This is a working text, aimed clearly
at trainee psychiatrists and those new to their field, although it will prove
useful to anyone working in the clinical end of mental health in the UK.  It
provides a series of case studies, going through the basic procedures and
processes involved with assessing and treating mental health problems.  This
book and the case studies it presents provides valuable material for preparing
workers for case conference discussions as well as group discussions in a
training environment.  As such it is a book I would clearly recommend to any
mental health worker in the UK today.

The text is, as mentioned, relevant
specifically to the UK and discusses illness management within this context but
this does not limit it unduly since it focuses on the way in which a patient
narrative is formed and it uses DSM-IV and ICD-10 as its basic protocols for
diagnoses.  There is nothing that is too country specific so as to make the
text unreadable in the US, Canada or Europe for example.  This also means it
provides an interesting case study in itself for those concerned with
theoretical rather than the practical or clinical side of mental health.

In term of the basic methodological
approach of the authors, their own introduction describes this as ‘eclectic’
and they operate a pragmatic and open approach to both diagnosis and treatment,
neither adhering solely to a biological model nor throwing out biological causation
in an overly ‘psychologized’ dogma.  The strengths of such a methodological
approach are no doubt derived from the breadth of medical and theoretical tools
subsequently made available but there is also a downside to such pragmatism.  
More concretely, the eclectic or pragmatic approach produces a sense of general
vagueness in psychiatric diagnoses, despite the use of DSM-IV and ICD-10 as the
basis of diagnostic protocols.  This vagueness relates inevitably to the way in
which a narrative is both constructed and then read.  Narrative strategy thus
becomes central, implicitly, as the tool of the psychiatrist, bringing with it
the difficulties — of plurality of point of view, of indetermination, of
interpretative over-coding — that are inherent in any narratology.

For example, the book places the
psychiatrist in a space of considerable narrative power since they become the
author of the life story upon which the diagnoses is based and of course this implies
power roles within the psychiatric relationship which have considerable ethical
impact.  This ethical situation is not explicitly addressed in any real detail
and it might be wise to at least flag the paradox involved in assuming the
authorial role in constructing a life-narrative, the goal of which in large
measure is to enable the user to develop their own capacity to act as author of
their lives.

The narratives that the book focuses
on are, of course, not simply life narratives but also care narratives, giving
an indication of the progress from diagnosis through prognosis and delivery of
care.  As such the book provides examples of the course of the psychiatric
relationships under study, enabling the reader to gain a sense of the various
options and care paths available.  The fact that the narratives in large part
end rather inconclusively — there is no real ‘cure’ or simple objective
closure to a mental health problem — points to another problem which the book
reflects rather than embodies.  This is indicated most obviously by the often
inconclusive or sad outcomes to many of the cases — for example, the last
story of Mr. Stone, an old man with probable Alzheimer’s, ends with him
slipping away from the psychiatric care, almost as though he was inevitably
forgotten by the system in which the psychiatrist is embedded.  There is a
sense of ongoing difficulty in the stories of the users and the role of
psychiatric care comes to be that of restructuring the personality of the user
to deal with psychiatric pressures rather than remove them. 

The inevitable messiness or real
lives reflected in the stories is what provides the sense of inconclusiveness
to many of them but this reflects the practical reality of psychiatric care and
the almost absolute dominance of practical solutions over theoretical stances
in the necessary intervention the psychiatrist is trained to provide.  The need
for a pragmatic approach, whilst usefully addressed in the introduction, could
be usefully developed theoretically as suggesting a need for a more holistic
and context driven basis for psychiatric intervention.  This itself points to
one concept that seems noticeably absent in too many of these stories, and that
is the concept of health.  The end result of the psychiatric intervention, if
simply reduced to a pragmatic necessity to address crises, never really
addresses more long term goals of mental health and as such can appear as a
handbook for maintaining a minimum level of mental health necessary to live within
a society rather than addressing the social implications addressed by
considering the conditions for a more rounded concept of mental health as a
state of happiness or contentment rather than an almost basic mental survival. 
Witness, for example, the over easy use of a notion of ‘social disability’ as a
concern for the psychiatrist when considering options for intervention (p.228,
p.235).  These social issues, of course, are not the immediate concerns of the
book but they limit the options of the psychiatrist.  The lack of long term
psychiatric therapy, despite the fact that a number of the case studies present
situations in which the psychiatrist is dealing with what are described quite
reasonably as ‘character’ difficulties, leaves one with a sense that the
psychiatrists are often sticking plasters over gaping wounds with little chance
of real success over and above temporary stabilization of someone’s life
situation.  Some mention of these difficulties can be found (p.253, p.263) when
the relationship of the psychiatrist to psychologists and psychotherapists is
touched upon but a short discussion of the context in which the psychiatrist is
forced to work might benefit this book by enabling the narrative structure to
not only be used to understand the client but also to enable a more self-aware
and theoretically conscious psychiatric practice.

© 2004 Matt Lee

Matt
Lee, University Of Sussex (PhD researcher, Philosophy)

Categories: Psychology, General