory of schizophrenia in three parts. The result is a concise direct work, at times dense and convoluted but always interesting and, for the most part, clinically relevant. His goal was a re-telling of psychosis as an understandable reaction towards intolerable pressures placed upon the patient by those around him. The first part sets out his basic concept of ontological insecurity. Taking in existential philosophy and phenomenology, he placed a key focus on what it’s like for the patient. He wanted to demonstrate meaning in psychosis or, to paraphrase Karl Jaspers, to render understandable the, by definition, ‘un-understandable’. He vividly described this ontological insecurity as an indefinable feeling of something lacking and a primary disturbance of the self. According to Laing, this is the root of the schizoid and schizophrenic disorders. He went on to elaborate this with his theory of the false self/real self system. Those who have their ‘real self’ undermined repeatedly in childhood will develop a false self to interact with the world. These people are then at risk of developing psychosis when, under pressure, the real self shrinks and dies and the false self becomes overwhelmed and can no longer cope. Laing trained at the Tavistock and his false self concept is closely related to Winnicott’s ideas, who was his supervisor at the time. In the third part, he demonstrates his theory with clinical vignettes and patient histories.
The Divided Self generated much lively discussion and a range of opinions, both positive and negative. As a general overview, the group felt that the book had a positive historical role in repositioning the patient’s lived experience right back at the heart of discussions about what it is to have schizophrenia. To seek meaning in psychotic experiences and attempt to understand them and, crucially, make the patient feel understood, is undoubtedly of great importance and Laing consistently stressed this. There were some ways in which his theory supported our collective clinical experience such as the close relationship between ontological insecurity and the self-disturbance symptoms seen in prodromal schizophrenia. However, the group struggled with his theory, particularly the difficulty it seems to have in generalising to the kinds of cases we see daily in our practice. There were also criticisms about the overall project that R D Laing undertook. On the one hand, he outlined a theory for schizophrenia, marking it as a disease and something that occurred only in those vulnerable to certain stresses e.g. those who are ontologically insecure with a friable false self. But then on the other, he seemed to push for a sociological explanation for madness making it a potential outcome for anyone in the right (or rather wrong) circumstances, and later, took it further to say that madness was purely a social construction. There is then his legacy of the ‘schizophrenogenic family’, particularly the mother and the unnecessary criticism and stress this has placed on many families of patients with schizophrenia.
A famous cult figure in his lifetime, it was inevitable that discussion would turn to the large divide between the man and the psychiatrist. Laing struggled with alcoholism and clinical depression throughout his life, was given to emotional and aggressive outbursts and fathered ten children by four different women. Despite his emphasis on the importance of parenting, he wasn’t a consistent figure for any of his children. That said, he had a reputation as a very caring clinician who often went to great lengths to engage and understand his patients.
There is no doubt that The Divided Self is a seminal work and over the course of the group, it became clear that it has important implications that resonate still today. R D Laing refocused psychiatry and placed the experiential component of our patient’s symptoms and the importance of active patient listening and engagement right back at the heart of the work we do.
Reading the Mind is open to any London psychiatry trainee. The next meeting will be on Tuesday 24th May and we will be reading The case of the Rat man by Sigmund Freud.
Dr Lisa Conlan, ST5 psychiatry trainee.