Madness Explained by Richard Bentall

David Healy applauds a radical new look at madness, and sniffs a bestseller
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Starting in the Fifties and continuing through the Sixties, Penguin/Pelican published a series of books on psychology and psychiatry. It began with the collected works of Freud and included Jung and, later, Anthony Storr, Charles Rycroft, Eric Berne and others. But the best-known books were those of R D Laing. They sold in huge numbers and helped to shape the Sixties in ways that have rarely been acknowledged.

Many psychiatrists now in their late forties or fifties entered mental health because of exposure to these books. The work of Laing and others influenced psychologists to enter a field just opening up in Britain: clinical psychology. Almost inexplicably, Penguin withdrew from popular mental health publishing in the mid-Seventies.

Did it come under pressure from an establishment threatened by an "anti-psychiatry" grown vast on the oxygen of Penguin's publicity? The problem for the establishment was that, in this case, the devil did seem to have all the best tunes. It was plainly a lot more difficult to sell orthodox or biological psychiatry than to sell the romantic search for meaning found in much of Sixties anti-psychiatry.

But Penguin seems to have been moving slowly back into this arena. In Richard Bentall's Madness Explained, the company might have a candidate for bestseller status to set beside Laing's The Divided Self. The parallels between the two figures are interesting. Both take issue with orthodox psychiatry, and personify the problems of the establishment in the figure of Emil Kraepelin. In 1896, this German psychiatrist established a classification of psychiatric disorders, centred on schizophrenia and manic-depressive illness, which has dominated the field ever since.

Both Laing and Bentall have been portrayed as obliterating the dividing line between sanity and madness. Both have been seen as claiming a central place for the patient within psychiatry. Both argue that psychosis is more understandable than is commonly conceded, and that sympathetic listening on the part of the therapist can pay off much more often than might be expected. Both highlight the dangers that can accompany an exclusively physical treatment of mental illness.

Both books, The Divided Self and Madness Explained, are formidable reads. Laing's was almost certainly read by very few from start to finish. It functioned for many as a bible to be dipped into in search of answers to personal confusions, rather than a psychiatric textbook. Plenty in Bentall's book can be used in just such a way.

While there are parallels, the differences are even more striking. Laing began as a darling of British psychiatry. A series of straw polls of psychiatrists in the mid-Sixties nominated him as the most likely British psychiatrist to be remembered at the turn of the century and beyond.

Richard Bentall, on the other hand, began as a bête noire for psychiatry. The overt hostility with which his early work was received may have been a direct legacy of psychiatry's flirtation with Laing. For years, Bentall's friends within psychiatry told him that they couldn't be seen in his company.

The extent of the hostility shows up in this book, in the repeated efforts Bentall takes both to distance himself from figures like Laing and Thomas Szasz, and to disarm his critics. But where Laing fell out of favour, something close to an unfailing reasonableness, and a pleasant disposition, make Bentall a poor candidate for the role of anti-psychiatric ogre. The persistence and gathering scope of his critique has begun to win him an audience even in psychiatry, where as a clinical psychologist he poses both a professional and an intellectual threat.

The full scope of this critique is laid out for the first time in Madness Explained. It must be almost unique in mental health by the extent to which it makes its points in terms of experimental detail alone. This book might, in fact, have the highest ratio of experimental finding to speculation of any within the field. The overarching thesis is that we have for too long focused on disease entities like schizophrenia and manic-depressive illness, and neglected symptoms such as delusions and hallucinations.

Is he right? Those worried about being led astray fortunately don't have to believe Bentall correct on all details to see the merits in his approach. The kind of research at the centre of this book began less than 15 years ago, when Bentall put together a back-of-an-envelope bid to his then employer, the University of Liverpool. He asked them to give him seed money for research on delusions, as there didn't seem to be much in this area.

There is a telling contrast between the output of replicable findings on psychotic symptoms achieved from the very modest financial support that came his way, and the close-to-zero clinical benefits from the recent investment of billions in genetic and neuro-imaging research focused on disease entities. But beyond the science, Bentall's approach gives all mental health professionals new reasons to listen to and talk to their patients. This alone would make his book worth reading.

Madness Explained will give many readers a glimpse both of answers to their own problems, and to questions about how the mind works. It opens vistas on how many of those disenfranchised by hi-tech research might be able to contribute to solving the age-old mysteries of mental illness. At the same time, hi-tech researchers within psychiatric genetics and neuro-imaging might profitably turn to it.

This is a book to seduce a new generation into psychiatry and psychology. If the Royal College of Psychiatrists had the imagination to offer Richard Bentall an honorary fellowship for contributions to psychopathology, they might improve the odds on one of "us" being counted as a significant figure 50 years from now.

David Healy's 'The Antidepressant Era' is published by Harvard

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