Richard Bentall on Madness Explained and Doctoring the Mind
On the future of mental health
Posted Feb 29, 2016
The following interview is part of a “future of mental health” interview series that will be running for 100+ days. This series presents different points of view about what helps a person in distress. I’ve aimed to be ecumenical and included many points of view different from my own. I hope you enjoy it. As with every service and resource in the mental health field, please do your due diligence. If you’d like to learn more about these philosophies, services, and organizations mentioned, follow the links provided.
Interview with Richard Bental
EM: What do you see as some of the major shortcomings of the current pseudo-medical “diagnosing and treating mental disorders” paradigm?
RB: Many people have commented that this paradigm is often perceived as dehumanizing by those who receive psychiatric care, but it is less often realized that the approach is poorly founded in science. For example, there is almost no evidence that diagnoses such as ‘schizophrenia’ and ‘bipolar disorder’ correspond to discrete entities (‘natural kinds’ in the language of philosophy).
Statistical studies show that symptoms do not clearly cluster into these separate categories, so that many patients have symptoms of more than one diagnosis and diagnostic disagreements between clinicians are common. Nor are diagnoses good predictors of outcome or treatment response (their main purpose from a clinical perspective). There is also evidence from epidemiological studies that psychotic-like experiences are much more common than has hitherto been thought (with about 10% of the population affected) and that these experiences exist on continua with healthy or ‘normal’ functioning: instead of the world falling into two groups (the psychotic and the non-psychotic) people vary in their disposition to psychosis and only a minority of people who have these experiences require or seek help.
EM: How well or poorly are we currently “treating mental illness,” would you say?
RB: If we are to believe the evidence from clinical trials there are many effective pharmacological and psychological treatments for mental illness. Epidemiological data, on the other hand, says otherwise. For example, since the Second World War, rates of common mental illness (depression and anxiety) have been increasing in the industrialized nations, whereas rates of recovery from severe mental illness have not improved despite the availability of apparently effective therapies such as antipsychotic drugs.
By contrast, in the case of physical illnesses such as cardiovascular disease or cancer, recovery and survival rates have improved dramatically over the same period, mainly because genuinely more effective treatments have become available. The same picture emerges from international comparisons. Countries with the best-resourced medical services have the best outcomes for physical illness (it is better to have a heart attack in Washington or London than in rural Africa) whereas precisely the opposite is the case for mental illness (developing nations with limited psychiatric resources have better outcomes and lower suicide rates). This is hardly evidence that conventional psychiatry has had a positive affect on the well-being and mental health of nations.
EM: Among your interests are the psychological roots of psychosis. Can you tell us a little bit about your views on “madness” and where it comes from?
RB: My interest in the psychological roots of psychosis has both personal (my brother Andrew committed suicide) and professional origins (I was trained in a behaviorist approach to psychology which – whatever its limitations – at least taught me to see human behavior in its social context). Conventional psychiatry has emphasized the genetic roots of psychosis based on the claim that twin and other studies show that schizophrenia is 80% heritable, which means that 80% of the cause is genetic. It seems shocking to me that this last claim – based on a complete misunderstanding of heritability estimates (h2) - is still been trotted out by genetic researchers, who should know better.
In fact, h2 is a partial correlation coefficient and, like all correlation coefficients, is not a measure of causality, with the consequence that there may be major environmental influences even if h2 is 100%. (In an imaginary world in which everyone smokes exactly 20 cigarettes a day h2 for lung cancer would be 100% - the only difference between people who become ill and those who do not would be genetic - but the main cause would still be smoking cigarettes.)
The only way you can estimate environmental influences is by measuring them. When we do this, we find a wide range of social and environmental risk factors. Some of these operate at the population level: being raised in poverty, in an unequal society (not quite the same thing), in an urban environment or in a migrant family all increase the risk of psychosis. Others operate at the individual level: sexual, emotional or physical abuse in childhood, being bullied at school, being separated from parents at an early age, living in a neighborhood in which one belongs to an ethnic minority – all of these increase psychosis risk.
Recent genetic research suggests that genetic risk is associated with 100s, possibly 1000s of genes, each with a tiny effect. There is not much we can do about these. However, we can do something about environmental risk factors. At the population level, making the world more just and less unequal, while trying to figure out the toxic aspects of the urban environmental will probably help prevent a lot of psychosis. At the individual level, if we can identify the psychological mechanisms linking adverse environments to psychosis (and there has been a lot of progress with this despite minimal funding) we should be able to devise more effective interventions for those who are already ill.
EM: Another of your interests is childhood trauma. How important is childhood trauma as a negative influence in a person’s life and what in your estimation helps heal childhood trauma the best?
RB: We estimate that any kind of childhood trauma increases the risk of psychosis about three-fold, and there is a dose-response relationship so that children who experience multiple traumas are at much higher risk. Other researchers have also found that trauma increases the risk of a wide range of non-psychotic disorders. (There is also evidence that adults who experienced trauma as children are much more likely to have poor physical health.)
But it’s also worth stating that childhood trauma is not necessarily a prophecy of doom, because some children are resilient or because later experiences help to restore mental health. It is also worth pointing out that there are many kinds of adult adversities that can provoke severe psychological distress, including debt and unemployment, dysfunctional marital relationships and occupational stress. The reality is that the social causes of mental ill-health are all around us.
EM: If you had a loved one in emotional or mental distress, what would you suggest that he or she do or try?
RB: This is a difficult question because there is no single way. For some people, psychological therapies can be helpful, and I don’t dispute the usefulness of medication in some cases. The important thing is to recognize diversity in needs and in the way that people respond to treatment, to allow people choice and for clinicians to be willing to change when their strategies fail. For example, much less iatrogenic harm would be caused if physicians were more willing to withdraw patients from drugs that are either ineffective or cause side effects that outweigh any clinical benefits; this rarely happens in my experience.
We should also remember that many effective resources for recovery lie outside the formal mental health system: with groups of survivors and mental health activists who are experts by experience and have developed alternatives; with practical help that can address the causes of mental ill health (housing assistance, debt counselling) and with healing communities, friendships and the kindness of others.
Richard Bentall is Professor of Clinical Psychology at Liverpool University and has previously held chairs at Manchester University and Bangor University. His research interests have mainly focused on psychosis. He has studied the cognitive and emotional mechanisms involved in psychotic symptoms such as hallucinations, paranoid delusions and manic states, using methods ranging from psychological experiments, and experience sampling to functional magnetic resonance imaging. Most recently, his research has focused on why social risk factors (for example childhood adversities such as poverty, abuse, and bullying) provoke the cognitive and emotional changes that lead to these symptoms. His books include Madness explained: Psychosis and human nature (Penguin, 2003) and Doctoring the mind: Why psychiatric treatments fail (Penguin, 2009).
Eric Maisel, Ph.D., is the author of 40+ books, among them The Future of Mental Health, Rethinking Depression, Mastering Creative Anxiety, Life Purpose Boot Camp and The Van Gogh Blues. Write Dr. Maisel at firstname.lastname@example.org, visit him at http://www.ericmaisel.com, and learn more about the future of mental health movement at http://www.thefutureofmentalhealth.com
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