Another View on Madness

In my last post I discussed psychiatry and anti-psychiatry and argued that the latter term has been used by institutional psychiatry to defend its inordinate reliance on psychopharmaceuticals.  By favouring psychopharmocology--the use of medication in treating mental illness--over psychotherapy--aptly described by Freud as the "talking cure"-- psychiatry has neglected perhaps the most important feature of psychological healing. Still it is true that the cautious and judicious use of psychopharmaceuticals may not only be life saving, it can also complement psychotherapy. But having just recently finished reading Kay Redfield Jamison's brilliant and eloquent memoir An Unquiet Mind, which recounts her lifelong battle with manic-depression (she prefers this old term for her disease to the current one, bi-polar disorder), I now have a somewhat different perspective on how medication may work as a treatment. Jamison is uniquely qualified to discuss the matter, for not only has she suffered the illness herself, but as a clinical psychologist and professor of psychiatry she possesses a deep scientific understanding of mood disorders. Fortunately, her credentials do not prevent her from being strongly in favour of psychotherapy and she expresses her view of therapy in lyrical passages of praise. But it must be noted that her psychotherapist was also a psychiatrist who, from the first, had always insisted that medication was essential for her to maintain equilibrium. For her part, Jamison is clear that lithium was the only thing that could have saved her from madness or death. For her, at least, psychotherapy was not the primary means of her life saving treatment, it was secondary. So does Jamison's case have implications for the treatment of severe mental illness in general?

I address this question without pretending to have any definite answers or even having the means of arriving at one. As a therapist I have no medical training and couldn't prescribe aspirin, let alone anti-psychotic medication. But both my reading and experience as a therapist incline me to be sceptical of the more extravagant claims of psychopharmacology. The evidence is both abundant and clear that the benefits of drugs therapy have been wildly oversold, in part, it seems, because medications need to be sold. It is also clear that the medical approach to mental illness has progressively moved away from trying to understand the experience of psychological distress as a means of gaining insight into madness and instead has tried to pin down symptoms in behaviour for discrete disease entities that never quite materialise. My own experience confirms what my reading has documented. Many of my clients have gone to their GP's or psychiatrists complaining of anxiety and depression and with scarcely an attempt to find out why they might be feeling that way, are given prescriptions for anti-depressants. While this has sometimes brought them short-term relief, it also had the effect of making them feel more helpless and confused about their emotional lives. The experience of such frustration is often what prompts people to turn to psychotherapy. They want to make sense of their experience, which is something that psychopharamaceuticals alone fails to do for them. But making sense has two rather different meanings which should not be conflated. Many, if not most of my clients come to therapy in order to make sense of what may be called a crisis of personal meaning. But for someone who is suffering from a severe psychosis as Jamison did, making sense of one's self experience in the throes of a psychotic breakdown means nothing less than trying to find enough emotional stability for ordinary living. In cases like hers, medication would seem indispensable for making any kind of sense at all. Yet not everybody would agree with her.

R.D. Laing once argued that by resorting to medication (usually without the patient's consent) psychiatry halted the potential for self healing that could occur naturally in psychotic breakdown. Breakdown can lead to breakthrough, as he put it. This does sometimes happen, but instances of it are surpassingly rare, even without any interference from psychiatry. Moreover, Laing made his argument in reference to schizophrenic breakdown, which though also classified as a psychosis, has much different characteristics than manic-depression (I follow Jamison's recommendation and use this term instead of bi-polar disorder). According to Laing, the schizophrenic could be regarded as almost a frustrated mystic and psychosis could be seen as a way of dealing with his frustration. Although Jamison, a psychologist who firmly believes in the biological origins of madness, has no tolerance for this line of thinking, when writing about manic-depression she makes a somewhat similar case. The manic depressive often possesses great intellectual and imaginative powers which can lead to great artistic, literary or scientific achievement. Indeed, in another book, Touched with Fire, she discusses how manic depression affected such great artists as Lord Byron, Vincent Van Gough and Virginia Woolf, both in the expression of their genius and in the torment of their emotional lives. But perhaps it is her own personal testimony that conveys even more strongly the sense of creative exaltation that arises out of a charged hypomanic state. In these high moods, she felt more intensely alive and open to the creative possibilities of being in the world. But she is equally clear about how dreadful and self nullifying her depressions felt, as well as how terrifying it was to feel possessed by wild, manic energy while feeling hopelessly doomed (it is this latter feeling that to her makes manic-depression the perfect term for the condition). Jamison admits that there are times when she misses the inspiration that her illness brought her. But she is also keenly aware that without lithium she would be either dead or insane. Unlike Laing, she finds no self healing potential in madness at all.

So who is right? Psychiatry or anti-psychiatry? The question is too misleading to be answered. Firstly, the term anti-psychiatry no longer possesses the radical, oppositional force that it once did and it now functions as an easy smear for any critic of institutional psychiatry (Jamison, to her credit, does not invoke the term). And the fact that the medical treatment of madness dates back to the earliest days of medicine tells us not only that it has always dealt with mental illness, but also that it always will. Even so, institutional psychiatry has lost trust by neglecting the human, experiential dimension of madness, perhaps the most uniquely human affliction there is, by becoming so consumed by the biology of mental illness. In treating the disease, it has lost interest in the experience of the people who suffer it. As an author of a definitive textbook on manic-depressive illness, Jamison knows all the available science on the disease. But as a non-scientist I am more impressed by her personal testimony about why she needs lithium in order to survive. I wonder who but the most rabid anti-psychiatrist would want to deny someone like her the medication? But by handing out medication indiscriminately, without concern for the experience of the patient, psychiatry is guilty of a similar dereliction of care. 

As a psychotherapist I can only observe the debate about the merits and dangers of medication without being able to participate in it. But I would still criticise any practitioner, medical or not, whose putative expertise sanctions ignoring the personal experience of the patient. Contrary to what Kraeplin said and institutional psychiatry believes, psychiatrists are not surgeons and they do need empathy in order to treat their patients. Perhaps reading An Unquiet Mind would be instructive for them.