When an editor declares that a book
does not attempt to be even handed or objective you know you’re in for a bit of
a ride. There’s a disarming frankness about such an admission, but it leaves a
reader wondering how far have the editors departed from objectivity in the
interests of restoring ‘balance’ after ‘a hundred years or more of
[imbalance]’. The topic of this book is madness, or more correctly problems
with the psychiatric model of madness, and some possible alternatives. Models of Madness is an ambitious title
that raises expectations. The book delivers on its promise to provide an
alternative to the medical model, although the content is of varying quality.
The best chapters offer carefully thought out analysis; some of the others are
irritatingly polemical. Still, you can’t say you weren’t warned. Models of Madness contains 24 chapters
in three sections. The chapters are written by numerous authors, including the
editors, John Read and Richard Bentnall, and the late Loren Mosher. There is
something of a tradition of psychology literature critical of psychiatry and Models of Madness is consistent with
that tradition, albeit that one of the authors, Mosher was a psychiatrist.

The three sections of the book
explore, respectively, the illness model of schizophrenia, social and psychological
approaches to madness, and evidence based psychosocial interventions. The range
and number of authors means that the book is somewhat uneven, both in focus and
quality. However the book is certainly thought-provoking. Clinicians working in
mental health services, particularly those working within some sort of medical
model, cannot read this book without facing some fundamental challenges to
psychiatric orthodoxies.

As the title suggests, the main
thrust of the book is directed at that standard psychiatric shibboleth,
schizophrenia. There is no question that schizophrenia is a problematic
concept, and Models of Madness wastes
no time in declaring that ‘schizophrenia is not an illness’ before reviewing
the substantial conceptual and empirical arguments against schizophrenia as a
disease. This sort of criticism is made easier by those biological
psychiatrists, and organizations such as the National Institute for Mental
Health, who insist, against the weight of evidence, that schizophrenia is a
brain disease of genetic origin. It is made even easier by those who
acknowledge the problems with the biological model, but claim that that good
old fallback ‘further research’ will inevitably identify the biological basis
of schizophrenia. The second chapter sets out the threefold program of the
book:

1. Treatment
   for madness suppresses unacceptable behaviors thoughts and feelings in
   support of social norms;
2. Treatments
   are frequently unhelpful and sometimes damaging and violent;
3. Experts
   disguise their sociopolitical function and the damage caused by treatments
   by insisting that people with mental illness have personal defects.

The program is pursued
inconsistently; although there are several returns to its central themes some
contributors seem unaware of them. Having declared the above program, chapter
two cites historical examples from East and West that support the idea of
madness as a form of oppression. There is too little analysis to paint on such
a wide canvas; a simply a stated position with some selectively interpreted
historical references do not constitute an argument. The focus then shifts to
the Inquisition and witchcraft which readers are invited to view as forerunners
of modern psychiatry. This chapter is far from convincing. The scope is so
broad that it is inevitably superficial, and it does not examine the historical
emergence of psychiatry with any sophistication. Tuke, for example is presented
as a medical apologist, and there is no discussion of his antagonism towards
the medical management of madness. The critique of the Kraeplinian model
however, presented in the following chapter, is more persuasive. It is a shame
that the Foucaldian interpretations of the first chapter are not carried
through to the second, as it is here that Foucalt’s notion of discourse could
have usefully been applied to the rising dominance of medicine. However John
Read does a good enough job unassisted to show that psychiatric language
involved an assertion of authority more than articulation of a theory or
science of psychiatry. A brief chapter on psychiatry prior to and during the
Nazi era argues that it is the biological theory of madness that legitimized
eugenic treatment and mass murder. As the chapter shows, this period of German
psychiatry has been little acknowledged by the psychiatric professions. But
while there is a theme of oppression of the mentally ill, it is something of a
stretch to cite this example in support of the authors’ argument against the
current biological model of schizophrenia.

The next chapter returns to the
reliability and validity of ‘schizophrenia’, following the arguments of Boyle and others who have shown schizophrenia to be
a problematic diagnostic category. The dimensional model Read argues for is
better supported by evidence, and more sensitive to individuals’ experiences of
distress. The remaining chapters of this section cover various biological
theories, heredity, and common treatments such as ECT and antipsychotic
medication, ending with an analysis of the role of pharmaceutical companies in
sponsoring research and promoting the role of drugs in psychiatric treatment.
The latter chapter in particular makes compelling reading and raises serious
ethical questions about the capacity of medicine to police itself.

The next section of the book
explores psychosocial approaches; those models that consider developmental and
psychological factors contributing to madness. A range of issues is discussed,
including poverty, gender, trauma and stress. A standout chapter in this
section is the contribution by Jim Geekie. Geekie’s chapter uses grounded
theory, linked to a Foucaldian analytical framework, to explore clients’
interpretations of psychotic experiences. The chapter reports work in progress,
but the findings are of interest because of the multiplicity of explanatory
frameworks reported by participants. What Geekie’s research shows is the
ordinariness of many of the personal explanations for psychotic experiences.
Geekie uses this evidence to argue for acknowledging people who experience
psychosis as experts on that experience. This is not an abandonment of the
professional responsibility to offer expertise; it is not even an abandonment
of professional explanations. It can involve challenging individuals’
explanations where these are proving unhelpful. But it is a recognition that
clinicians need to work with people rather than impose views upon them. If it
seems simple, that is because such straightforward arguments need increasingly
to be articulated so that clinicians are reminded of the importance of
listening to the person’s story.

The final section of the book
covers psychosocial interventions such as cognitive therapy, psychodynamic
psychotherapy and family therapy. There is a final chapter from Loren Mosher on
non-hospital non-drug intervention in first episode psychosis. This section
reviews a range of research, as well as covering broader social issues and
models of service delivery. The chapters are mixed, with some such as
Johannssens’ review of early intervention providing a descriptive overview of a
range of programs across the world, and others such as Morrison’s on cognitive
interventions providing considerable detail on the use of cognitive
interventions. There is also a range of views of the central concept of the
book, schizophrenia. Morrison focuses on psychosis and discusses hallucinations
and delusions separately, while Johannssen uses both ‘psychosis’ and
‘schizophrenia’ in discussing the various programs reviewed. Mosher returns to
the program of the book, using his chapter on Soteria styled intervention to
argue firmly against the medicalization of madness.

Although this is a somewhat uneven
book there is enough material in it to offer a serious challenge to mental
health clinicians to examine their conceptual models and to consider a range of
alternative explanations for psychosis. If the book does not succeed in
articulating a unified model of madness that is a small matter, as the more
important task is to attend to the multiplicity of factors, social, personal
and biological that need to be considered in any satisfactory framework. The
strength of Models of Madness lies in
the range of literature it brings together, in a generally accessible form,
within a single volume. The book could have used a final chapter that drew its various
strands together, and in particular returned to the program set out in chapter
two. This is a book that is unlikely to win new adherents for its cause. That
is a pity, because its less polemical chapters contain discussion and analysis
that clinicians and others with an interest in madness would find both useful
and informative.

© 2005 Tony O’Brien

Tony O’Brien is a lecturer in
mental health nursing at the University of Auckland, New Zealand: a.obrien@auckland.ac.nz

Categories: Psychology, MentalHealth