The book has been praised for being a remarkably balanced account in a field which tends toward the polemical, and for carefully examining the interaction between culture and our experience of mental distress.
…it became quite clear for me that there are rather strict rules about how to behave when you’re crazy in any given epoch, as Ian Hacking has so pithily put it. There are ways in which the cultural understanding of mind and body at any given time plays into the nature of diagnoses, along with historical and sociocultural forces. The way in which we express our discomforts, dissatisfactions, excesses, madnesses is through those particular understandings. So symptoms will feed into diagnoses, diagnoses will feed back on symptoms. Institutional forms, media, and everything else all comes into play, and you end up having a model, or “most-expressed” disease for any given period.
So, for example, towards the late part of the nineteenth century, many explanations had to do with nerves, and you had a disease called neurasthenia, which actually covers a great gamut of problems and disorders. Following on that you have hysteria, that very interesting set of ways of behaving which actually shows women suffering from anesthesia — they can’t feel their skin — and various forms of paralyses and mutisms. In a way, all of these reflect the kinds of things that are wanted of women in that period, and also the kinds of prompts fed to them as they live their condition. And so once a particular kind of liberty for women comes into play, hysteria begins to alter, to change into other things.
Today we have one of the dominant ways for women to express discomfort with who they are is to develop a body illness such as anorexia or bulimia. Many things come into play, but one of them is that we live in an increasingly virtual age, where the body itself is problematic. Body disorders are one way of expressing our misery. So, yes, there’s a cultural expression to symptoms and indeed diagnoses.
The interview is also interesting for a brief outburst of resentment stemming from the current state of UK mental health politics.
The UK government is in the process of spending ¬£300 million on making psychological therapies widely available on the National Health Service. Not unsurprisingly, it has focused its money on therapies which have been proven to be effective through randomised controlled trials.
As cognitive behavioural therapy has the most evidence for its effectiveness most (although not all) of the money is going to fund CBT. Needless to say, this has caused all sorts of hell from the tribes of mental health.
This month’s British Journal of Psychiatry has an article entitled “Wake-up call for British psychiatry” where some of Britain’s leading psychiatrists argue that this money is being spent to the detriment of medical services.
I think this is a valid point. It’s an argument over which evidence-based treatments the government should spend its money on. However, some of the strongest attacks have come from other schools of therapy, especially those evidence-shy Freudians.
Appignanesi, chair of the trustees of the Freud Museum, manages a wonderfully misinformed put down. Apparently CBT is being touted as:
a cure-all for everything. And of course it’s not. It’s merely a form of self-control over the mind. It obviously helps adolescents to order their lives in some ways, but may not help much more than that, and to think of it as a cure-all is not going to help many people. It may make an intervention in the first instance but it won’t work over the longer term
In fact, it’s being funded to treat conditions in adults for which there is evidence for its effectiveness, and there is good evidence that it has lasting long-term beneficial effects, particularly for depression.
In the same vein, Mick Cooper, a leading existential psychotherapist, recently issued a widely reported statement saying the idea that CBT is more effective is a ‘myth’ because that while there had been more studies on CBT, but that did not necessarily mean it was more effective than other types of therapy.
Unfortunately, it seems he can’t distinguish between ‘more evidence for its effectiveness’ and ‘more effective’, which, of course, are quite different.
To get any particular therapy funded, it just needs research to show its effectiveness. It’s a fairly straightforward ‘put up or shut up’ situation.
Of course, the issue of who funds the research is another matter, but as psychoanalysis largely survives through the private patronage of the upper middle classes and aristocracy in the UK (I kid you not), you would think it shouldn’t be too hard to get someone to fund the studies.
Link to Lisa Appignanesi interview.