Madness Explained

by Richard P. Bental

  Thanks for reading early drafts of various chapters and making encouraging noises go to my partner Aisling O’Kane, to the father (psychologist) and son (biologist) team of David and Ben Dickins (who checked my genetics), to Paul French, to John Read and finally to Tim Beck (who reminded me that it takes much less time to write a good chapter than a very, very good chapter). I would also like to offer special thanks to Stefan McGrath of Penguin Books, who first asked me to write this volume, tolerated my complete inability to stick to deadlines, and whose helpful feedback ensured that the final product was not so large that a wheelbarrow would be required to move it from one place to another.

  No doubt I have left important people out of this list, and will find myself apologizing to them at a later date. Of course, my memory is less than perfect. In any case, it is time to reclaim my life and move on to projects new.

  Richard Bentall

  August, 2002

  Part One

  The Origins of our Misunderstandings about Madness

  Figure 1.1 The North Wales Hospital, Denbigh, photographed in 1930 (reproduced from C. Wynne (1995) The North Wales Hospital Denbigh, 1842–1995. Denbigh: Gee & Son). The hospital was opened in 1848 on twenty acres of land donated for the purpose by a local landowner, Joseph Ablett, of Llanbedr Hall. At its peak, during the 1950s, the hospital was home to some 1500 patients. Its closure, first announced in 1960, was not completed until 1995.

  1

  Emil Kraepelin’s Big Idea

  What a curious attitude scientists have – ‘We still don’t know that; but it is knowable and it is only a matter of time before we get to know it!’ As if that went without saying. Ludwig Wittgenstein1

  It is nearly twenty years since I first walked on to a psychiatric ward. At the time I was an undergraduate psychology student at the University College of North Wales, naive about the harsh realities of psychiatric care, but determined to prove myself in the hope of securing a career in clinical psychology.* Like most students in the 1970s, I wore faded blue jeans and a sweatshirt for all occasions. This caused at least one nurse to mistake me for a patient. (She attempted to overcome her embarrassment byexplaining that she had assumed I was a psychopath rather than a schizophrenic. Apparently the patients attending the hospital’s drug rehabilitation unit nearly all wore jeans and nearly all were thought to show evidence of a ‘psychopathic’ or anti-social personality.)

  The North Wales Hospital was located just outside the quiet market town of Denbigh. I was visiting in order to carry out a small research project with some of the hospital’s long-term patients. I commuted the forty-two miles between Bangor and Denbigh in a disintegrating Austin mini, purchased with £300 I had earned by labouring in a Sheffield tool factory during my summer vacation. Descending the winding A543 into the centre of the town, I had to proceed cautiously because my brakes were not reliable. Unable to afford repairs, I was no exception to the delusion of immortality that is peculiarly strong in the ambitious young.

  From the centre of Denbigh, a narrow road led up a hill and past a ruined thirteenth-century castle. Beyond the summit, the hospital came into view – a stone-grey Victorian fortress, standing in spacious and neatly maintained gardens, behind which stood the Clwyd hills. On a sunny day, it looked like an ‘asylum’ in the true sense of the word: a refuge, a place isolated from the troubles of the world. This illusion would be broken only after stepping through the imposing entrance, into the dark, antiseptic-smelling corridors that led to the psychiatric wards.

  The ward on which I attempted to carry out my research was a large dormitory divided by wooden partitions into sleeping, sitting and dining areas. The paint was yellowing and the furniture had seen better times. The ward always reeked of cigarettes and sometimes also smelt of urine. It was home to about ten women, mostly elderly, who had spent most of their lives in psychiatric hospitals, and all of whom had been diagnosed as suffering from schizophrenia. They were cared for by uniformed nurses who, like generations of their predecessors, had been drawn from the population of the nearby town. In order to improve the women’s self-care skills, a form of behaviour-modification programme (known as a ‘token economy’) had been introduced under the supervision of one of the hospital’s few psychologists. The women were rewarded with plastic tokens if they completed various routine tasks (for example, getting up by a particular time, washing and dressing appropriately) and they could exchange their accumulated tokens for various forms of ‘reinforcement’ (usually cigarettes or sweets). It was a mechanistic form of rehabilitation (and one that has largely fallen out of favour) but its effects were occasionally dramatic. Before its introduction, one patient had been so determined to mutilate herself that the nurses had taken to tying her arms to her bed to prevent her from harming herself during the night. A year after the programme had been introduced, she was sleeping normally and was able to work as a nursing assistant on one of the other wards.

  Despite these kinds of benefits, most of the women continued to exhibit a bewildering range of symptoms. Some appeared to talk to imaginary voices. Others expressed bizarre ideas. One believed that she had written a famous Russian novel. Another kept insisting that ‘Peter Pickering has plucked my brain’, a delusion which became more intelligible when inspection of her case notes revealed that she had been given a prefrontal leucotomy (a crude brain operation) many years earlier. (The notes recorded that the operation had been given under local anaesthetic and that she had become highly distressed at the precise moment that the knife had been inserted into her brain.)

  One of the women had been mute for many years. Another spoke in a chaotic jumble of invented words and half-finished sentences. Most exhibited emotional or disorganized behaviour of one sort or another. (I recall that one lady of about 70 would periodically announce ‘I’m going up the pole’ before running from one end of the ward to the other, screaming loudly.) They were all vulnerable to maltreatment and exploitation. For example, one had been sexually abused in a toilet by a hospital visitor, who had attempted to buy her silence with a cigarette. How the women had come to be at the North Wales Hospital was something of a mystery. Most of the medical notes were too old and too vague to give any useful information about their early lives.2

  The experiment I conducted under the supervision of the psychologist who was running the token system was designed to test the effectiveness of a simple form of psychological treatment, known as self-instructional training. The aim of the treatment was to improve the patients’ ability to focus their attention when attempting daily tasks, on the assumption that this would facilitate their rehabilitation. The study called for each of the women to be given a short battery of memory and reasoning tests before and after several sessions of treatment, each lasting for perhaps half an hour. In each session, I would encourage the women to talk out aloud to themselves while solving various puzzles – to literally instruct themselves about what they were doing. In this way, the psychologist and I hoped that they would regain the capacity for focused verbal thought that we assumed they had lost as a consequence of their many years of living in an institution.

  Some years later, I formulated what I now refer to as my ‘first law of research’, with which I entertain students who are about to embark on their first scientific projects. The law states that, by the time an experiment has been completed, the researcher will know how it should have been done properly. My own first adventure in experimental clinical psychology was no exception to this rule. I worked with each of the women for several hours, trying to teach them the relatively simple strategies that I believed would help them, becoming increasingly frustrated at their indifference to my efforts which, in retrospect, had little relevance to their needs. They, in turn, sometimes became frustrated with me, but more often struggled to be nice to the scruffy young man in jeans who energetically cajoled them to speak out loud while assembling simple jigsaws, or while matching groups of similar patterns. There was not a single aspect of my relationship with the women
that I would now describe as therapeutic for either party.

  Life has been kind to me in the years following the completion of the study. Some months later, I wrote up my results, said goodbye to the North Wales Hospital and collected my degree.3 Although I failed to secure a place on a clinical psychology training course, I was not particularly disappointed – competition for training places was very strong. Plan B was to study for adoctorate in experimental psychology, so I gratefully accepted an offer to stay on at Bangor. Four years later, after completing my Ph.D., I secured a place on the clinical psychology course at the University of Liverpool. Sixteen years later still, I head up a small research team at the nearby University of Manchester, studying the kinds of problems that I had observed but poorly understood at Denbigh.

  I suspect that life has been less kind to the women who suffered from those problems. Even a self-absorbed and ambitious young student could sense that the best they might experience in their declining years was humane custodial care. I imagine that most have now died. The North Wales Hospital now lies silent and empty, closed down like many similar institutions in the effort to move psychiatric services into the community. From the vantage point of the hospital bowling green, once immaculate but now overgrown, the building still looks peaceful in a ghostly sort of way. Because of its fine architectural features it is protected from demolition. Perhaps it will find a new lease of life as company offices or a large hotel.

  With few exceptions, the psychiatric wards of today are located in general hospitals alongside surgical, medical and other types of services. Long-stay patients, unless they are judged to pose a significant danger to themselves or other people, live in small apartments or hostels hidden in the suburbs of towns and cities. Admissions to hospital are restricted to those who are floridly disturbed. Discharge back into the community is usually after a matter of weeks by which time, hopefully, the patient’s worst symptoms have been controlled by medication. Visiting such a ward, one sees patients with a variety of diagnoses wandering aimlessly around. Some talk out loud to their voices, or charge around in a manic frenzy. However, on closer scrutiny, the overwhelming impression is one of inactivity and loneliness. Many patients sit in the ward lounge, silently smoking cigarettes, their faces glued to daytime television shows. The nurses, who now wear casual clothes instead of uniforms, spend most of their time in the nursing office, talking only to those patients who are most obviously distressed. The psychiatrists and psychologists are even less in evidence – patients on many wards see their psychiatrists for only a few minutes every week and the psychologists are almost entirely absent, confined by their own choice to outpatient clinics. There seems to be a lack of therapeutic contact between the patients and the staff. The patients are simply being ‘warehoused’ in the hope that their medication will do the trick.

  I do not believe that this reflects much improvement compared to the standard of care that I encountered twenty years ago. Indeed, the psychiatrist and anthropologist Richard Warner, who has studied changes in psychiatric practice over many years, has argued that the success of psychiatric treatment today is little improved on that achieved in the first decades of the twentieth century, before the development of modern psychiatric drugs.4 It would be tempting to blame this depressing state of affairs on the quality of the staff who work in our psychiatric services. Certainly, I have met some nurses, psychiatrists and psychologists who appear to be indifferent to the needs of their patients, and who would be much better employed in some other line of work. However, they are the exceptions. Most mental health professionals are hard-working, caring and thoroughly frustrated at their inability to do better for their patients.

  In this book I will argue that the main problem faced by modern psychiatric services is not one of personnel or resources (although these may be important) but one of ideas. I will suggest that we have been labouring under serious misunderstandings about the nature of madness for more than a century, and that many contemporary approaches to the problem, although cloaked with the appearance of scientific rigour, have more in common with astrology than rational science. Only by abolishing these misunderstandings can we hope to improve the lot of the most impoverished, neglected and vulnerable of our citizens.

  The orthodox approach which I will show must be rejected is based on two false assumptions: first, that madness can be divided into a small number of diseases (for example, schizophrenia and manic depression) and, second, that the manifestations or ‘symptoms’ of madness cannot be understood interms of the psychology of the person who suffers from them. These assumptions were spelt out explicitly by the early psychiatrists whose writings have most influenced modern psychiatric thinking, and whose ideas remain unquestioned by many psychiatrists today. By tracing the history of these apparently innocuous assumptions, we will be able to see why they proved so disastrous to the well-being of patients.

  Who was Emil Kraepelin?

  Trusting in the wings of my will

  I swore to dispatch the misery of my people,

  To drive us through peril and danger

  And fulfil the promise of their prosperity

  Arduous and long the journey. In bloody victories

  And with an ardent heart did I execute my mission

  To but one enemy was I to succumb:

  The thanklessness and delusion of my own people.

  Emil Kraepelin, c. 19205

  Despite important developments elsewhere, the world centre of psychiatry and most other medical specialities in the nineteenth century was Germany, partly because more researchers pursued higher degrees there than anywhere else. It was a German, Johann Christian Reil, who first coined the term ‘psychiatry’ from the Greek ‘psyche’ (soul) and ‘iatros’ (doctor).6 Teaching in psychiatry began in Leipzig in 1811, and professors of the new discipline began to appear at other German universities soon afterwards. In 1865 Wilhelm Griesinger established the first modern-style university psychiatry department in Berlin, where teaching and research were pursued alongside clinical work. Two years later, he founded one of the first academic journals in psychiatry, the Archives for Psychiatry and Nervous Disease.

  Researchers of the period spent much of their time staring down microscopes at post-mortem brain tissue in the hope of discovering the biological basis of mental illness. In the process, they made many important discoveries about the structure of the human nervous system. The historian Edward Shorter has dubbed this era ‘the age of the first biological psychiatry’ to contrast it with our own times, in which a biological approach is also dominant.

  As Shorter has observed, it is the German psychiatrist Emil Kraepe-lin rather than Freud who should be seen as the central figure in the history of psychiatry.7 Kraepelin was born in 1856 (the same year as Freud) in Neustrelitz, a village near the Baltic Sea. It is said that he learned early to respect authority, a disposition that in later life would manifest itself in his unwavering admiration of Bismarck and in his authorship of nationalistic poems, the quality of which can be judged from that quoted at the beginning of this section. He was much influenced by his older brother Karl, a respected biologist who made contributions to the classification of plant species. Studying medicine at Würzburg, Kraepelin graduated in 1878, having earlier won a prize for an essay entitled ‘The influence of acute diseases on the origin of mental diseases’.

  His enthusiasm for psychiatry was reinforced by a period of further study in Leipzig, where he had planned to work under the supervision of the noted psychiatrist and brain anatomist Paul Flechsig.8 However, Flechsig had little interest in the psychological issues that interested Kraepelin. (It is said that Flechsig only once recorded the life circumstances of a patient, a depressed young man whom he wrote up for his doctoral dissertation.) The two men did not get on and, after a couple of months, Kraepelin was sacked, allegedly because Flechsig did not consider him able enough to deputize in his absence. (This dispute was apparently quite personal. Flechsig later formally accused Kraepelin of making d
erogatory remarks about his official oath, briefly stalling Kraepelin’s promotion, until friends persuaded the Ministry of Culture to intervene on his behalf.) It was in these difficult circumstances that Kraepelin was rescued by Wilhelm Wundt, a philosopher who is widely credited with being the first experimental psychologist. Working in Wundt’s laboratory, he immersed himself in simple psychological experiments. His new master was to remain an important influence on Kraepelin’s life and work, and encouraged him to write the first, fairly insubstantial edition of his Compendium of Psychiatry. After a series of revisions, this book would have near-revolutionary impact on the theory of psychiatry.

  In 1883, the year in which the first edition of the Compendium appeared, Kraepelin became a lecturer at the District Mental Hospital in Munich. He was appointed professor of psychiatry in Dorpat in Russia (now Tartu in Estonia) in 1886, and it was there that he first began to develop his ideas on psychiatric classification. It was not until 1891, however, when he moved to the psychiatric hospital of the University of Heidelberg in the German state of Baden, that he was able to put these ideas to the test by amassing data from a large number of patients. By 1896 he had collected over 1000 case studies. This effort brought him into some conflict with the local authorities responsible for the administration of psychiatric services.9 At that time, the care of the insane in Baden was organized into three districts, each served by a hospital, one of which was the University clinic at Heidelberg. From there, patients could be transferred to the two other institutions at Emmendingen and Pforzheim, the former specializing in the care of patients who were capable of productive work and the latter in the care of patients whose illnesses were chronic and unremitting. Kraepelin’s complaint was, first, that records transferred with the patients became difficult to access for the purposes of scientific investigation and, second, that transfers were not happening speedily enough, limiting the number of new patients that were available for him to study. The dispute escalated into an argument about Kraepelin’s clinical autonomy and it was partly for this reason that he accepted a position at the University clinic in Munich in 1902, where he opened the German Psychiatric Research Institute (now the Max Planck Institute of Psychiatry) in 1917.