Still angry after all these years

Breakdown
October 16, 1998

More than ten years ago I started my training at the Maudsley Hospital, beginning the process that converted me from being a real doctor into a psychiatrist. The junior staff at the Maudsley, who then, as now, fancied themselves as "young Turks", ran a magazine called, without much originality, Bedlam. It included a poor man's In the Psychiatrist's Chair. I was sent to interview Kingsley Amis because psychiatrists figured large in his novels, although often portrayed either as stupid or totally barking.

We met in a seedy pub in Clerkenwell. Amis immediately told me he had just refused to appear in the real Psychiatrist's Chair because he didn't like psychiatrists or the Irish - Anthony Clare scored on both counts. Things went from bad to worse, until I asked him the basis of his remarkably accurate portrayal of mental illness in Stanley and the Women. "Easy," replied Mr Amis, "from Stuart Sutherland's book Breakdown. You should read it if you claim to be a psychiatrist." So I did, and he was right.

It is still easy for me to remember the impression it made on me. At that time, junior psychiatrists like myself felt obliged to read all those writers who attempted to derive some higher meaning or social critique from the experience of mental illness - R. D. Laing being the prime example.

Stuart Sutherland, a professor of English, was an antidote to the theories - not for him the intellectual dazzlement of Foucault or the sophistry of Thomas Szasz. He had been there, been mentally ill, and it was awful.

In minute, humiliating detail he described the pain and horror of first depression and then mania. It was unromantic, realistic, and authentic. It is difficult to see how Sutherland could improve on his story at the second time of telling, and wisely he does not try.

What has changed is the second half of the book, in which Sutherland relinquishes the first-person narrative, and gives a tour d'horizon of the modern mental health scene. I do not know if Sutherland ever met Amis, but they would have enjoyed each other because Sutherland's tone alternates between the sceptical and the outraged in a manner worthy of the old devil himself.

When Sutherland begins to dismantle the feeble thinking and Panglossian ideals of the modern therapeutic state I was taken back to that pub in Clerkenwell - the book's disdain for the wilder shores of New Age nonsense could be lifted from any late Amis. Amis himself died before counselling became a new religion, but he would have shared Sutherland's disdain for how no self-respecting disaster is complete without the arrival of teams of "trained counsellors", who are as much part of the theatre of disaster as the emergency service sirens. We recently showed that there is no evidence to suggest this "debriefing" does any good, and a suggestion that it might actually harm.

Sutherland quotes with approval research showing that neither therapist experience nor adherence to any particular psychotherapeutic church makes any difference. It is also neither necessary nor desirable to have a therapist who has experienced the same problems as you - a cardiologist is no better at the job if he or she has poor coronary arteries. Nevertheless, while psychotherapists can be their own worst enemies, and psychoanalysis has the same scientific status as graphology, analytically trained psychiatrists of my acquaintance are some of the wisest clinicians I know.

Likewise, we must acknowledge the efforts of cognitive and behaviour therapies to transform themselves into modern, evidence-based disciplines. When the talking therapies claim to be able to address fundamental questions of existence, they often degenerate into the obscure or the banal, but when the question is: "Will 12 sessions of cognitive therapy help me through my second episode of major depression?", the answer is generally positive.

In the final section, Sutherland dissects the utopian, irrational or ill-informed ideas that can so easily pass for thought in the field of mental illness. He concludes that recovered memory is a dangerous fashion. Mental illness is not a creation of society to protect it from deviants. Like any other illness, mental illness should be treated by doctors, despite their many shortcomings. Having watched a television programme on ME, he affirms that mental illness remains deeply stigmatised. Involuntary commitment is sometimes necessary, and it is ethical to treat people against their will in extremis. Sutherland mocks the idealistic left, but is equally scathing about the view from the Daily Express. The mentally ill are not more dangerous than the rest of us, except to themselves. Neither more compulsory treatment nor better community care will eliminate homicide by the mentally ill. I used to think that the contrary arguments disappeared two decades ago, but having attended recent conferences on the future of mental health services I am not so sure.

Sutherland's main message is for those who seek to romanticise mental illness. Mental illness does not improve creativity or ennoble the spirit. For Sutherland mental illness was about anguish - to himself, his wife and his children, and he would rather do without it.

Simon Wessely is professor of psychological medicine, Maudsley Hospital, London.

Breakdown: A Personal Crisis and a Medical Dilemma

Author - Stuart Sutherland
ISBN - 0 19 852380 7
Publisher - Oxford University Press
Price - £19.99
Pages - 308

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