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Psychiatry

Book Review: Balint Matters

20 Jun, 17 | by amcfarlane

Balint Matters: Psychosomatics and the Art of Assessment by Jonathan Sklar, London: Karnac, 2017, 254 pages, £27.99.

Reviewed by Dr Neil Vickers.

Michael Balint is mentioned in medical humanities circles as a revered ancestor, much as one might talk about William Empson as a significant figure in the history of English literary criticism. Everyone knows they’re important but surprisingly few people read either writer today or even know why they should. (An important exception is Josie Billington’s superb Is Literature Healthy? – reviewed here – which devotes a chapter to Balint.) Empson did theory before Theory, and Balint did narrative medicine before Narrative Medicine. Both men were at least as interesting as what came after them and yet both have become unduly sepia-tinted with the passage of time. Part of the reason for this fading in Balint’s case has to do with the fact that his clinical examples are firmly rooted in the sociological reality of the 1940s and 50s. The world Balint describes is hidebound by class. As a psychoanalytically-minded medical humanist, I occasionally press a copy of Balint’s classic, The Doctor, the Patient and the Illness (1957) on M.Sc students, but always with the caveat about his antiquated case material. ‘Someone should update it,’ I whisper, as they saunter out of the room.

Now someone has updated it. In his new book, Balint Matters, Jonathan Sklar, psychiatrist, psychoanalyst and leader of Balint groups (as well as a leading scholar of Ferenczi’s thinking) has produced a masterly summary of the Balint technique, along with a history of Michael Balint’s contribution to the theory of the doctor-patient relationship in collaboration with his wife, Enid. The second half of the book, entitled ‘Assessment’, which I won’t discuss here could be published as a volume in its own right. Assessing a patient for psychodynamic treatment is a topic on which surprisingly little has been written.

Michael Balint was born Mihály Bergsmann in Budapest in 1896. His parents were descendants of German-Jewish families who had been in Hungary for only two or three generations. (This German-Jewish world of Leopoldstadt is described in a wonderful series of autobiographical interviews that Georg Lukacs gave towards the end of his life, published as Gelebtes Denken). In 1916, young Mihály took the momentous decision to abandon Judaism in the hope of eluding the anti-Semitism that was still rife in Austro-Hungary and changed his name to Bálint (which means ‘Valentine’ in Magyar). He first came into contact with psychoanalytic ideas while a medical student in Budapest. His fellow-medical student and first wife, Alice Szekely-Kovacs, was one of Sándor Ferenczi’s analytic patients. Balint himself held off from having analysis with Ferenczi at first, and following the overthrow of the Hungarian Soviet Republic (which had bestowed a public professorship of psychoanalysis on Ferenczi, a world first) Michael and Alice fled to Berlin in 1919 to train as analysts at the Berlin Psychoanalytic Institute, where both had analysis with Hans Sachs, and where Michael did a PhD in chemistry and physics. The couple went back to Budapest in 1924 and became patients, colleagues and friends of Ferenczi. Balint became Ferenczi’s literary executor and the chief exponent of his thinking in the international psychoanalytic movement for decades. If the rediscovery of Ferenczi has reinforced the air of ‘always the bridesmaid, never the bride’ hanging over Balint, so has the explosion of interest in Winnicott, with whom he has so much in common.

Balint’s main contributions lie in two areas: psychosomatics, understood holistically as the study of the relationship between mental and physical disturbances; and the uses of therapeutic regression, which he explored in his other great book, The Basic Fault (1967). Sklar’s concern is with the first and specifically with the work Balint developed at the Tavistock Clinic in the 1940s and 50s with his third wife, Enid (Alice having died shortly after they arrived in England, to escape the Anschluss). Balint focused his attention on how the doctor’s attitudes and approach affected the course of an illness, and suggested that ‘the most frequently used drug in general practice was the doctor himself, i.e. it was not only the bottle of medicine or the box of pills that mattered, but the way the doctor gave them to his patient—in fact, the whole atmosphere in which the drug was given and taken.’

Sklar offers a number of clinical vignettes from Balint groups he has facilitated, describing how this works in practice. These case histories for me formed the heart of the book. I won’t spoil the reader’s pleasure by describing too many of them but among those that stood out for me was the case of a 70-year-old woman who was addicted to dihydrocodeine, a strong opioid analgesic. The woman had complained of a pain in the hip but a scan revealed only minor osteoarthritis. Her condition never seemed to improve. She made occasional visits to a cousin who lived far away and would ask her doctor for a bumper supply of painkillers to get her through. Then, much against the patient’s will, her daughter visited the GP and told her that her mother never went to see a cousin, and that the story was just a ruse to get more prescription opioids. The GP was appalled to realise that in the course of the previous year she had prescribed more than 3,000 dihydrocodeine tablets to this woman. In discussion with the group, the GP realised she knew nothing about her patient’s history. With a bit of help from Sklar, the group discussion included the following ideas: 1) the patient had an addictive relationship to the doctor; 2) the doctor felt depressed on behalf of the patient; 3) the doctor was unconsciously acting as a container for aspects of her patient’s mind, perhaps playing the part of a distant depressed mother, who gave her daughter ‘the wrong medicine.’ Feeling, noticing and understanding these projections didn’t cure the patient but they did give her doctor more freedom in the way she related to her. Addiction could now be seen as a way of representing early childhood deprivation.

Balint groups have also been used with psychiatrists. Sklar is fascinating on the attempts by some trainees to use Balint groups as a covert form of personal analysis. This arises not least because of the peculiar pressures of working with severely disturbed patients. The kinds of problems many of the trainee psychiatrists brought had to do with the ways in which they were made to carry aspects of their patients’ mental disturbances. Again, to pull out just one example, Sklar describes the case of a young psychiatrist, Dr L, overwhelmed by the suicide of a male patient who had been admitted at his mother’s request, shortly after the latter’s recent remarriage. Dr L bitterly regretted not administering ECT. Perhaps it would have saved him? She was also worried about the effect of the suicide on the other patients on the ward where the man was being treated. The nurses had suggested that a community ward meeting should be convened to break the news. The group listened to Dr L’s anxieties and asked for information about the patient’s history. It turned out that his biological father had killed himself by electrocution. Sklar asked how the ward meeting had gone. It had been fine for the most part though a psychotic woman had to be removed. This woman had told the meeting she was the angel of death and that there would be more deaths. Somewhat to the group’s surprise, Sklar observed that the psychotic woman had voiced what was in effect Dr L’s own worst fear about herself. Here was an instance of the need to listen to the very mad, as barometers of the most split-off emotions in the room. The psychotic woman had been excluded because she was voicing the emotions that were most unacceptable to the group. Dr L then remembered that her patient had killed himself on his mother’s birthday and that her recent marriage was to an electrician. These snippets, combined with the knowledge of the patient’s father’s suicide, shed new light on the hopes she had placed in ECT. They amounted to a re-enactment of the patient’s deep upset over his father’s suicide and at the same time offered a means to shut out and ignore the meaning of the mother’s marriage to an electrician. As a result of this meeting, Dr L softened down her until-then vigorously-asserted opinions about psychiatry’s exclusively organic basis.

For me, the most moving chapter in the book describes Sklar’s work in the early 2000s at a hospital in an unnamed city in South Africa. In 2007, it was estimated that nearly 6 million South Africans had HIV or AIDS, or 12 per cent of the population. This was overwhelming to the medical professions attempting to offer treatment at a time when antiretrovirals were beyond most people’s reach. Thabo Mbeki’s refusal to believe that HIV had anything to do with AIDS licensed widespread denial of the natural history of the disease and its behavioural causes. Of course, the doctors knew how AIDS was commonly transmitted but the overwhelming nature of the incidence of the disease and the need to shield families from stigma meant that patients were often treated as if they were just medically irrelevant dying people. The doctors for whom Sklar acted as a Balint facilitator told him of their anger at the way AIDS patients were treated as undeserving and subhuman. But they also described the primitive fears the disease evoked in the workplace. The whole practice of medicine was at risk of becoming warped by the cultural phantasies surrounding it.

Sklar’s book deserves to be read by anyone who wants to know how to listen to patients with an analytic ear, how to understand the dilemmas of clinical practice analytically, or why psychoanalysis still has so much to offer physical medicine. As his title makes clear, Balint matters, particularly in an environment where doctors and patients are urged to forget about the whole person and focus instead on gross symptoms and quick fixes. As a result of his endeavours, it should be easy for most readers to imagine a Balintian response to many clinical dilemmas. It is even possible that this brilliant exposition of Balint’s thought will initiate a new phase in the reception of this underrated and very fertile thinker, and bring about further extensions of the Balint model of the kind Sklar himself has achieved here.

Book Review: The Snake in the Clinic

28 Feb, 17 | by cquigley

 

Guy Dargert, The Snake in the Clinic: Psychotherapy’s Role in Medicine and Healing. London: Karnac, 2016

 

Reviewed by Dr Jane Slater

 

The best review of a book is unlikely to be written by an enthusiast, so I need to confess upfront that this book blew me away. The first time I read it, I entertained passersby with involuntary exclamations of “ Yes” and “ That’s SO true”, and even on one sublime paragraph, “ Go Guy”. Thus, my first task was to rein in my paeans of praise and attempt to be objective.

In titling the book The Snake in the Clinic, Dargert refers to the snake coiled around the staff of Aesclepius, the god of healing, a symbol used by the British Medical Association. The book reminds us that in the age of the serum rhubarb, scans for everything and a pill for every ill, we forget at our peril the crucial role of simply understanding what an illness is doing for us. The wisdom of the ancients deserves review and benefits our patients and ourselves, cutting through the fog of technology into which modern medicine risks becoming lost.

The Snake in the Clinic is an overview of the art of healing, bringing together strands of orthodox clinical medicine (p.45, illness being the opposite of health) with various psychotherapeutic philosophies, and interweaving them with ancient understanding of the purpose of illness (p.142, dancing with illness). Indeed, the whole premise of the book is to re-jig our concept of illness from something to be avoided and fought (p.40, the War on Cancer) to a gift: the illness itself can bring an opportunity to heal or make whole some broken area within us (p.46, Jung’s thoughts). Dargert even takes us to the ultimate with his question, “Can there be a healthy death?” (to which the  medic’ asked responded, “A young fit man in an RTA?”). Along with all GPs, I have been privileged to have seen many a ‘healthy death’ over the course of my career – patients wholly at peace with themselves at the end.

Dargert questions our very concept of illness and wellness, contrasting the WHO definition of health as an absence of disease with the idea of health as a state of equilibrium, a balance between so many factors in our lives that are at odds with one another: the pressure to conform and to live up to expectations versus the wild spirit wishing a different path. He gives numerous examples from patient encounters to illustrate his points, which was valuable in cementing my understanding of sometimes alien ideas.

Dargert draws on Taoist, Buddhist, tribal religions and the concept of the Daimon (so well realised by Phillip Pullman in his Northern Lights trilogy as the connection between the physical body, mind and spirit) to exemplify his holistic approach. There are also explorations of dream material as a bridge to the unconscious,  holding vital keys to those physical and psychological problems seeking solutions.

He is unafraid to quote his detractors, such as Susan Sontag’s rant against the use of psychotherapy in the treatment of cancer, though hers seemed a misplaced criticism of what psychotherapy could achieve: it seeks not to get rid of the disease or symptom, but to understand what it may offer, and through this understanding find an acceptance and an ability to fully live despite the condition. Whilst encouraging the use of all available therapies and not abjuring the more physical medical approach, Dargert rather seeks to balance and complete the process of achieving wellness by simultaneously exploring the effects of the dis-ease on the soul or psyche. If ever I were to need the aid of an oncologist, I hope to find a Guy Dargert character in the wings helping me to interpret and make sense of what it all means to me and my life. We’re around for so short a time, it behoves us all to be proactive in looking for meaning for ourselves and our patients before our little lights are snuffed  out.

To combine erudition with readability is a skill indeed, and Dargert displays both with humour and an infectious sense of questing which comes only from a therapist and pedagogue brimming with life. It is well researched, engagingly composed, and absorbing. I would love this book to be a set text for GP registrars, and indeed would commend it both to those in the business of healing and those requiring of the same.

My only criticism is that I couldn’t find it as an audio book – listening in the car between visits and clinics is one of the few “ breaks” one has these days. But it is a good bedtime read also.

Who knows what you might dream…

Book Review: Thinking in Cases

23 Jan, 17 | by cquigley

 

Thinking in Cases

by John Forrester. Published by Polity, 2016.

Reviewed by Dr Neil Vickers

 

John Forrester, who died in 2015, was the most original historian of the human sciences of his generation. His great love was the history of psychoanalysis – he was for 10 years the editor of the journal History and Psychoanalysis – and he published no fewer than 4 major books in that field, including the classic Freud’s Women (which he wrote with his wife, Lisa Appignanesi).

Thinking in Cases is the first of two books to be published posthumously, the second being the monumental Freud in Cambridge (co-authored with Laura Cameron), due out later this year. It comprises six essays written over the last two decades on what he memorably termed ‘case-based reasoning’. Forrester, along with many historians of science, believed that case-based reasoning had embedded itself in a variety of disciplines, in ways that experts were often reluctant to acknowledge. It might be thought that in the era of evidence-based medicine, medical education no longer needs the case. Yet, as Forrester argues in his classic essay, ‘If P, Then What? Thinking in Cases’ (1996), novice practitioners learn their science by absorbing a handful of standard experiments from scientific textbooks. These case studies – for that is what they are – serve not only to make the underlying principles more memorable, they also provide something like a shared professional memory.

Much of Forrester’s thinking on case-based reasoning was informed by his decades-long engagement with the work of Thomas Kuhn, with whom he studied in the early 1970s. The most brilliant essay in the book (‘On Kuhn’s Case’) treats the evolution of Kuhn’s thought as a case study in how the philosophy of science actually works at an individual level. Kuhn, it turns out, came from a family that was steeped in psychoanalysis. His grandmother had analysis in Cincinnati with Alfred Adler, sometime in the 1910s or early 1920s. His mother edited some of Karen Horney’s works. And most important of all, he twice underwent psychoanalysis himself, first (briefly) as a child, and again as an adult, between 1946 and 1948. The end of this second analysis coincided with two great changes in Kuhn’s life. He was admitted into the Society of Fellows at Harvard which enabled him to abandon his career as a theoretical physicist and to become a historian of science instead. And he embarked on a marriage that lasted 30 years. He decided to abandon physics for history when he read Aristotle’s Physics. At first he was baffled by the great man’s obtuseness. How could someone who had written so penetratingly on so many other subjects have got the laws of the physics so wrong? But one day it dawned on him that Aristotle was investing concepts like ‘motion’ with completely different meanings from the Newtonian ones he had learned as a boy, and that, once he had made allowances for this altered usage, Aristotle’s physics not only made sense but was far in advance of its time. This Gestalt shift in his own thinking was the first instance of the famous ‘paradigm shift’ which became the master idea of Kuhn’s book The Structure of Scientific Revolutions (1962). Forrester leaves us in no doubt that it was the result of analysis. In an interview published in 2000, Kuhn stated that it was while he was in analysis that he learned ‘to climb inside people’s heads’. He recognised that this ability was central to his work as a historian of science and that for this reason he owed psychoanalysis ‘a tremendous debt’, even though he didn’t much enjoy being a patient. The Aristotle epiphany occurred while he was in analysis. Forrester points out that Kuhn’s method was both individualistic and psychologistic. Kuhn called himself an internalist historian of science because of his overriding preoccupation with the problems his subjects were trying to solve. The historical contexts in which they tried to solve them were a secondary matter. But he was an internalist in the more informal sense that he worked by climbing into other people’s heads. In the same interview Kuhn recalled feeling he could ‘read texts, get inside the heads of the people who wrote them, better than anybody in the world’. These other people were encountered as auxiliary selves – extensions of himself. Forrester quotes several anecdotes Kuhn told about himself in which new selves – famous scientists all – would arise almost in the manner of out-of-body experiences.

The other highlights of the book for me were two pieces on the LA analyst, Robert J. Stoller (1924-99). The first puts forward an extended speculation concerning Stoller’s analysis of a woman on whom he conferred the pseudonym Belle. Belle is the protagonist of one of Stoller’s best books, Sexual Excitement: The Dynamics of Erotic Life (1986). The turning-point in Belle’s analysis occurred when she described a daydream she’d nurtured from childhood in which a figure called The Director instructed her to humiliate herself sexually before a group of adults (and sometimes animals). Stoller was bothered by what he took to be his patient’s seductive behaviour towards him. It was only in retrospect he realised she was pressing him into the role of the Director. (Belle’s mother was a famous Hollywood actress who took up with a number of Directors. The injunction to perform was everywhere in family life.) Forrester suggests it was from Belle that Stoller drew his controversial theory that sexual excitement ultimately depended on hostility. He suggests that the book detailing her case history, written years after her treatment ended, was an attempt to model a more benign form of watchfulness for her. Stoller consulted Belle over every draft of the book and gave her carte blanche to alter anything she didn’t agree with. It was sobering for them both to discover that they had very different views of what had been valuable in their work together. Forrester suggests that the writing of the book was the decisive part of the treatment for through it he showed her that he didn’t need to be entertained by her. ‘If he had not published his book,’ he writes, ‘her analysis would have been a failure.’

The second Stoller-related chapter (unpublished until now) is a paper on ‘Agnes’, one of the world’s first male-to-female transsexuals. Agnes’s case was first described in Harold Garfinkel’s Studies in Ethnomethodology (1967) but Garfinkel took Stoller on as a co-author as he was one of Agnes’s psychiatrists. Agnes claimed to have been born intersexed and, starting in the late 1950s, went through an arduous vetting procedure lasting many years in order to obtain surgical gender reassignment. Many years later she told Stoller that from the age of 12 she had in fact taken her mother’s hormone replacement medication which resulted in her acquiring female secondary sex characteristics. Garfinkel the sociologist thought that Agnes’s attempts to pass as female shed light on what maleness and femaleness were, as socially-credited qualities summoned up into being every moment of every day. Her deception about her history was just another instance of what she had to do to ‘pass’. Stoller on the other hand originated the concept of core gender identity on the basis of his treatment of Agnes. He met Agnes’s mother and discovered that she had regarded herself as male from the age of eight and that she had passed her own ambivalence about her gender identity on to her adored son, whose transformation into a woman she supported wholeheartedly.

Thinking in Cases is an ideal introduction to Forrester’s thought, containing some of his most important papers. He combined a scientist’s delight in devising new methods to understand recondite things with an exceptionally acute sense of the role of contingency in intellectual discovery. These strengths were central to his style of reasoning and, as these pages testify, made him one of a kind. Everyone with an interest in the medical case history and its wider ramifications should read this book.

Wellcome Book Prize Winner 2016 – ‘It’s All In Your Head’ reviewed

23 Jun, 16 | by cquigley

It's All in Your Head

 

Suzanne O’Sullivan, It’s All In Your Head: True Stories of Imaginary Illness. London: Vintage, 2016; first publ in hardback 2015 by Chatto & Windus

Reviewed by Professor Edward Shorter

The very subtitle of the book makes one nervous: “stories of imaginary illness.” If there is one phrase that psychosomatic patients – who have symptoms without lesions ­– do not want to hear it is that their problems are “all in their heads.” Even though O’Sullivan may use the phrase ironically, it does take us back to the days when discovering organic causation was the Mecca of medical practice and psychiatry was left to “the shrinks.” Of course things are more complicated, and O’Sullivan, a neurology consultant at the National Hospital for Neurology and Neurosurgery knows this well. The book does make some finer distinctions so that “all in your head” doesn’t come out and hit us in the face. But still, O’Sullivan says that “psychosomatic refers to physical symptoms that occur for psychological reasons . . . How many are aware of the frequency with which our emotions can produce serious disability where no physical disease of any sort exists to explain it?” So in other words the origin of such symptoms is clearly psychological. These patients amount, she says, to fully a third of the cases seen in general practice and in neurology.

The book is a kind of odyssey of patients O’Sullivan has seen whose problems seem to have been caused by mental distress – a tour interleaved with explanations of historical figures such as the Parisian neurologist Jean-Martin Charcot, who once peopled this scene.

O’Sullivan has gone to such lengths to obscure the patients’ actual identities that one is never entirely sure whether the “Paulines” and “Matthews” that parade through these pages are more fictional than real – though their complaints are real. And O’Sullivan, it must be said, writes beautifully, a low-key golden flow of prose that makes the book simply a good read. There are no references. No authorities are invoked. This is the author, a veteran neurologist, speaking to us from the heart.

But is what the heart says true? How reliable is her analysis that psychosomatic symptoms are “physical symptoms that mask emotional distress”?

Right off the bat, there are problems with this stress-causes-functional-illness model. There are several major causes of psychosomatic symptoms, some of which get short shrift.

One, O’Sullivan tells us about classical psychosomatic symptoms that are caused by “stress” or by the emotional overlay of underlying organic disease. Her patients’ emotional woes are apparent to her in the course of many clinical interviews, and she ends up referring many of them to a “psychiatrist.” This is the most useless referral imaginable, as psychiatrists shun and fear psychosomatic patients and can usually do little for them because the patients themselves reject the whole notion of “psychogenesis”; patients usually accept such referrals only with the greatest reservation, convinced – not entirely incorrectly – that they are being turfed.

Two, O’Sullivan is silent about a huge source of psychosomatic illness, namely the phenomenon of suggestion. Patients who can be suggested into illness require no deep psychological problems, no intractable “stress,” to become symptomatic. They simply are suggestible.

A perfect illustration of suggestibility is epidemic hysteria: Sally begins vomiting and suddenly all the ten-year-olds in the schoolyard start vomiting as well. The public health authorities rush in. There is alarm in the press. An organic cause is never found but everybody is better the next day. It is an epidemic of suggestion that has invested the schoolyard.

The culture can be a source of suggestion as well, a subject on which O’Sullivan is silent. The culture can tell us that “fatigue” or “pain” are acceptable models of presenting illness, and these patients turn up in physicians’ surgeries with “myalgic encephalomyelitis” (ME), known as “chronic fatigue syndrome” (CFS) on the other side of the Pond. They do not in fact have an occult organic illness called “ME” but have suggested themselves into their chronic pain, fatigue and dizziness because the culture says those are appropriate symptoms. (And the culture has largely ceased to sanction “paralysis” as a convincing symptom – too easy to disprove with a negative Babinski.)

Three, frank psychiatric illnesses may spin off somatic symptoms. Patients with melancholic depression will light up the medical charts like a Christmas tree. Their aches and pains are legion, and disappear once the melancholia – one of the most treatment-responsive illnesses in psychiatry – is successfully treated. Catatonia shoots off somatic symptomatology, the stupors, tics and stereotypies often misdiagnosed as organic disease and the catatonia not recognized. Why does this matter?Catatonia is another highly treatment-responsive disorder, but there’s nothing “psychosomatic” about it. In medicine, therefore, the concept of psychosomatic can get one into rough psychiatric water.

It is striking that O’Sullivan sees deep sadness as a source of psychosomaticity rather than as a symptom of glaring psychiatric psychopathology. “I have met many people whose sadness is so overwhelming that they cannot bear to feel it,” she writes. Yoo hoo!  Such melancholic patients are indeed candidates for psychiatric treatment, not for repeated neurological assessments.

There is, finally, a fourth variety of apparent “psychosomatic” illness. But it is quite foreign to the other three and is usually not included in reviews of the topic. It is malingering. One rather has the feeling that some of O’Sullivan’s patients –  their gaze strictly averted from hers, their long silences – were malingerers. (She presents one.) You can’t prove that someone is not fatigued, or not in pain. But you can prove that they don’t have multiple sclerosis or another upper motor neuron lesion. So malingerers choose symptoms that can’t be disproven. And many physicians who work, for example, in insurance medicine, cast a cynical eye upon many of the complaints that O’Sullivan takes for true-bill.

How best to treat these patients? O’Sullivan has good words for a procedure that has largely passed from medicine, namely the amobarbital (amytal) interview. But it is increasingly seen as outmoded and dangerous (the barbiturates have undeservedly acquired a bad reputation, and most physicians are simply not in the habit of prescribing them).

O’Sullivan believes in letting the patients have it full blast: Your “disability has a psychological cause.” Sorry. The patients are left open-mouthed, since virtually every psychosomatic patient in the history of the world has had a profound belief in the organicity of his or her woes. And even though we have exalted “never lying to patients” to a beacon of medical ethics, in fact there are moments when a bit of evasion may prove therapeutic.

“Shahina” comes in with a contracture of the fingers of one hand. Another consultant recommends a botulinum injection. Bingo! The contracture releases instantly. Shahina is cured! Now, usually you take your therapeutic victories where you can get them. But O’Sullivan presses on. She tells Shahina that normally the botulinum works only after a day or two. “The speed at which your hand responded to the toxin makes me wonder if there is a chance that the spasm in your hand might have had a psychological rather than a physical cause.”

Shahina responds, “You think I’m mad?” No, of course not but…

This is actually a model of what not to do: throw patients into confusion with the relentless urge to enlighten them about their supposed psychological problems.

For other patients, as I have argued above, the psychiatrist is held out as the solution of choice. This is a problematic idea, and it is dismaying to see it propagated so vehemently in these pages. Psychiatrists tend to be baffled by such referrals. “This is a patient whose chief complaint is chest pain? C’mon!”

The general internist, the rheumatologist, or another neurologist should be the physicians of reference, because only they are able to build the necessary therapeutic alliance, to keep the myth of organicity semi-intact. It is this myth that patients require to retain their self-respect, while the real therapy takes places in the context of the doctor-patient relationship. What actually works is spending a lot of time with these patients and letting them tell and, if necessary, retell their stories. This is cathartic. But it is advice that is most unwelcome to many clinicians because it takes so much time.

It is not really fair for me to second-guess Dr O’Sullivan from the comfort of my armchair thousands of miles away. Physicians on the front line of medicine, at Queen’s Square and elsewhere, have to cope as best they can – and with relatives that make Himmler seem like Santa Claus. (O’Sullivan’s patience in dealing with these furies is remarkable.) The take-home message is that the book is a great immersion in psychosomatic problems. One may quibble about some of the author’s therapeutic choices but this is for the Thursday afternoon seminar room. If you want to get a head-on feeling for the clinical experience of psychosomatic patients, read this book.

 

Edward Shorter is Jason A Hannah Professor of the History of Medicine in the Faculty of Medicine of the University of Toronto, where he also has the academic rank of Professor of Psychiatry. Among his books is From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era (New York: Basic Books, 1992)

 

 

The Reading Room: The Other Side of Silence

20 May, 16 | by cquigley

 

The Other Side of Silence_CMYK_cropped

The Other Side of Silence: A Psychiatrist’s Memoir of Depression by Linda Gask.

Vie Books, 2015

Reviewed by Dr Lilian Hickey

There is a shocking, but humane and tender poetry in George Eliot’s lines in Middlemarch which refer to the deafening ‘roar’ of life that might lie ‘on the other side of silence’ in our ordinary day-to-day emotional experiences –  if we only had ears to hear it (or the courage to bear it). We humans spare ourselves, Eliot says, by securely, routinely, tuning out from awareness of the more unmanageable aspects of life – for our sanity’s sake (‘wadding’ ourselves in ‘stupidity’).

Linda Gask takes some of these words of Eliot’s for the title of her memoir, which has a fierce, tenacious, calm and utterly generous sense of commitment in her remarkably frank account of that potentially overwhelming ‘roar’, both in her own life, but also in her accounts of many of her patients’ lives from her long career. Her book sets out to help others through her very personal account of a life beset by periods of severe depression, as well as by episodes of disabling anxiety, difficult obsessional ruminations and even paranoia. Her professional life as an esteemed psychiatrist, researcher and educator has been deeply, tacitly informed by her awareness of her own fragilities, which have included times of almost suicidal desperation, and her story is a compelling one of love, loss, betrayal, kindness, hope and dedication. (And also, tellingly, of some very kind and good doctoring and therapy, hers and others’, along the way)

The bedrock of her memoir rests, as most lives tend to, in the matrix of her childhood experiences, which she brings to life in simple, vivid, often unhappy, detail. Her labouring father always had oil-stained hands, from long and dangerous hours spent tending to the workings of a funfair ride…his determined and passionate nature has been passed down to his only daughter, who adored him.  She can see how she has become her father’s daughter, and benefited from his ambition for her. His later rages, sometimes violent in her adolescence, and his sudden death while she is in Edinburgh working as a house officer, are for a long time impossible for her to take in. It is years later with the help of her first therapist that she begins to make sense of her relationship with her father and what his loss has meant. (Though she says she can never be sure exactly how proud he might have been of her achievements, praise and pride were not in the family behavioural lexicon). Her relentlessly unhappy, critical, jealous mother is cold and ever-unappeasable, but in the book, the lack of warm maternal care seems especially hard to place – if not describe – in the origins and seams of her very real childhood, and then adult, distress. Perhaps the great tragedy of her family unhappiness however lay in the persistent, mostly silent, tormented obsessive compulsive illness of her younger brother, whose later apparently ineffective psychiatric care is described. The lack of any help or support for his childhood torment and its deeply devastating effect on family life,  seem to have been important factors in her later coming to find in psychiatry a place where she could become the sort of doctor who could bear to hear and think about the roaring of despair.

Gask’s childhood sensitivities to unspoken emotional weathers, and to the fears and distress of others, bring to her professional life a capacity for concern, clear sighted clinical observation and an ability to attend to, and be concerned about, troubled states of mind.  The book is also, amongst its chapters, a reminder of the stresses of undergraduate medical studies, the pressures of long hours as a junior doctor and of what it can be like to work in neglected, down-at-heels psychiatric facilities. The notion of asylum for those is distress is thought about, and often in her story seems much more in evidence in the kindness of professionals than in the tatty surroundings offered to the mentally ill.

The professionals who make a difference to Gask are described candidly – the kind, the solid, the unreliable, the awkward and the wise. We are reminded that the right psychiatrist or therapist can be an astonishing lifeline on the edge of a mental abyss, and over the years her medical and psychotherapeutic relationships have been essential aspects of her own soul-rescuing in times of dread or confusion.

The book reads both easily and uncontroversially because of the truths it elaborates with quiet honesty and rigour. Its exposition is simple, its creed straightforward – that there are different kinds of depression, that everyone’s experience of mental distress is uniquely theirs in its origins and setting, and that professional kindness and expert unflinching attention matter profoundly. There are different sorts of treatments and some have worked for Gask better than others. That things change – illness and the medical and psychological therapies which help, at different times in life – is a given.

The self and the coordinates of being are tested by depression, but this is a memoir of a life lived with, ultimately, very considerable personal and professional achievement. What is exceptional in this volume is the absolute sanity of its project. It is one of the least mad books on madness imaginable, and it most essentially promotes hopefulness inspite of its tales of real despair and disorientation. It will change the understanding of anyone who has heard the whisper of Eliot’s roar at any point in their lives. Which is, presumably, all of us.

 

 

Lilian Hickey

Consultant in Older Adult Mental Health

Fulbrook Centre

Churchill Hospital

Oxford OX3 7JU.

Ayesha Ahmad: Introduction to Global Humanities—Through Creation, Violence Will Die

15 Mar, 16 | by Ayesha Ahmad

Against the backdrop of violence, I have been examining through my research the qualities of our human condition that perpetuate both our survival and our spirit.

As an introduction to an ongoing series on Global Humanities, I will be discussing ways we can counter the dominant narrative of violence.

Our globalised world, or rather, the collective ‘Other’, is met through encounters from suffering—the patients that enter our clinical settings, the individuals that sacrifice their lives to reach the shores of safety, and the images that we only ever see from afar of stories that breathe suffering.

more…

The Reading Room: Ronald Britton’s ‘Between Mind and Brain’

27 Jan, 16 | by cquigley

 

Between Mind and Brain: Models of the Mind and Models in the Mind

by Ronald Britton. Published by Karnac, 2015.

 

Reviewed by Dr Neil Vickers.

 

Ronald Britton is one of the most significant psychoanalytic theorists writing today. Now retired from clinical practice, though still active in training, he is perhaps best known for his contributions to Kleinian theory. His first book, Belief and Imagination: Explorations in Psychoanalysis (1998), asked questions such as ‘What is and where is the Imagination in any modern model of the Mind?’ and ‘How can we conceive of it in psychoanalytic terms?’ His second, Sex, Death and the Superego: Experiences in Psychoanalysis (2003), set out his thinking on three concepts that were important to psychoanalysis historically. Britton has always used literature as a kind of interlocutor for analytic theory. Belief and Imagination contains lengthy discussions of, and arguments with, Wordsworth and Coleridge, Blake, Milton and Rilke, as well as Freud, Klein and Bion; and Sex, Death and the Superego contains a compelling reading of the Book of Job and a fascinating extended speculation about the role that Wagner’s operas played in Jung’s correspondence with Sabina Spielrein. Britton is a medical humanist avant la lettre.

 

The theme of his new book, Between Mind and Brain: Models of the Mind and Models in the Mind, is that we think in models. Britton’s concern is more with the mind than the brain though the early chapters do make reference to contemporary neuroscience. In the first chapter Britton asks a question that once tormented Freud: would psychoanalysis and brain science ever arrive at a substantially overlapping account of mental experience? Britton’s answer is ‘probably not,’ though he thinks the reasons for this have changed since Freud’s time. The success of quantum biological models in neurology has resulted in a situation in which a mechanistic account of how the brain works has been replaced by one that is probabilistic (so outcomes can never fully be determined in advance), and full of complex, counterintuitive interaction (Patrick Haggard of Queen Square has demonstrated that, in a range of situations, the brain executes our intentions before these are consciously formulated in the mind). Freud originally hoped to ground concepts like repression in the workings of different types of neurones. Today, Britton suggests, convergence would have to be sought in other places, using different concepts borrowed from each discipline. At one point, he playfully suggests that the evaporating black holes of quantum mechanics might somehow dovetail with the psychic ‘black holes’ that psychoanalysts have described in very disturbed children. But the comparison remains at the level of play, because the two models aim to capture very different things. And models, along with their potential and limitations, are where Britton’s real interest lies.

 

For better or worse, psychoanalysis, like other psychotherapies, has to derive its models from directly-reported mental experience. Fantasies, conscious and unconscious, are models in Britton’s sense. But so too are theoretical constructs such as the Oedipus complex, the ‘depressive position’, or ‘basic assumptions’. Many people imagine that psychoanalysts apply these models dogmatically to their patients. On this view, patients are talked into seeing their difficulties as having an Oedipal origin, say. Britton takes this case apart at some length. The psychoanalyst, in his view, should aim as far as possible to set aside all models, especially those to which he is most attached. They will only distort what he sees. To understand another person, you have to tolerate not understanding him or her for a long time. Britton is on record as saying that he assumes he does not understand his patients for the first two years of four- or five-times-a-week analysis. Of course, psychoanalytic models are brought in, sceptically, but only gradually.

 

Occasionally, patients’ difficulties will be very well captured by a model. In Chapter 6, Britton gives the example of a man called Peter who entered psychoanalytic psychotherapy with a stammer. Peter led a very ordered life. He did not work. He had a celibate marriage. He avoided talking to his mother on the telephone, writing typed letters to her instead. And he appeared to have few friends. The model that seemed to fit Peter’s case was of a narcissistic organisation, as described by Herbert Rosenfeld. Patients in the grip of narcissistic organisations may want to make contact with others in the outside world but are prevented from doing so by an internal figure or group of figures who threatens terrible punishment. So it seemed with Peter who felt he had to isolate himself from his wife and mother and from the world of work for reasons that were unclear. Eventually he revealed that from the age of fourteen, ‘there had been a voice in his head that had ordered him not to speak and not to get close to anyone’ (53). Stammering was a way of obeying that voice. Peter also revealed he never stammered and could talk fluently when he was at home alone or when he was with children. Britton and Peter’s analyst took care not to introduce Rosenfeld’s model directly in Peter’s treatment until such time as he gave them cause to, which to their amazed delight he did. The model might otherwise have been a source of distortion and misunderstanding.

 

Analytic models can be useful only if they illuminate the analyst’s subjective experience of the patient’s subjective experience. But before such a point can be reached, analyst and patient have to learn to hear one another in as unprejudiced a manner as each can manage. It is to Britton’s credit that he does not minimise how difficult this can be for both parties. This stage of ‘building out into the dark’ as Freud called it, has its own micro-models too. Chief among these are the beliefs that the patient holds about himself and his analyst. ‘Believing,’ writes Britton, ‘is a form of object-relating. I think belief as an act is, in the realm of knowledge, what attachment is in the realm of love. The language of belief is clearly cast in the language of a relationship’ (82). For this reason, beliefs offer a point of entry into the patient’s internal world and the figures who inhabit it. They supply models of that world, seen from a certain point of view. At a more basic level still are the unmentalised psychophysical experiences that manifest themselves in the transference as ‘imageless expectations’ (19). These await transformation into the models constituted by fantasies, symbols and dream elements. These lower-level models form the bedrock of most patients’ and analysts’ analytic experience. The larger theoretical models such as the Oedipus complex or the ‘depressive position’ shimmer in and out of view but they must take their shape from this more detailed and theoretically open work. They have no substantial existence independently of it.

 

The systole and diastole of this process are transference and countertransference. Britton subscribes to the now widely-held but once heretical view that the analyst’s countertransference, far from being an obstacle to analytic progress, is a spur to it. The analyst has to be willing to receive the patient’s unconscious fantasies and to allow them to act on his unconscious mind. The hope is that the analyst will have enough self-understanding to distinguish what belongs to the patient from what he brings himself. Acting as the crucible for other people’s unconscious experience in this way is intellectually and emotionally demanding. As Britton observes, ‘Analytic neutrality does not mean freedom from emotion, it means unbiased observation of its play within ourselves’ (23). In his last book, Sex, Death and the Superego (2003), Britton went so far as to propose a new psychoanalytic nosography based on the kinds of countertransference experience that different sorts of patients evoke and some of that work is rehearsed again in chapter 7 of Between Mind and Brain.

 

Unsurprisingly, given his previous books, Britton thinks that literature and theology are rich sources of models of mental life. This volume contains interesting new material on myth as a model of mental life and on writing by Blake, Milton and Mary Shelley. Britton sees Milton as a man divided against himself. The theologian author of De Doctrina Christiana needed to secure himself against a suspicion that God might be a sadist (a line of inquiry which Stanley Fish argues runs through Paradise Lost). But the poet of Paradise Lost makes Satan the hero of his poem and depicts him as ‘a whole person experiencing conflict, remorse and dread’ (115). Satan (distinct from Milton) is a destructive narcissist in Herbert Rosenfeld’s terms and by engaging with him imaginatively, Milton defends himself against the depressive melancholia Britton thinks lay at the core of his theology. Britton has a vivid sense of what an achievement it is to live out ones conflicts in this way. In similar vein, Britton reads Blake’s Marriage of Heaven and Hell as an exploration of what is entailed in substituting one’s own ideal self for the superego. Most impressive of all is the chapter on Mary Shelley’s Frankenstein (‘What made Frankenstein’s creature into a monster?’). which Britton reads as a parable about the absolute horror of perinatal rejection for both mother and child’ (106).

 

I have given the barest indication of the many riches contained in this very fine book. I was left with only one puzzle. Britton says a great deal about Darwin the man in this book but very little about Darwinism’s implications for psychoanalysis. He complains at one point that the radicalism of Darwin’s theory of evolution has scarcely penetrated educated opinion. I think he’s wrong about that but what about Darwinian models of psychoanalysis: Bowlby’s, pre-eminently, but also the more modern version of attachment theory promulgated in this country by Peter Fonagy, Anthony Bateman and Mary Target and in the United States by figures such as Allan Schore? Neuropsychoanalysis is completely Darwinian in outlook. It would be good to have Britton’s opinion of these models, not least because they engage so many of his interests. The same thought was with me when it came to neuroscience, a field Britton holds in high regard. Neuroscience uses a thoroughly Darwinian framework when considering the structures of the brain: the basal ganglia making up the reptilian complex were the first to evolve; later came the limbic system, the seat of most of our emotional reactions; finally, the neocortex evolved, from which we humans derive so many of our cognitive advantages. These structures, which can be found in non-human animals too in different proportions, now supply the basis for a great deal of neuroscientific theory. Has psychoanalysis nothing to say about them?

These quibbles are based on a wish that the book had been longer. Coming away from it, my overall feeling was of gratitude for such an incisively-argued and powerful book.

The Reading Room: A review of ‘Performance, Madness and Psychiatry’

4 Feb, 15 | by cquigley

 

Performance, Madness and Psychiatry

Isolated Acts

Edited by Anna Harpin & Juliet Foster

 

Reviewed by Femi Oyebode

National Centre for Mental Health

25 Vincent Drive

Edgbaston, Birmingham B15 2FG

Femi_oyebode@msn.com

 

In the spring of 1836, John Clare (1793-1864) visited Peterborough and accompanied Mrs. Marsh, the bishop’s wife, to the theatre to see Merchant of Venice. At the beginning of the fourth act, Clare became restless. In the scene where Portia delivered judgment, Clare stood up and addressed the actor performing the part of Shylock: “You villain, you murderous villain”. Frederick Martin 1 wrote

“Great was the astonishment of all the good citizens of Peterborough…Such an utter breach of decorum was never heard of within the walls of the episcopal city. It was in vain that those nearest to Clare tried to keep him on his seat and induce him to be quiet; he kept shouting, louder than ever, and ended by making attempts to get upon the stage. At last, the performance had to be suspended, and Mrs. Marsh, after some difficulty, got away with her guest”.

Soon after that event Mr. Skrimshaw, a surgeon, saw Clare and declared “what, indeed, was obvious to all the persons in the house – that the poor poet was a lunatic”.

This book, edited by Harpin and Foster deals with many of the issues that are raised by the account above: What is the nature of mental illness? How do we come to recognize it? What is the right (morally right) stance to take in respect of it? In what way can theatrical (P)erformance be distinguished from (p)erformance in everyday life? And, so on. We can and do denote a theatrical space as a place designated for performance and this is not necessarily merely a building. In traditional society it might very well be a clearance in the forest first encircled by trees and then by a circle of people. The theatrical space in this arrangement is literally centre stage and the theatrical performance is encircled (What Elias Canetti terms “The Crowd as a Ring”) as it is in an arena. Think of the Roman Coliseum or the Grand Amphitheatre in Ephesus, or Congo Square in New Orleans. In contemporary European tradition, the stage is at an elevated focal point, usually at one end of an oblong building. Convention determines where the actors play and how the audience behaves and this is always being re-defined by playwrights. There is a sense in which the distinction between being a spectator or an audience is itself a commentary on the implicit rules governing what is expected in theatre. We go to see a play but sit in the auditorium as part of an audience whereas at a football stadium we are spectators. To return to John Clare, one could argue that in performing from the audience’s space, Clare was making of himself a spectacle and this breach in the usual conventions of behavior was a social signal that all was not well with him. In essence he had breached the implicit rules that governed how theatrical space is utilized.

Harpin and Foster write in the afterword to their wonderful book

“This is a book about madness, space and performance. In it we have paused over these three concepts and their interrelations in order to try to better understand the cultural politics and meanings of madness. The diverse, even clashing voices in the collection evidence how far this remains fiercely contested terrain”.

The remarkable achievement is that the editors, despite the extent of the contested and disputed territory, have managed to produce a text that sticks to task, that is thematically unified, except for the first chapter. Richard Stern in his chapter “Smart’s Authority and the Eighteenth-Century Mad-Business” focuses on Christopher Smart, a poet and Dr. William Battie who may have treated him. We are told that Smart was admitted to St. Luke’s where William Battie was Head Physician in May 1757 and discharged in May 1758. He was later admitted to Potter’s private madhouse in 1759 and discharged in 1763. He was arrested in April 1770 for debt and died n prison in May 1771. Stern’s approach is to examine the use of language in Smart’s poem Jubilate Agno and Battie’s A Treatise. There is practically no reference to the nature of theatre nor is there reference to the problematics of performing madness, of representing madness in language, or of the true dilemma of what one does when challenged by obvious anomalous experiences and behaviors that cause concern.

Stern writes

“I want to conclude this chapter by firstly celebrating Jubilate Agno as a poem. At the very least, it is a voice from the madhouse at a time when many other people in similar circumstances were silenced. The content of the poem challenges psychiatry to justify its terminology, its methods and the language that it is using. It represents the richness of felt experience and warns against a rigid determinism. It also shines a light on confinement as seen of the perspective of the confined, where there can be a sense of double-suffering, or of suffering played out again and again: suffering as mental disturbance, alienation, isolation, social death, and the suffering under the fact of confinement…”

This is all very well, but the superior tone of admonishment of an abstraction termed “psychiatry” does little to sketch out what Stern’s own contribution would be in a complex area that demands more than merely clever and righteous statements. John Perceval’s (1803-1876) A narrative of the treatment experienced by a gentleman during a state of mental derangement; designed to explain the causes and the nature of insanity deals comprehensively with the facts of confinement and makes a clearer, more directly eloquent and, fulsome case against unnecessary confinement. For a description of the subjective experience of severe delusions and hallucinations including a legal argument against incarceration Daniel Schreber’s (1842-1911) Memoirs of My Nervous Illness is unparalleled. And, if it is poetry written under conditions of incarceration that one seeks then John Clare’s poetry written whilst he was at Northampton Asylum or Ivor Gurney’s (1890-1937) poetry written whilst at the City of London Mental Hospital speak to the distress, the emotional turmoil and the desolate inner landscape that is mental illness.

Juliet Foster, in her chapter “Performance in Bethlem, Fulbourn and Brookwood Hospitals: a social psychological and social historical examination”, deals with theatrical performances in psychiatric hospitals. This is a reminder of what has been lost with the closure of Asylums. This is not to glorify asylums but rather to say that community care has not fulfilled all its promise and the idea that communities will embrace the mentally ill was just that, idealistic. The paradox is that there can be even more isolation and alienation in wider society than in asylums. Theatrical performances were only one of the variety of entertainments put on in asylums, dances were another popular form of entertainment. John Burnside’s poem “The Asylum Dance” and Patrick McGrath’s novel Asylum take the asylum dance as a centerpiece of asylum life. Foster concludes that

“Entertainment…is centred around the idea of providing a diversion or a distraction, or even a link in some way to the world outside of the asylum, and to everyday experiences and practices”.

It isn’t often that the literature on asylums recognizes and acknowledges the desire to do good, to alleviate suffering in the residents, and to harness the humanity of the staff in the service of their charges.

In the section titled “Applying Performance”, first Susan Cox in her chapter “Reflections on autonomy and ethics in research-based theatre and then Sarah Rudolph’s “Whose mind is it anyway?: Acting and mental illness” deal with the intricacies of ‘acting mad’ in theatre. There is here an assumption that theatre has an implicit educational if not moral purpose. Cox talks about

“When applied theatre is successful in opening us differently to experiences of mental illness…we may reflect from a new vantage point, on the implications of our own forms of engagement with mental illness, such as through understanding what it might be like to live with dementia…”

And,

“Challenges include the ethics of fictionalizing the real life experiences of research participants and the problems that can arise when participants and/or audiences over-identify with the physical or mental health conditions being performed, perhaps even becoming re-traumatized by a highly convincing theatrical performance”.

This view suggests that a special duty of care exists towards the audience when theatre tackles sensitive issues. This is on the face of it a thoughtful and caring position. But, it can also be read as assuming vulnerability in participants and audiences in special settings that inexorably results in self-censorship. The implication is that there are matters that are too sensitive to be enacted. Or, that there are particular enactments that will be more troubling than others. All audiences bring with them, into theatre, inner life of varying composition. Blanche Dubois in Streetcar Named Desire or the Tyrone family in Long Day’s Journey into Night depending on the sensitivities of the audience have the capacity to provoke disquiet in individuals who have been raped or whose parents have a strained marriage, etc. One could argue that the power of theatre resides precisely in this confluence between what is being played on stage and what is jostling for resolution in the mind of the audience. To make the point again and in a different way, I hope that a mobile library in a psychiatric hospital would have books of all kinds, not a list of the most supposedly innocuous texts so as to protect patients from troubling texts.

Rudolph’s chapter is a must read for anyone with an interest in the use of theatre in psychiatry. It examines the pitfalls as well as the triumphs of this area of work. It makes the point, that ought not to need making, that mental illness is not a metaphor, it is a real lived experience. Schizophrenia or dementia does not stand in for other matters, they are not symbols infused with meaning with the goal of speaking about a world in schism or a degenerate world, etc. And, mental distress is multifarious in presentation. The experiences are manifold. It may be true that ‘dramatic’ enactments in which florid gestures and violent outbursts occur are easier to comprehend but in fact life is more subtle, more nuanced, and hence representations that recognize that agony is best suggested than caricatured would ultimately be closer to the truth of mental illness.

The final section “Theatrical Maladies” is a tour de force. Bridget Escolme takes Ophelia and analyses different productions of Hamlet with a view to discovering the underlying motifs, the rationale for the varying portrayals. She traces “how different historical epochs have mapped their fears and wishes around children onto their fears and wishes around the ‘mad’…Questions of how ideas of insanity produce Ophelia and how Ophelia produces ideas about insanity…”. Hers is a feminist reading but her conclusion that there is a tradition of “calming and confining Ophelia and her representation” can just as easily be read as a fear of madness per se. Greek theatre kept mad actions from view and the Roman theatre only rendered visible the mad fool, innocent and funny, and thereby unthreatening for the audience. There is a way in which madness is hidden from view but it may be true as Escolme argues that madness is the more malignant, “embarrassing and disturbing” in a woman. Harpin’s final chapter “Dislocated: Metaphors of madness in British theatre” addresses the question of what it is, metaphorically, to be mad. This is quite distinct from using mental illness as a metaphor, a symbol for matters unconnected to it. It is examining what it is like, metaphorically, to be mad. This understanding is important because it gives a handle on the experience and allows it to be accurately represented in art. Harpin starts by saying that in relation to madness

“First, there is the recurrent sense of journeying that attends on madness. Secondly, the dominant notion of place renders ‘mad’ experience an inherently geographical encounter. Madness, then, is figured as a location, as site…To be mad is to be…displaced, dislocated, gone”.

She goes on

“Juliet LH Foster’s study of mental health service-users’ representations of their experiences argues that mental illness frequently figures as a place (woods, clouds, traps, prisons, abyss, pit) or journey (mountain, tightrope, maze, tunnel)”.

The challenge then is how to embody the metaphor, how to concretize what is beyond language, that which is unspeakable. That, after all, is what drama is.

To return to John Clare, his performance at the theatre during the production of Merchant of Venice signaled a dislocation within. And, this dislocation was made visible in his speaking from the auditorium to the actors on stage. Theatrical representation of madness could learn from this event, that speaking from the ‘wrong’ place is a possible expression of madness. And, this might involve shifting the balance of where the audience is in relation to the stage and emphasize that the person sitting next to you in theatre, that is your neighbor, like you is liable to emotional turmoil.

I will leave the last word to Anna Harpin

“Plays locate madness precisely along a spectrum of human experiences without ever flattening out the particularity of the encounter…dramatists encourage a political reflection on the nature and boundaries of ‘health’ and ‘illness’.

 

References

  1. Martin, Frederick (1865) The Life of John Clare. Gutenberg Ebook no B470 [http://eBooks.Gutenberg.us/Gutenberg/eBooks05/77jclr10.zip and http://eBooks.Gutenberg.us/Gutenberg/eBooks05/8jclr10.zip]

 

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