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All in the brain?

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All in the brain?

Stephen Fry’s exploration of manic depression (in the current BBC series on mental health, ‘In the Mind‘) has drawn both praise and criticism.  Psychology Professor Richard Bentall, has sent an open letter to the actor which offers a differing perspective. The letter is reproduced here with permission.

 

Dear Stephen,

You and I attended the same public school (Uppingham, in Rutland) at the same time, in the early 1970s, and our unhappy experiences there have undoubtedly helped to shape our different trajectories, which have led us to a shared interest in mental health.

In your case, your premature departure from Uppingham, and your adventures immediately afterwards, were documented in your wonderful book, Moab is my Washpot. Your subsequent openness about your own mental health difficulties, for which I salute you, has been an inspiration to other mental health sufferers.

In my case, despite a lacklustre academic performance which I attribute mainly to spending much of my adolescence feeling depressed and emotionally abused, I managed to make my way to university and eventually pursued a career in clinical psychology. (My brother, unfortunately, was much worse affected by his time at the school; his expulsion was the start of a long downward spiral that culminated in his suicide, an event that haunts me twenty years later, and which reinforces my determination to improve the public understanding of mental ill-health.)

I have now spent more than thirty years researching severe mental illness, focusing especially on patients with psychosis (who, in conventional psychiatry, are typically diagnosed with ‘bipolar disorder’ or ‘schizophrenia’). It is from this perspective that, reluctantly, I must now ask you to rethink the way that you portray these conditions to the general public. I know that you wish to demystify and destigmatise mental illness, which are surely laudable aims, but my worry is that some aspects of your approach may have the opposite effect from that which you intend.

Conventional psychiatry tends to decontextualise psychiatric disorders, seeing them as discrete brain conditions that are largely genetically determined and barely influenced by the slings and arrows of misfortune, and it was this perspective that was uniquely presented in your recent programme The not so secret life of a manic depressive ten years on. According to this ‘brain conditions’ view, psychiatric disorders occur largely out of the blue in individuals who are genetically vulnerable, and the only appropriate response is to find the right medication.  Even then, it is usually assumed that severe mental illnesses are life long conditions that can only be managed by continuous treatment. However, research into severe mental illness conducted over the last twenty years (not only by me, although I have contributed) tells a more complex story.

To begin with, we now know to a level of certainty that diagnoses such as ‘bipolar disorder’ and ‘schizophrenia’ are not separate conditions[1]. Furthermore, there is no clear line between severe psychiatric disorders and healthy functioning[2], with the consequence that large numbers of people manage to live productive lives despite experiencing symptoms at some time or another, and without seeking help[3]. There is, for example, an international network for people who hear voices, many of whom manage perfectly well without psychiatric care[4]. (In my experience, psychiatrists are often troubled by this ‘fuzziness’ at the edges of mental ill health, which I find puzzling as doctors in physical health have no difficulties with handling arbitrary boundaries; there is no sharp dividing line between healthy and unhealthy blood pressure, for example.)

It also appears that the outcomes for severe mental illness are much more variable than was once thought. Longitudinal research suggests that a surprising number of people manage to make full or partial recoveries[5], even when not taking medication. A complication is that recovery means different things for different people; whereas psychiatrists typically think of recovery in terms of recovery from symptoms, patients more often emphasise the importance of self-esteem, hope for the future, and a valued role in society[6].

Of course genes play a role in making some people more vulnerable to psychiatric disorder than others, but the latest research in molecular genetics challenges simplistic assumptions about ‘schizophrenia’ and ‘bipolar disorder’ being primarily genetic conditions. The genetic risk appears to be shared across a wide range of diagnostic groupings – the same genes are involved when people are diagnosed with schizophrenia, bipolar disorder, ADHD and even, in some cases, autism[7]. More importantly, genetic risk is widely distributed in the population with hundreds, possibly thousands of genes involved, each conferring a tiny increase in risk[8]. Hence (to quote American genetic researcher Kenneth Kendler),

‘The genetic risk for schizophrenia is widely distributed in human populations so that we all carry some degree of risk’[9].

Of course, some people (possibly yourself) have more of these genes than others, but the fact that so many are involved suggests that it is very unlikely that studying them will lead to therapeutic innovations anytime soon. By contrast, consider Huntington’s Disease, a terrible degenerative neurological condition that is caused by a single dominant gene with a known biological function. Many years after this gene was discovered there is still no sign of a medical therapy for this simplest of all the genetic conditions.

In your programme, you did not attempt to link your own mental health difficulties to circumstances despite the fact that your story suggested that episodes had been triggered by specific events on at least two occasions (after bravely confronting an extreme homophobe in Uganda, and after extensive jet travel). More importantly, perhaps for understandable reasons, you seemed reluctant to explore any possible connections between your difficulties now and your experiences earlier in life. In fact, recent epidemiological studies have pointed to a wide range of social and environmental factors that increase the risk of mental ill health[10], some of which I am guessing you may be familiar with from personal experience.

These include poverty in childhood[11] and early exposure to urban environments[12]; migration[13] and belonging to an ethnic minority[14] (probably not problems encountered by most public school boys in the early 1970s) but also early separation from parents; childhood sexual, physical and emotional abuse; and bullying in schools[15]. In each of these cases, the evidence of link with future psychiatric disorder is very strong indeed – at least as strong as the genetic evidence. Moreover, there is now good evidence that these kinds of experiences can affect brain structure, explaining the abnormal neuroimaging findings that have been reported for psychiatric patients[16], and that they lead to stress sensitivity and extreme mood fluctuations in adulthood[17]. And of course, there are a myriad of adult adversities that also contribute to mental ill health (debt[18], unhappy marriages[19], excessively demanding work environments[20] and the threat of unemployment[21], to name but a few). Arguably, the biggest cause of human misery is miserable relationships with other people, conducted in miserable circumstances.

Why is all this important? Well, for one thing, many psychiatric patients in Britain feel that services too often ignore their life stories, treating them more like surgical or neurological patients than people whose difficulties have arisen in response to challenging circumstances. In the words of Eleanor Longden, a well-known voice hearer and mental health activist,

‘They almost always ask what is wrong with you and hardly ever ask what happened to you’[22].

Patients are routinely offered powerful drugs as shown in your programme (I am not saying they don’t have a place) but very rarely the kinds of psychological therapies that may help them to come to terms with these kinds of experiences, or even practical advice (debt counselling probably has a place in the treatment of depression, for example).

Patients’ dissatisfaction with an exclusively medical approach is well founded, because research has shown that this approach has been extraordinarily unsuccessful, despite what clinicians often assert. Whereas survival and recovery rates for severe physical conditions such as cancer and heart disease have improved dramatically since the end of the Second World War[23], recovery rates for severe mental illness have not shifted at all[24]. Even more surprising, you might think, those countries which spend the least on psychiatric services have the best outcomes for severe mental illness[25] whereas those that spend the most have the highest suicide rates[26]. No doubt, if we understood the psychological mechanisms that lead from childhood misfortune to mental illness, we could do more to help people. However, research funding in mental health is being almost exclusively channelled into genetic and neurobiological studies, which have little realistic prospect of yielding practical interventions.

To make matters worse, research shows that exclusively biological theories of mental illness contribute to the stigma experienced by mental health patients, which I know you want to reduce[27]. The more that ordinary people think of mental illness as a genetically-determined brain condition, and the less they recognise it to be a reaction to misfortune, the more they shun mental health patients. The biomedical model of mental illness, which your programme showcased, makes it all too easy to believe that humans belong to two sub-species: the mentally well and the mentally ill.

Finally, the biomedical approach entirely neglects the public health dimension of mental illness. Given the evidence from epidemiological studies, we can almost certainly dramatically reduce the prevalence of mental illness in the population by, for example, addressing childhood poverty and inequality, figuring out which aspects of the urban environment are toxic (you might or might not be surprised to know that living close to a park appears to provide some protection against mental illness[28]) and by ensuring that all of our children experience more benign childhoods than the ones we experienced. We cannot do any of these things if we spend all of our time peering into test tubes.

Let my finish by saying, Stephen, that I have the highest respect for you, and I thank you for your efforts to reach out to people who are suffering from mental illness. Please continue with this important work. But please, from now on, do so in a more balanced way.

Sincerely

Richard Bentall

Professor of Clinical Psychology at Liverpool University and Former Uppinghamian

You can follow Richard on Twitter @RichardBentall. Richard has provided a number of notes and references below for those interested in reading further.

 

[1]           The literature on this is complex, but includes studies of patients with symptoms along the schizoaffective dimension (e.g. Tamminga, C.A., Pearlson, G., Keshavan, M., Sweeney, J., Clementz, B., & Thaker, G. (2014). Bipolar and Schizophrenia Network for Intermediate Phenotypes: Outcomes across the psychosis continuum. Schizophrenia Bulletin, 40 suppl 2, S131-S137. doi:10.1093/schbul/sbt179); statistical studies of symptom variation (e.g. Reininghaus, U., Priebe, S., & Bentall, R.P. (2013). Testing the psychopathology of psychosis: Evidence for a general psychosis dimension. Schizophrenia Bulletin, 39, 884-895) and studies showing shared genetic contributions to apparently different psychiatric disorders (e.g. Lichtenstein, P., Yip, B.H., Bjork, C., Pawitan, Y., Cannon, T.D., Sullivan, P.F., & Hultman, C.M. (2009). Common genetic determinants of schizophrenia and bipolar disorder in Swedish families: a population-based study. Lancet, 373, 234-239).

 

[2]           Again, the literature on this is complex, but includes psychological studies of people with psychosis-prone personality traits (Raine, A. (2006). Schizotypal personality: Neurodevelopmental and psychological trajectories. Annual Review of Clinical Psychology, 2, 291-326), including sub-clinical bipolar traits (e.g. Bentall, R.P, Myin-Germeys, I., Smith, A., Knowles, R., Jones, S.H., Smith, T., & Tai, S. (2011). Hypomanic personality, stability of self-esteem and response styles to negative mood. Clinical Psychology and Psychotherapy, 18, 397-410) and also ‘psychometric’ studies which use complex statistical methods (‘taxometrics’) to discover whether there are any natural breaks in the continuum between healthy functioning and psychiatric disorder (e.g. Haslam, N., Holland, E., & Kuppens, P. (2012). Categories versus dimensions in personality and psychopathology: A quantitative review of taxometric research. Psychological Medicine, 42, 903-920).

 

[3]           There are many epidemiological studies which show a surprisingly high prevalence of psychotic-like experiences in the general population. See, for example, Johns, L.C., & van Os, J. (2001). The continuity of psychotic experiences in the general populations. Clinical Psychology Review, 21, 1125-1141. This phenomenon has been demonstrated in respect to bipolar symptoms; see for example, Merikangas, K.R., Akiskal, H.S., Angst, J., Greenberg, P.E., Hirschfield, R.M.A., Petukhova, M. and Kessler, R.C. (2007) Lifetime and 12-Month prevalence of bipolar spectrum disorder in the National Comorbidity Survey Replication. Archives of General Psychiatry, 64, 543-552

 

[4]           http://www.intervoiceonline.org/

 

[5]           See, for example, Harding, C.M., Brooks, G.W., Ashikage, T., & Strauss, J.S. (1987). The Vermont longitudinal study of persons with severe mental illness: II. Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. American Journal of Psychiatry, 144, 727-735, and Harrow, M., & Jobe, T.H. (2007). Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: A 15-year multifollow-up study. Journal of Nervous and Mental Disease, 195, 406-414.

 

[6]           Morrison, A. P., Shryane, N., Beck, R., Heffernan, S., Law, H., McCusker, R., & Bentall, R.P. (2013). Psychosocial and neuropsychiatric predictors of subjective recovery from psychosis. Psychiatry Research, 208, 203–209.

 

[7]           Psychiatric Genomics Consortium. (2013). Genetic relationship between five psychiatric disorders estimated from genome-wide SNPs. Nature Genetics, 984-994. Note that this finding, from analyzing DNA, is completely consistent with the results of population genetic studies such as Lichtenstein et al. (2009) ibid.

 

[8]           The International Schizophrenia Consortium. (2009). Common polygenic variation contributes to risk of schizophrenia and bipolar disorder. Nature, 460, 748-752.

 

[9]           Kendler, K.S. (2014). A joint history of the nature of genetic variation and the nature of schizophrenia. Molecular Psychiatry. doi:10.1038/mp.2014.94

 

[10]         For a recent review, see Bentall, R.P., de Sousa, P., Varese, F., Wickham, S., Sitko, K., Haarmans, M., & Read, J. (2015). From adversity to psychosis: Pathways and mechanisms from specific adversities to specific symptoms. Social Psychiatry and Psychiatric Epidemiology, 49, 1011-1022.

 

[11]         See, for example, Wicks, S., Hjern, A., & Daman, C. (2010). Social risk or genetic liability for psychosis? A study of children born in Sweden and reared by adoptive parents. American Journal of Psychiatry, 167, 1240-1246.

 

[12]         Vassos, E., Pedersen, C.B., Murray, R.M., Collier, D.A., & Lewis, C.M. (2012). Meta-analysis of the association of urbanicity with schizophrenia. Schizophrenia Bulletin, 38, 1118-1123.

 

[13]         Cantor-Graee, E., & Selten, J.P. (2005). Schizophrenia and migration: A meta-analysis and review. American Journal of Psychiatry, 163, 478-487.

 

[14]         Veling, W., Susser, E., van Os, J., Mackenbach, J.P., Selten, J.P., & Hoek, H.W. (2008). Ethnic density of neighborhoods and incidence of psychotic disorders among immigrants. American Journal of Psychiatry, 165, 66-73.

 

[15]         For a meta-analytic summary of the effects of childhood adversity (separation from parents, bullying, childhood abuse) see Varese, F., Smeets, F., Drukker, M., Lieverse, R., Lataster, T., Viechtbauer, W, Read, J, van Os, J. and Bentall, R.P. (2012). Childhood adversities increase the risk of psychosis: A meta-analysis of patient-control, prospective and cross-sectional cohort studies. Schizophrenia Bulletin, 38, 661-671. doi:10.1093/schbul/sbs050

 

[16]         Sheffield, J.M., Williams, L.F., Woodward, N.D., & Heckers, S. (2013). Reduced gray matter volume in psychotic disorder patients with a history of childhood sexual abuse. Schizophrenia Research, 143, 185-191.

 

[17]         Glaser, J.P., Van Os, J, Portegijs, P.J., & Myin-Germey, I. (2006). Childhood trauma and emotional reactivity to daily life stress in adult frequent attenders of general practitioners. Journal of Psychosomatic Research, 61, 229-236.

 

[18]         Meltzer, H., Bebbington, P., Brugha, T., Farrell, M., & Jenkins, R. (2013). The relationship between personal debt and specific common mental disorders. European Journal of Public Health, 23, 108-113.

 

[19]         Wade, T.J., & Pevalin, D.J. (2006). Marital transitions and mental health. Journal of Health and Social Behavior, 45, 155-170.

 

[20]         Stansfeld, S. & Candy, B. (2006). Psychosocial work environment and mental health: A meta-analytic review. Scandinavian Journal of Work, Environment & Health, 32, 443-462.

 

[21]         Barr, B., Taylor-Robinson, D., Scott-Samuel, A., & McKee, M. Suicides associated with the 2008-10 economic recession in England: Time trend analysis. British Medical Journal, 345, e5142. doi:10.1136/bmj.e5142

 

[22]         https://www.ted.com/talks/eleanor_longden_the_voices_in_my_head?language=en

 

[23]         See Chapter 1 of my book Doctoring the mind: Why psychiatric treatments fail (Penguin, 2009) for evidence on historical recovery rates for cancer and heart disease.

 

[24]         This was first pointed out by Richard Warner (1985) in his book Recovery from schizophrenia: Psychiatry and political economy. New York: Routledge & Kegan Paul. For a recent meta-analysis of the historical data, see Jääskeläinen, E., Juola, P., Hirvonen, N., McGrath, J.J., Saha, S., Isohanni, M., & Miettunen, J. (2013). A systematic review and meta-analysis of recovery in schizophrenia. Schizophrenia Bulletin, 39, 1296-1306. doi:10.1093/schbul/sbs130

 

[25]         Sartorius, N., Jablensky, A., Ernberg, G., Leff, J., Korten, A., & Gulibant, W. (1987). Course of schizophrenia in different countries: Some results of a WHO comparative 5-year follow-up study. In H. Hafner, W.G. Gattaz, & W. Janzarik (Eds.), Search for the causes of schizophrenia (Vol. 16, pp. 909-928). Berlin: Springer. See, for more recent data, Saha, S., Chant, D., Welham, J., & McGrath, J.A. (2007). A systematic review of the prevalence of schizophrenia. PLoS Medicine, 2. e141.

 

[26]         See, for example, Shah, A., Bhandarkar, R., & Bhatia, G. (2010). The relationship between general population suicide rates and mental health funding, service provision and national policy: A cross-national study. International Journal of Social Psychiatry, 56, 448-453; and also Rajkumar, A.P., Brinda, E.M., Duba, A.S., Thangadurai, P., & Jacob, K.S. (2013). National suicide rates and mental health system indicators: An eological study of 191 countries. International Journal of Law and Psychiatry, 36, 339-342.

 

[27]         See Read, J., Haslam, N., Sayce, L., & Davies, E. (2006). Prejudice and schizophrenia: A review of the ‘mental illness is an illness like any other’ approach. Acta Psychiatrica Scandinavica, 114, 303-318, and Angermeyer, M.C., Holzinger, A., Carta, M.G., & Schomerus, G. (2011). Biogenetic explanations and public acceptance of mental illness: systematic review of population studies. British Journal of Psychiatry, 199, 367-372.

 

[28]         van den Berg, A.E., Maas, J., Verheij, R.A., & Groenewegen, P.P. (2010). Green space as a buffer between stressful life events and health. Social Science and Medicine, 70, 1203-1210.

 

 

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113 comments on “All in the brain?

  1. This piece crystallises my own discomfort with the programme discussed and the others in the series so far. I don’t want to down play the importance of medication but the perspective offered thus far has been extremely narrow.

  2. I’m deeply impressed by and appreciative of Richard’s letter pulling so much research evidence together into a single succinct piece, that will stand as a valuable resource for many of us. I agree the makers of the TV programme showed little interest in the social or psychological causes of mental health problems, but they did show the importance of social and psychological support in recovery. The last person shown was a young woman who, having broken her back jumping out of a window in the deluded belief she could fly (no exploration of the circumstances that led to this), was shown with a small group of friends whose support enabled her to enjoy normal social activities.

  3. I question if Stephen Fry has in some way being used as a pawn in a wider BBC, media and government campaign around these issues? Let’s face it the BBC and what they broadcast is allegedly controlled and financed by ‘darker forces’ at work. Or does Mr Fry willingly choose to discount any past trauma etc? He is an intelligent guy and I find it hard to believe he hasn’t researched further causes of emotional distress. But really he only needs to look in his own backyard for the answers he seeks expects others to absorb via ‘his’ programs. Looking in to test tubes are unlikely to find these answers or remedies, as Richard Bentall eloquently states.

    1. I am so pleased to know Mental Health has now come to the be discussed more.
      My grandson needed help after cutting himself and having a terrible temper towards his mother who eventually sought help from a hospital that dealt with this sort of thing as he felt suicidal and theatened to carry out the act, but was ignored and sent to a type of refuge where his life became even worse , he did
      what he threatened after years of depresion leaving us so very sad.
      There are so many people who feel life is not worth living, and do need help
      and are being ignored.

    2. Good comment and superb observation/perception. There is no rush to reveal the truth so that people do not suffer – – – because someone powerful BENEFITS from the lie.

  4. I have sent this email to Richard Bentall

    Dear Professor Bentall

    Great letter, and important to have written it. However, please DO NOT assume all doctors work within such a biomedical framework. It is a pity that your letter strongly implies this.

    I am a partially retired community paediatrician. Also ex boarding school, with the added problem of having ADHD, unrecognised in the 60 s, and put through school with a peer group that was a year older, and experienced lots of bullying mainly from staff, but some pupils as well.

    I have no problem with recognising that genotype alters vulnerabilities to environmental triggers ( I have coeliac disease). I have no problem working with dimensional disorders such as autism and ADHD, or recognising that the children I saw in domestic abuse refuges or in the child protection service or the asylum population had a range of emotional and behavioural difficulties that merged into those discrete categories of disorder so beloved of psychiatrists. Child psychiatry HAS become more and more biomedical, partly a result of the dominance of molecular research in the past 25 years, but also a function of extreme staff shortages that forces practitioners to continually keep narrowing their service access criteria (I have witnessed a big cultural shift in child psychiatry during my working life in consequence). This has been to the detriment of hundreds of thousands of children, who will of course present to adult mental health services eventually, if they live that long. Community paediatrics have had to pick up many of these children denied CAMH services, without the training or experience.

    Conversely I have also had the experiences of child psychotherapists/clinical psychologists treating children for several years,failing to recognise that they had significant neurodevelopmental disorders such as autism or Tourette’s . That’s not good either.

    My problem with your letter is that it polarises the nurture/nature debate, which I think is extremely unhelpful. I also think that the debate itself is ridiculous and unneccessay. I have felt this for several years and am fed up it is not only continuing, but raging more strongly.

    The weight of evidence that has emerged from the life course sciences over the last 20 years or so, the increasing understanding of the impact of early life experiences on the way the brains develop, wire up and function, and our increasing understanding of epigentic mechanisms mean that we need to look at mental illness as a function of:

    1 our genes
    2 how the environment influences and sometimes limit how those genes are expressed
    3 how adverse environments in early years directly affects early brain development ( with lifelong consequences for structure and function)
    4 how psychologically adverse experiences later in childhood and adulthood interact with the first three

    Please let us stop this divisive approach. Neither a wholly biomedical or a wholly psychological one is THE answer. We need a merging of both approaches if we are best able to effectively help our patients, one that acknowledges the complexity of the real world. And that means nature, nature-nurture, and nurture need to feed into the assessment and care plan for every patient.
    Best wishes

    Elspeth Webb MSc, FRCP, FRCPCH, DCH, DTM&H, FHEA
    Honorary Professor of Child Health
    SOCSI
    Cardiff University.

    1. Dear Elspeth,

      Thank you for responding to my open letter.

      I am, of course aware, that many psychiatrists are as unhappy with the exclusively biomedical approach as many psychologists and service users, and hence I am sure that there is much that we can agree about. For example, like me you note that you have seen psychiatry shift towards the biomedical approach over the course of your career and, also like me, you attribute this partly to the dominance of molecular research but also to tightening resources. We can also agree that it is not good when psychologists fail to take into account neurodevelopmental difficulties when trying to help patients (although, of course, neurodevelopmental difficulties do not necessarily preclude psychological approaches being helpful).

      However, I cannot agree that my letter polarizes the nature/nurture debate. I made it clear that genetic research has an important place (actually citing important findings in the field) and acknowledged that individuals vary in their genetic vulnerability to severe mental illness (although not in the way that was anticipated when molecular research kicked off in the early 1980s). What I actually complained about was the extent to which neurobiological approaches have crowded out all other (potentially more useful, at least in the short to medium term) approaches to psychiatric research and care, and that social determinants of mental ill-health have been increasingly neglected by researchers, clinicians and the media.

      Sadly, the fact that someone like you can see this call for a rebalancing as divisive just illustrates how far the dominance of the biomedical approach reaches. Indeed, you say that you reject this approach but it is actually evident in your thinking when you say that:

      “we need to look at mental illness as a function of:

      1 our genes
      2 how the environment influences and sometimes limit how those genes are expressed
      3 how adverse environments in early years directly affects early brain development ( with lifelong consequences for structure and function)
      4 how psychologically adverse experiences later in childhood and adulthood interact with the first three”

      This list plays lip-service to environmental influences but only in as much as they affect genes and brain development. You make no mention of cognitive and emotional development (which are not the same as brain development, even though they are instantiated in the brain) or the kinds of psychological processes (self-esteem and related mechanisms; ruminative and other response styles; cognitive styles; emotional regulation; emotion-related memory biases; executive and self-regulatory processes) which have been shown to be crucial in psychiatric disorders, and which can be targeted by evidence-based psychological therapies which are at least as effective as pharmacotherapies in most circumstances.

      I think this just illustrates how far psychology (in the broadest sense of the term) has dropped off the map of psychiatry.

      Sincerely

      Richard

      1. I worked closely with my late friend Dick Warner, and his views about the social issues related to the causes, courses and outcomes of mental health problems, were the latest in a long tradition of evidence about the social dimensions of illness. These dimensions apply equally to physical illnesses, see the work of Querido in the late fifties. While Richard B is quite right to say that psychological approaches are as effective as medication what he fails to say is that the focus of psychological therapies remains mainly on symptom relief. Some psychiatrists and psychologists seem to believe that relief promotes recovery and while this is the case for some people, the environment, as one blogger put it, still ‘sucks’. The major service changes in the post war years have seen the social components of care and treatment privatised, contracted out and in a positive sense allowed service user groups to fill that void. This is true in the west, in the USA UK and Australia. However, as Dick also pointed out the response to illness by families and societies is culturally different. The QOL work we did showed the very different familial and societal responses of families in Italy and Colorado to the same illness in a family member. In the UK at least we have been trying to ‘integrate’ services that have been.rent apart by rampant managerialism in the public sector. As a consequence social workers mental health training varies from the weak to the nonexistent and their presence in community mental health teams likewise. My other friend and colleague of nearly 50 years, Sir David Goldberg once told me that he wished the RCP had taken a stronger stand against the 1970s Seebohm generic reform of local authority social services. Me too. As l say the very fortunate unintended consequence of all this is that recovery has been placed more firmly in the hands of those who know best what their environment has done and is still doing to them.

        1. Hi Peter,

          Its great to hear from you. Although it was a bit of a shock because I did not know, until I read your post, that Richard Warner was no longer with us. He was a really nice man, and his book, Recovery from Schizophrenia: Psychiatry and political economy (1985), was absolutely groundbreaking. He was the first person to point out that the introduction of antipsychotics had not brought about an improvement in recovery rates, an observation that some people still regard as contentious but which is supported by a recent meta-analysis cited at the end of my letter to Stephen Fry.

          In early editions of his book, Richard mooted the idea that some patients did better without antipsychotics but he later backed off from this position. When I asked him why a few years ago, he did not give me much in the way of a clear answer. However, I note that he argued vigorously against the wisdom of early intervention in psychosis, arguing that there was no case for giving medication to people in the at-risk group.

          On your main point, I absolutely agree that psychotherapy isn’t a panacea and that its not likely to be helpful (or its likely to be only amerliorative) if the environment sucks. This problem applies not only to the severe psychiatric disorders but also to the common ones which you have studied so well. Its understandable that GPs reach for the prescription pad, but many of the people who visit them are, of course, suffering from problems like debt, unhappy marriages and unsatisfactory relationships, and it is only by addressing these (not easy of course) that they can live happier lives.

          1. Thanks for your response Richard. A memorial conference is being planned for Dick. I am not sure where it is up to, I will have to check with Lucy Warner. Alan Rosen and Jim Mandiburg are involved. I am sure that Dick would appreciate input from you. I will keep you informed.
            When I heard Dick was having hospice at home (most common in the USA, I had no idea) I went to see him and we spent 3 days together and he passed away the day after I left. I will always be grateful to my wife Sherrill who ‘insisted’ I went to see him. And to top it all, the Broncos won the superbowl!!
            Best wishes
            Peter

    2. I agree that mental illness is a result of previous social problems, I always said so when Drs tried to give me meds whilst bringing up my three children on bennifits, and was highly aware of the deprevation issue. However social inequality and poverty has just continued, and become dreadful under this government, and lack of therapies other than drugs. I recently asked for therapy, but here in rural Wales there isn’t any. I suffered a lot bringing up my children singlehandedly, especially from poverty and social isolation. Bu the time I reached 40, I broke down, and my GP put me on a tricyclic anti depressant for circumstantion depression, they helped a bit. Then a friend went on prosac, and the change (for the better) in her prompted me to ask my GP if I could go on them. I was given them without any problem. Couldn’t stay on prosac because it made me feel homocidal. I was then given efexor, an evil drug, which I reckon gave me brain damage, but GP wouldn’t listen, so I stopped it, and went into a catatonic state until mt daughter called out the psychiatriac team and the Dr perusaded me to go back on drugs, cipramill 40mg. I have been on these since 1999. I have tried again and again to come off them, both cold turkey and tapering. Both ways don’t work. The withdrawal symptoms are so severe that I am unable to stop this drug. And there is no help to come off, unlike alcoholics. I am currently in the phase of increasing my dose from 10mgs (the lowest I managed this time round) on to 20mgs and may well have to go back up to 40mgs. The symptoms are awfull, like full blown flu and sinusitis, that’s after you get over the brain zaps etc. I hate being on these drugs, but I am unable to come off. That is the worst of it. There must be thousands of people out there stuck on these nasty drugs (which are touted as non adicted). I am so angry, and at present so frustrated at being so ill for so long, that I am even thinking of ways to kill myself. I blame the drugs companies, and GPs for my pridicament. There has never been any good quality trerapy, and social problems are NEVER addressed. It IS the social, environmental things that start the problems, but I can’t see things changing in this political climate. I am glad I am 65 now and nearer death, I can’t stand living in this evil world much longer, and feel sorry for the babies being borne. I am glad that you pointed out the social and childhood experiences as a contributing factor, and not just the same old chemical imballance excuse. Thank you.

      1. Dear Pauline,

        I’m so very sorry to hear your story, and the dreadful time that you have been having with medication. From your account (obviously I don’t know your circumstances in any detail) your difficulties seem to relate to living in isolation, with very little money and all the stresses associated with being a single mother. Perhaps it is not surprising that, under these circumstances, the best that might be hoped for is that drugs would have ameliorated your stress a little, but it does not seem that they have even done that. Indeed, your account illustrates some of the positive aspects of drug treatment – you say that Prozac helped your friend – but also the negative ones which, in your case seem to have far outweighed any benefits.

        Recent evidence from clinical trials shows that the response to any psychiatric drug is highly unpredicatable. In the case of antipsychotics, for example, about a quarter of patients seem to get very dramatic benefits and the rest seem to get just modest or no benefits at all. The evidence is similar in the case of antidepressants. Against these gains experienced by perhaps a minority, there are side effects which, in some cases, are very serious. Hence, when the benefits and costs are weighed, some patients are definitely harmed by psychiatric drugs, a fact that many doctors are reluctant to acknowledge but which, it seems to me, is the only reasonable interpretation of the existing evidence.

        That drugs sometimes cause harm would not be a problem if (a) clinicians were willing to acknowledge that this is the case; (b) they were willing to carefully monitor patients on a ‘suck it and see’ basis and then withdraw them from drugs when harms outweigh benefits; and (c) there was reasonable provision of alternatives such as psychotherapy, practical help to deal with the sources of stress, or even plain social support. This is hardly rocket science. However, these conditions do not exist in most services, so that patients are continually encouraged to take medication even when it is not helpful and no other forms of help are provided. From what you say, it seems that this is the situation in rural Wales, but it is also true of many services in urban areas. Surely, anyone with any common sense can see that this should not be acceptable?

        It makes me sad to say that I am not sure whether there are many words of comfort I can offer you. You say that you cannot face the world much longer and that you are glad you are old enough to be near death but, if you are not yet 65, you should have a good many years ahead of you, and you have a right to enjoy those years in peace and dignity. If services are so useless in your area, I wonder whether there is any other form of support you can reach out to? I don’t know your area but, if you email my university address (just look me up at Liverpool University) I’ll see if there is anyone close to you who might have some suggestions.

        In the meantime, take care.

        Richard

    3. I have to agree with Dr Webb.

      The conditions in question are all very complex and after many years of observation, I have come to believe that they result from a combination of genetics, environment and circumstances. in each case some or all of these will have been a contributory factor.

      Certainly, traumatic experiences play a part, but I see that not as a cause, but as a catalyst or trigger that needs the genetic vulnerability to result in bipolar, BPD, schizophrenia, etc. Then there is the strong suspicion that environmental factors can also affect the outcome – be it chemical, hormonal or even infectious agents like T. Gondii.

      We need to look at ALL of these and at each individual case as presented.

      1. Dear LukeJohn,

        I do not think that anyone is disagreeing with the proposition that both genes and environment contribute to mental illness. Certainly I am not. However, your prioritizing of genes as a causal vulnerability factor, whilst traumatic experiences play a part “not as a cause, but as a catalyst or trigger” is an assumption rather than empirically tested model, and begs the question of what counts as a cause.

        In fact, there has been a lot of discussion about the problem of inferring causation in both the medical and philosophical literature. Although there is not universal agreement, most people in medicine would accept a set of nine criteria proposed by the great British epidemiologist Austin Bradford Hill (1897-1991), which can be found at: https://en.wikipedia.org/wiki/Bradford_Hill_criteria.

        Hill proposed these criteria when faced with a sceptical medical profession which was reluctant to accept his discovery of a link between smoking and lung cancer (surprisingly, you might think, the idea that they were linked seemed proposterous to many doctors at that time, just as today many doctors are reluctant to accept that life adversity might cause mental ill-health). The criteria include, for example, that the association must be strong and consistent and that there must be a dose response effect (the more cigarettes smoked, the higher the risk of lung cancer, for example).

        Judged by Hills’ criteria, the case for believing that childhood trauma and other social factors play a causal role in mental illness is very strong indeed. Indeed, it is interesting to compare the evidence for these factors against the evidence for genes. As noted in my letter to Stephen Fry, the latest molecular evidence suggests that genetic risk is continuously distributed in the population, with many genes each having a tiny effect, and everyone carrying some degree of genetic risk. The highest risk associated with any particular genetic common variant can be expressed as an odds ratio (OR) of about 1.1. In my meta-analysis of studies of childhood trauma and psychosis (Varese et al 2012, cited in the letter to Fry), the OR for any single trauma was about 3, and there was a dose response relationship so that people with a history of multiple traumas had a much higher risk. In fact, the ORs and dose-response relationships were not dramatically different from those reported in the case of cigarettes and lung cancer so, if you are prepared to accept that smoking causes diseases of the lungs you should also be prepared to accept that the maltreatment of children causes mental illness.

        But in a way, perhaps it does not matter whether you say that life stress is a cause or a trigger. We cannot change people’s genes, but if we are smart, we should be able to find ways of protecting chhildren from bad experiences and everyone from all the other influences that you want to call triggers. So if you want to make the world mentally healthier, don’t look in the test tube. Look around you.

        Richard

        1. Dr Bentall,

          Thank you for the detailed and thoughtful reply. I agree that my observations are not entirely clinical, but when it comes to conditions that involve so many, diverse factors, it is hard to imagine almost any study providing clear, verifiable results. As you note yourself, medications can result in a wide range of results, from significant improvement to almost no effect, to exacerbation of the condition.

          In support of your position that we should not underestimate external factors, I find the article at the link below very interesting:
          http://www.madinamerica.com/2013/08/societies-little-coercion-little-mental-illness/

    4. Although I couldn’t have survived this long without understanding as much of the medical data as possible (my American “private school” final paper in high school Chemistry, ’69, was on the potential for the transfer of knowledge through the transfer of r-RNA) I of course am and must write as a lay person. I like this article, although of course I do unyieldingly think of getting better in the terms of a “patient” as I am one. My psychological history has allowed me to understand both the genetic and contextual aspects of mental illness. I’ve had 3 major breakdowns. After the first two, I was young or lucky enough to be in circumstances that enabled me to withdraw from society completely for about 2-3 months (including psych wards, although both times I benefited from talk therapy and the second was on quite vigilant suicide watch by close friends). Both times I recovered in the “patient’s” sense of the term for decades (I’m 64). When the 3rd struck, I had responsibilities that necessitated that I keep going and was so I was medicated for the first time. That was over 20 years ago, and I’ve never really recovered. In fact, early on the ironically even greater stress caused by symptoms being alleviated just enough to allow me to (happily, desirously) take on greater responsibilities ~ combined with what I found to be the often highly distorting effect of both benziods but also, more insidiously, “everyday anti-depressant” psychotropics ~ finally lead to the need for electro-convulsive shock treatments 16 years ago. So please excuse my grammar, even for an American, as I was one of the apparently very few who suffer brain damage from this first-line treatment (diagnosed by 2 neurologists, over 4 years apart, administering the standard battery of tests over two days with consistent results). As suggested by one of the neurologists, I’m on what’s loosely referred to as the “autism regime” of B12, Folate and D vitamins, and as also suggested by the same neurologist and my psychiatrist (yes, talk therapy) I do Yoga Therapy almost daily. But I’m extremely lucky to be able to do so! Indeed, the contextual aspect twice provided me with the best route to health and it seems that it may again. What we patients know so well from experience and therefore worry about so much is that even the “educated” population in general takes it to mean that the illness isn’t, like diabetes or cancer, “real” and that with enough willpower it can be snapped out of. And there’s the rub, because it is and it can’t. Thank heavens, Dr. Bentall really seems to get it. I use this analogy with temerity, but here in America we’re having a more~than~rhetorical war over the slogans “Black Lives Matter” versus “All Lives Matter”. Although “in my day” we knew that human rights was something we for which were all it together and “All Lives Matter” would have made the point most saliently, these days the (to me somewhat divisive) statement “Black Lives Matter” is what must be understood and the former would be divisive, given not the larger truth but hopefully as this era’s route to it. In the same way, I see Dr. Bentall as presenting not so much a divisive picture as a bigger one (“All Lives Matter”) which would be so much more difficult if not impossible to achieve and which, as I said, even the educated public rather blithely (and conveniently?) misunderstands. This picture thus elicits an overpowering visceral reaction is almost impossible to overcome, given the stakes. However, contextual withdrawal with limited periods of talk therapy and suicide watch allowed long and strong recoveries for me, and I’m seeking one again, with Yoga Therapy (a specific regime) as the first step ~ except of course for those (for me) rare times when death appears the better alternative. (Experience tells me to state clearly that my mention of suicide is part of a realistic discussion, not a cry for help. I’m well seen-to.) Thank you.

    5. Dear Elizabeth,

      I am submitting an essay for an MA Course in Mental Health and would like permission to use your comments in relation to Bentall’s letter. I agree that we need a united and holistic approach if services are to benefit from the services available. If you could email me I would very much appreciate your reply.

      Best Wishes,

      Vanessa McKnight

  5. John Yerbury Dent 1888-1962 was a successful physician who throughout his career warned against the ‘medicalisation of misery’. He did employ a bio medical route to recovery but emphasised the crucial importance that these interventions HAD to be short. Sadly this lesson has been lost and we have disappeared into the culture of dependence on pharmacology which, for obvious reasons, hasn’t wanted to disprove us of our illusory faith. I am surprised that FRY hasn’t clocked this.

  6. Professor Bentall is a very important figure in destigmatizing western mental health. I try to learn from him as much as I can.

  7. what works for one may not work for another,if it works for you,keep doing it if not try something else ……simple`s (as in go compare)

    1. But if you are not offered alternatives (usually no mentioning any other possibilities at all) how do you know what to look for? It’s like: “drowning is a problem of a person himself”. If you are new to psychiatry – you trust psychiatrist’s own (!) opinion and only later ( years passing by) and realizing you are not getting better – then you start to look for other ways…

  8. I found watching the programme excruciating. Once again mental health difficulties were depicted as life-long medical ‘illnesses’ to be treated with life-long medication with life-long dependence on psychiatry with its archaic premise of ‘chemical imbalances’ and irreversible genetic brain malfunction. It painted a hopeless picture that I am very familiar with and I speak now from personal experience. 27 years in the psychiatric system, three and a half years on psychiatric wards and not one psychiatrist/mental health professional ever bothered to ask what happened to me before my first episode at 31 and how that has been affecting me since. Apparently I was born mad and my ‘illness’ would manifest itself eventually.

    4 years ago I discovered and studied the work and also been privy to the lectures of Professor Richard Bentall and it has literally changed my life. Also many other pioneers such as Peter Kinderman, John Read, David Pilgrim, Judith Herman, Jacqui Dillon, Joanna Moncrieff, Philip Thomas, Robert Whitaker, Jaakko Sekkula and many more. And historically: Loren Mosher, R.D. Laing, Erving Goffman, Michel Foucault, Thomas Szasz.

    Please read those books Stephen. You are one of the most brilliant human beings in the world and like me have been inveigled into trusting psychiatry (a ‘Royal’ College’ no less) to find the solution for us. Then being bamboozled by snake-oil salesmen into medical/pharmaceutical hell.

    1. Hi Derry,

      Thanks for posting this. Your personal experience illustrates all too well that the things that mental health services try to do to help so often have the opposite effect. If we all push together – experts by experience, professionals and researchers – perhaps we can move things in a more humane direction. But there are a lot of forces pushing in the opposite direction so its going to be very hard work.

      Richard

      Richard
      Richard

  9. Excellent letter. Thank you Richard.

    Lots of well meaning people seem to think it is very important to talk-up the biological aspects of mental illness, or indeed, talk only about those aspects. The common comparison when talking about the stigma of mental health problems is to say ‘Would you talk like that about diabetes? No? Well mental illness is just the same — a biological illness.’

    There seems to be a disturbing assumption in this that only illnesses with a biological basis are worthy of our sympathy. It is as if people with a psychological or experience-derived mental health problem (which of course in turn shapes out neurology, but let’s leave that aside for now) are not worthy of attention, or worse, are not “really ill.” Such people, by implication, are simply weak, or too lazy to just work their problems out and get on with things.

    But of course, people with psychological, reactive, experience-driven mental illnesses are *just as worthy of our compassion* as those whose difficulties have a purely biological origin. If our society could accept that, then I think we would have overcome a major hurdle in de-stigmatising mental health problems.

    Stephen Fry seems to have fallen into the trap of seeing psychologically-based illness as weakness, or at very least as ‘less worthy’. One can speculate as to why, but I think some clues are in his famous (commendably frank and stigma-busting) remarks to Richard Herring in 2013 about a recent suicide attempt, and in particular, people asking him why he would “be so stupid” to want to do such a thing:

    “That’s the point. There is no why, it’s not the right question. There’s no ‘reason’. If there were a reason for it, you could ‘reason’ someone out of it, and you could tell them ‘why’ they shouldn’t take their own life.”

    Here, he surely knowingly confuses two different meanings of the word “reason”: ‘If there were a reason [cause] you could reason [argue with logic] someone out of it.’

    Aside from the obvious question of “How do you *know* there isn’t a complicated psychological reason you haven’t fully explored yet?” Stephen seems to be fearful of the notion that to succumb to mental illness that has a non-biological ’cause’ (e.g. to feel bad because of a poor acting review) is to suffer a failure of possibly his most well-celebrated characteristic, namely his cleverness, rationality, or ‘reason’. If hanging on to the the notion that he is clever is the most important part of his self-worth, that might requires therefore denying that experiential causes of mental illness exist, or at least that a person succumbing to these causes is something of an intellectual failure, and so not worthy of our compassion.

    Ironically, this seems to be a perfect example of how an emotion (fear of losing identity, of being seen as ‘stupid’ when one’s reputation rests on being seen as ‘clever’) can completely over-rule intellect, even in the cleverest people. Perhaps especially in the cleverest.

    This seems to be the curse of the self-esteem see-saw (super-self-worth one minute, crushing self-hate the next). Letting this kind of self-judgment go, and indeed letting our judgment of others go, is, I think, crucial in reducing societal stigma of mental illness, and in being able to treat ourselves and each other with compassion, whatever our faults.

    Stephen Fry is already well-loved, for many good reasons. Not least, I think, because we can sense the scared and fallible human being behind the big brainy exterior. I can’t help but imagine he would be held in even greater affection and regard if he took the brave step of shining a light on the part of mental ill-health that comes unquestionably from the sometimes horrid bits of life that fuck up our minds and brains. That is to say, the experiential and psychological causes you document so well in your letter. Because of course, we are not truly loved on the basis of how strong, impressive or clever we are, but on how real, honest and kind we are, in all our lovable weakness. Sometimes our emotions get in the way of us remembering that.

  10. You know what they say about Steven? He’s the stupid man’s idea of what an intelligent man is.

    Excellent reply by the Professor. In my own experience depression is caused because life sucks. The best cure (and the same for repeat offenders) is to get out of the sucky environment. In my case I moved to China, have a great standard of living, work only a few hours a day and haven’t had a second of depression.

    1. Well said. I have heard said that migration is a better solution than suicide. It worked for me too!
      I “ran away from home” at the age of 46, after my ex remarried and our children had reached their twenties, because to stay would have been psychological hell (I also had a MOTHER…). In my case it was Australia to the UK. Mother England was very good to me. Got a Doctorate in Clinical Psychology at Canterbury Christ Church University. Came to feel good about myself living in England’s green and pleasant land. Now retired back to Australia and have the strength to meet family and other societal challenges (plus some of the main offenders in my family have mercifully passed on). But I shall keep in mind China as an option as I always believe in having a “get out” clause when life gets unbearable. As for pills, I believe they have their place in mental illness but are monstrously over prescribed. Vested interests as others have suggested? Afraid so Stephen Fry.

  11. Hello everyone and brilliant letter Richard, thank you so much for writing it.

    I have huge respect for Stephen and others who are trying to reduce stigma and discrimination, especially those who like both him and Richard are prepared to be open about their own experiences. But as I have argued in earlier posts on this site (https://blogs.canterbury.ac.uk/discursive/when-the-ads-dont-work/ and https://blogs.canterbury.ac.uk/discursive/im-sicker-than-i-thought-i-was/) I worry that despite people’s best intentions, promoting an ‘illness like any other’ approach, as the BBC is currently doing, ironically risks making things worse.

    I’d just like to draw people’s attention to the Only Us Campaign – if you haven’t come across it, it’s an inspired (in my view) campaign to reduce discrimination and stigma in the ways that Richard suggests. Brainchild of Mirabai Swingler, an NHS Chaplain, the idea is to get us all starting conversations about mental health by wearing a badge showing a smiley face but also with a tear. The campaign (https://twitter.com/OnlyUsCampaign) describes its aims in this way:

    “There’s ‘Them’ and there’s ‘Us’. We are well, happy and safe. They are mentally ill and dangerous.
    Is this really true? Or is the uncomfortable truth that there’s a continuum, a scale along which we all slide back and forth during our lives, sometimes happy, occasionally depressed or very anxious; mostly well balanced but with moody moments; usually in touch with reality, but at times detached or even psychotic. When we separate ourselves and imagine humanity divided into two different groups, we hurt those labelled as sick, even mad. We allow stigma, prejudice and exclusion to ruin potentially good and creative lives. But we also hurt ourselves, because we stress ourselves out with false smiles and the suppression of our own vulnerabilities. There is no them and us. THERE’S ONLY US.”

    1. This is a great campaign, but the government and its mental “health” workers will use the campaign promote their ‘focussing on what people can do agenda’ which has already caused massive suffering. For example, Alistair Campbell worked hard to privatise welfare. I can see Lord David Freud saying, backing this too.

  12. I am fortunate (and I use the word advisedly) to have a GP who understands my Bipolar condition. I was also able to participate in the NHS pilot Recovery programme where ,as is suggested by Prof Bentall, the differences in the depth and width of the condition make a common treatment somewhat difficult. I am not ashamed or frightened of my illness any more, and working with some people who have been in the world of mental health has taught me a lot and given me some limited patience and enables me where to find my true treasures and pleasures in life. I know I am prone to becoming very tetchy when ill, particularly when stress breaks out, but I always try to catch it before it takes me over and if I do ‘relapse’ I know I will be well again very shortly to resume life where I left off, intelligent, able and capable of dealing with things that most of society (apart from us select few) know very little about and thus frightened of.

    I firmly believe that anybody, be they living with schizophrenia, manic depression or whatever, can offer a huge amount to an employer and to the community. After all, we’ve tried to come face to face with ourselves, tried to overcome adversity through sheer stubborn strength of character and very often have great insight, especially with regards to social values art and music. You learn the value of true friends.
    Sadly we also learn who and how many our enemies are!

  13. Well written indeed and the emphasis on the exclusive bio-medical approach in the Stephen Fry programme was particularly well noted. Having said that the writer runs the risk of falling into the trap of the false splitting of biogenetics v environmental factors regarding production of subjectivity and symptom/sinthome. The danger of reading childhood poverty and misfortune as high risk factors in producing psychiatric disorders e.g. seems to me to over emphasise the object (misery as objective) and underplays the role of the subject of fantasy and of symbolic inscription. In seminar II e.g. in chapter Play of Writing,(1953) Lacan shifts the emphasis of the Freudian psychic apparatus from object of perception to symbol. Much as Richard Bentall does in his letter to Stephen, Lacan, the analyst critiques the psychiatric biomedical model.
    Lacan introduces the difference between object and symbol as being crucial in emergence of subjectivity. This allows a shift, a liberation (parole) from the pathological object in it’s formulations, both as biomedical knowledge function and as sociological, environmental cause. The title of the chapter Play of Writing brings to mind Stephen’s paricular enjoyment of language.

  14. Excellent article which I can vouch for. I recovered from a terrifying periodf 15 years ago having had help from a former NHS consultant psychiatrist who had left the system because he could see it was containing rather than curing patients. Thank goodness for people like him…..and you.

  15. Thank you for publishing this enormously erudite, balanced and compassionate letter. As someone who was given a bipolar diagnosis as a young woman, I have been very perturbed by the one-sided view of mental illness thus far portrayed in the BBC’s #InTheMind series and in the Stephen Fry programme, in particular. As the President of Mind, Stephen would do well to offer service-users alternative views.

    I remember very well the day that I received my diagnosis. I was told that I had a lifelong illness and that I would always need medication. During one particularly tough period of rapid-cycling, I was told that I could forget about living a normal life again. These dire predictions only served to create more inner storms and the onset of a long period of suicidality, as I grappled with the enormity of what I had been told by the very biologically oriented psychiatrist I had been seeing at the time. I spent the best part of five years in and out of hospitals, and at one point, could see no hope at all. I made a decision not to have children as it seemed too much of a risk. ( I was told that I would not be able to take lithium while pregnant and that my only option would be ECT if I became unwell). Since I had already been given ECT (without my consent), I decided that I didn’t wish to take this risk. My marriage broke down and I had little option but to try to begin life again.

    Not one of the dire predictions came true. I have now enjoyed 25 years of recovery and have not seen a psychiatrist in this time. Since my last hospitalisation, I have completed four university degrees and now work as a professional person. Medication was very useful to me on my journey to recovery – and I honestly believe that I would be dead now, if I hadn’t made use of it. At times, the feelings and experiences were too overwhelming to manage alone, and I am grateful to those psychiatrists – and one in particular – who encouraged a bigger view and believed in my potential as an individual. Psychotherapy was enormously helpful in assisting me to understand myself, the impact of my background and the triggers for the mood swings. Learning to live more gently and not pushing myself too hard was a vital part of the healing process.

    I believe it is wrong, utterly wrong, to convey messages of hopeless to service-users, whether by means of professional practice or through the medium of broadcasting. Humans are vastly complicated and there is much that remains to be understood about mental illness. Healing is found in many different ways, with medication being only one of a possible range of responses. Richard Bentall, I salute you.

    1. Thnks for the inspiring story, Fay. I hope people who are currently suffering from mental health difficulties get to read it and see that the future is not bleak.

      It always amazes me that doctors don’t realise how damaging the ‘lifelong illness’ story is. I can remember watching patients visibly shrink when told that they should accept that they will always be ill. There is actually research that shows that the more that patients with psychosis accept that they have ‘schizophrenia’, the more at risk they are of depression and suicide. Tell someone that they’ve got a lifelong brain disease and that they’ll always struggle to have a normal life, and, of course they loose hope. And, as you’re story illustrates, its not even true. Its not rocket science.

    2. Well written Fay! I am going to rad Your blogg. I have also, more or less, “recoverd” from the disease, but still I think this is a life-long disease, because I know quit well that if I am not taking particulary precoursions, I will get ill again. I think that pasients should know that bipolarity, is lifelong, so they can take their precorsions; but this does, of course not, mean that they are in a hoopless condition. This is rather a question of telling People in the right way, of how they actually can menage to live a good life, in spit of what probably IS a life-long condition; unless you take Your precoursions.

  16. Thank you, Richard. I’ve written a number of blogs on this site about my ‘bipolar’ experiences and my recovery, for those who are interested. You’ll find me listed under ‘authors’.

  17. There’s a road back, from everywhere you go.
    If you lose your way, with perhaps a little help from another,
    You’ll find an inner map, one which eludes most who seldom know loss.
    When you find the courage to read that map,
    You’ll discover a life less travelled, but one you never knew possible,
    Full of joy and loving kindness for yourself,
    And all living things.

  18. Although over-classification of mental health problems may be unhelpful, a complete lack of system in analysing them is at least as dangerous. Think of the indiscriminate way in which people were consigned to asylums, as little as (or perhaps even less than) a century ago, sometimes for life, without any proper diagnosis of specific illness or discrimination in treatment.

    But having been diagnosed with one specific disorder may let the sufferer, and those closest to (and often most closely affected by) him, blame all his difficult behaviour on that one disorder, rather than being open to the possibility that the sufferer may be affected by several different mental health problems. Acknowledging the one diagnosed disorder – perhaps reluctantly, given the stigma still attached to any mental ill-health diagnosis – may make the sufferer actively defensive about the possibility of being affected by other disorders, with potentially awful consequences for his immediate family.

    I speak as one very closely related to someone who first suffered in his very early 20s from what, during a further episode nearly 20 years later, was finally acknowledged to be bipolar disorder. Yet his behaviour since has increasingly been characterised by a terrifyingly violent temper and almost every symptom of narcissistic personality disorder – problems which neither he nor those still closest to him can bring themselves to acknowledge or help him to find treatment for. The results included a broken family, the near-suicide of at least one of his ‘victims’ and disinheritance of the victim by a mother so terrified of her own son’s temper that she dared not stand up to and thereby risk any chance (however remote) being similarly ill-treated by him.

    Nowadays, as in the past, the truth can set people free from the consequences of hiding and denying mental illness. We just have to find the strength to open the door in the wall of silence that is too easily allowed to build up and imprison people in a wretched psychological environment.

  19. I love this letter. Nearly 9 years after i finally left inpatient psychiatric care it makes a but more sense in light of Richard Bentall’s comments. I have a theory though, that some patients (myself at the time included) find comfort in the concept of their suffering being of a genetic/biological cause with a discrete diagnosis. Where mental illness came with huge shame, guilt and low self worth, a diagnosis and biological explanation helped me to feel less worthless for failing to function and for being a burden on others. It helped me to understand the acute and excruciating pain that i couldnt find a cause for. It has taken all this time to realise that this medical view, whilst preserving my self esteem somewhat, probably delayed my recovery significantly.

    1. Yes, Liz I agree with your thoughts on the biological/genetic labelling sometimes being helpful. It gives a cause especially when I just don’t want to discuss reasons with people, it provides a crutch when one is needed, and somewhere to hide when I can’t face the hard work of pulling out the threads of emotional causation.
      Following the various programmes about mental illness, one drawback is that in some cases a little knowledge can be a bad thing. Some people become ‘experts’ in the latest TV illness and look for guinea pigs on which to practice their new theories. Friends have argued with each other and with me over aspects of my wellbeing and treatment. I am assumed to be “Like Stephen Fry.” It is considered ok to tell me whether or not I should take medication, and “Does Stephen take it?” I haven’t seen the programme yet, I will over the next few days, when I feel like it. If I watch it when I am in the wrong place, it may affect me in an unhelpful way.

      So, yes, it can help to think that this is all genetic, or caused by a bump on the head when I was ten. However, the most important thing to me is getting on with my life in a better way. Whilst it is interesting to debate the research, my personal development is not dependent on or affected by the content of a celebrity TV documentary or its associated critiques.

  20. Thank you Richard for a well-needed, overdue balanced protest.

    In addition to the “myriad of adult adversities that also contribute to mental ill health” and “miserable relationships with other people, conducted in miserable circumstances”, I would like to suggest that a quote from Jimmy Reid’s Glasgow address from 1972 still provides relevancy today “Society and its prevailing sense of values leads to another form of alienation. It alienates some from humanity. It partially de-humanises some people, makes them insensitive, ruthless in their handling of fellow human beings, self-centred and grasping. The irony is, they are often considered normal and well-adjusted. It is my sincere contention that anyone who can be totally adjusted to our society is in greater need of psychiatric analysis and treatment than anyone else.” (http://bfanon.blogspot.co.uk/2011/09/jimmy-reids-glasgow-address-still.html)

    I willingly admit to amateur, very subjective views on mental health for which I stand to be corrected but I basically have faith in the good of most of humanity, most of us being born physically and mentally healthy. It is this good and honest care for our fellow humans which is “knocked” out of us resulting in a huge disconnect between what we do on a day to day basis and that which we know to be right and just. Somewhere in that disconnected void is where we experience the pain of trying to/having to reconcile our daily lives, actions and beliefs (c.f. the example of every baby being born an atheist) as we enter Adam Curtis’ The Trap.

    There is no money to be made in honestly addressing the true causes of much mental “illness” as it requires time, effort, care and humanity – qualities which are being increasingly devalued.

  21. Firstly, for context, I haven’t watched the programme, perhaps I will tomorrow, for its perspective.

    That said, I found Prof Bentall’s letter clear and positive, and it prompted a response, for which thanks for the space to write.

    There seem to be three issues:
    1: There is comment on the existence of a noticed proportion of the medical profession and society [which can include policy makers, patients, their families and friends], who see mental health issues as conditions that are to be pharmacologically managed. Prof Bentall doesn’t try to establish that percentage. He doesn’t need to. The relevance is that it exists, and contrasts with a counter view of mental health.

    2: There isn’t a clearly established, shared model of the illness shaping factors that is sufficient. For example, much as genes and environment have been noted, it would be better to distinguish environment as physical and social. It would also be better to distinguish not just genes as part of the individual, but also aspects such as postural patterns, emotional patterns, and perceptual filters [how people sense the world]. ie: a systemic approach that will also include a factor of here/now context [existing state and current environment that may contribute to a heightened vulnerability to triggers – I’m not a clinician so my apologies for not using your language exactly].

    3: The description of routes to positive outcomes other than via pharmacology seem less clear, perhaps because the choice of intervention is less clear rather than the interventions themselves. This is related to the ‘fuzzy edges’ where the boundaries of illness are not clear cut, and probably that the range of possible interventions is greater.

    Of these three the first is the most critical, because the beliefs and perceptual filters of a practitioner, person who is ill and society affect their stance and the approach they take. Without a shift here, as is expressed in many of the comments, then any different model of factors, or the range of routes is likely to fall on stony ground. This is true regardless of what camp you sit in – those who have the defined, clear, pharma or gene model and those whose models are more multifactorial and fuzzy-edged.

    That means that mutual understanding, or in the case of most on this post, developing an understanding of those who believe mental conditions are to be managed/are ‘incurable’ is paramount.

    Any understanding of peoples’ worlds must be elicited from a neutral standpoint. Anyone with an opposing view, or vested interest, will either be distrusted, antagonise or be liable to bias. The aim is to elicit someone’s truth. The interviewer’s truth, with regard to mental health, is wholly irrelevant.

    It could be that those who hold a pharma or gene model of mental health experience the world in black and white, not grey, and are more quantitative than qualitative. They may also be more internally oriented than externally. Modelling those who ‘excel in’ or exemplify their model can be compared to the equivalent in the alternate fuzzy-edged, multifactorial model.

    Such insight can then be used as a focus for discussion, along with other data, to open out the topic. Regardless of which, if any, model a participant holds such a discussion can be tough, as it is openly about looking at the problem from multiple perspectives, but that’s then a question of the quality of the facilitator.

    The aim of such a discussion is to identify a better systemic model of mental health, and the deduced treatment routes without accusation or blame. Because, when it comes down to it, I am sure most professionals have the individual’s well-being at heart. Antagonism and blame just polarise those involved, which critically means leaving a proportion of people [particularly patients and their families] stuck, in neither group, confused, feeling forgotten…or worse still feeling argued around or over in a no win situation.

    But hey, for those in psychology you’ll know this already…and as none of you know me [I suspect] then this has just been some trivial and obvious post, and the issues will be resolved in a week or two;)

    All the best, and thanks again for the forum to express a perspective on an issue that is important to all concerned, and that’s all society.

  22. Psychiatrist . . .

    The issue here, I think, is about whether it is nature or nurture that is the cause of mental illness.
    In my opinion it’s a combination.
    If a doctor said to me ..
    “Sorry, the unrelenting physical and emotional abuse and the accompanying fear and bewilderment you experienced in your most vulnerable and impressionable years as a child has absolutely nothing to do with your mental illness.” I would that assessment find hard to accept.
    Of course Stephen Fry doesn’t speak for all manic-depressives . . any more than what I myself (also a manic-depressive) might expound on the subject. Cheers!

    Patient .

    1. Dear Psychiatrist,

      Thanks for your contribution. I don’t think anyone is denying that both nature and nurture play a role, but the problem is that the latter (which we can change) is ignored whilst the former (which we can’t) is privilaged in both academica nd media representations of mental health.

      For more thoughts about the nature vs nurture controversy, you might want to look at my responses to Elspeth Webb and LukeJohn above. For an illustration of how damaging a narrow biomedical approach can be, you might want to read the distressing testimony of Pauline Selston, also in the trail of comments above.

      Richard

    2. Apologies Terry – I addressed my reply to ‘Dear psychiatrist’ not out of disrespect. In a rush I misread your comment and missed your name.

      1. No worries, Richard. I too rushed my ‘contribution” .
        (I’m not a psychiatrist). But I do have bipolar-disorder.
        My ‘contribution’ was really just an exercise in creative-writing.
        I write more often-than-not as a form-of-therapy . . . which I find
        helpful in clarifying my somewhat erratic-thoughts and feelings.
        Writing for me is almost a borderline obsessive-compulsive-disorder.
        So.
        So now that I’ve chanced upon this site . . I might contribute more
        of my stuff-and-nonsense and I may well drive you and your readers mad.
        But, hopefully – ha, hope springs infernal – entertain you and your readers as well.

        Cheers from Terry
        (@comictragic)

  23. Yes and yes and yes! As a mental health practitioner and a voice hearer, I could not agree more. Most of my clients are young adults with psychosis. Most of my clients have horrendous and long term abuse histories. I’m trying to battle a system that attempts to say it is all genes and if they would just take their meds they would be fine. In many cases meds do help. But they are only a piece. and so often meds are delivered by psychiatrists as if they randomly loaded a shot gun with various meds and fired. Whatever lands in the patient’s mouth is what they prescribe. It seems to have very little since behind it and far too often I have seen grave harm.
    When I try to work with the voices directly, many of my colleagues seem afraid. They think it’s dangerous for meet go there. But I get much better results than simply ignoring voices as if they were a broken knee instead of a part of the person which should be respected.

  24. Richard Bentall cites his own work rather too frequently for my liking. There is a big Psychology vs Psychiatry war here – largely on the part of the Psychologists. It worries me that they (you) seem so sure of the greater importance of ‘nurture’ vs ‘nature’ and suggest that the more money that goes into mental health services, the worse the outcome … Please don’t tell David Cameron or we know what will happen next. Zero funding, zero benefits, zero help, which is what you would seem to propose . Or could it be private psychologists and tedious, pointless ‘mindfulness’ apps for those who can afford it? Major objectors to Big Pharma may have some very good points, but they also usually have something of their own to sell.

    1. Dear Maggie,

      Its disappointing that you think this is just about psychology-psychiatry rivalry. As for the weight given to nature vs nurture, I was pointing out that much of the media representation of mental health seems to ignore environmental influences entirely, with the awful consequences that I spelt out in the final paragraphs of mt letter to Stephen Fry.

      It’s a mistake to think we can quantify how much is genetic and how much environmental anyway. Both play a role but interact in complex ways. If you look back at my letter to Stephen Fry you’ll see that I did acknowledge the role of genes, but pointed out that the latest molecular research suggests a much more nuanced understanding of genetic risk than that provided by BBC programme makers.

      Richard

  25. Bad equals bad–good equals good–good thinking makes good chemical pictures– bad does the opposite– so it doesn’t matter where you look– or think you should– the reality is in being good to feel good- feeling good to think good– so no matter where anyone goes with it its in the thinking and feeling– but feeling creates thinking– so that’s the main ingredient — and what needs to be fixed– and that’s behaviour and experience–and that has to be fixed for anything else–your brain for instance- to work properly– mind you everyone’s entitled and free to think, believe, and have the treatment they like– “except for those being force treated by the authority”– and that’s bad– that’s the authority– and that makes the authority bad– if that authority holds people down to poison them when they don’t believe or want it because of what it does to them– it does bad- then for those people to keep adding bad– is a crime– not a health or a care–but a crime– the sad thing is the only people who recognise it as a crime– are those being force treated and their families– and a few evolved compassionate people– the rest of society are the sheep–and they’ve brought it– which is why half the planets drugged and sick–killing each other– or drugged tripping and happy– its so hard to get sheep to come away from the herd — especially when they’ve got so many shepherds.

  26. Perhaps it is worth pointing out that the nature vs nurture debate is as much a debate about power and politics as it is about science. It has become increasingly unpopular, and therefore under-funded, within the neoliberal culture of post-Thatcher/Reagan politics to pay attention to the environmental aspects of mental ill health – and psychological life more generally.

  27. Dear Richard – I am interested in what you mean in your letter by the latter part of “Patients are routinely offered powerful drugs…but very rarely the kinds of psychological therapies that may help them to come to terms with these kinds of experiences…”.
    As others have remarked, your letter is well-referenced in terms of research, but I notice that no empirical research is cited here regarding the latter claim. I am genuinely curious if you know of any published empirical work showing that psychological therapies help people with such diagnoses (schizophrenia, bipolar disorder) ‘come to terms with their experiences’?

    1. Dear Keith.

      Thanks for your comment. As you and I (and many in the mental health professions) know, there has been some dispute, not only about the effectiveness of individual psychological therapies for severe mental illness but also, if they are helpful, about why they are helpful. Your own meta-analysis (Jauhar, S., et al. (2014). Cognitive-behavioural therapy for the symptoms of schizophrenia: Systematic review and meta-analysis with examination of potential bias. British Journal of Psychiatry, 204, 20-29) has been helpful in highlighting the fact that CBT is not as effective as we would like it to be, although I think your conclusions are too pessimistic and that even your calculations do not suggest that it is not effective at all when targeted at symptoms (the effect sizes of about 0.4 – for all studies – and 0.2 calculated for the most rigourous studies – by Wykes, T., et al. Schizophrenia Bulletin, 34, 523-527 look about right to me). But a few additional caveats are warranted.

      First, the above mentioned findings have concerned the effects of CBT on symptoms, but there are many other kinds of outcomes that are important to patients. For example, there is good evidence that family therapy can reduce relapse rates, even though symptoms do not seem to be affected by this kind of treatment (Pilling, S., Bebbington, P., Kuipers, E., Garety, P.A., Geddes, J.R., Orbach, G., & Morgan, . (2002). Psychological treatments in schizophrenia: I Meta-analysis of family intervention and cognitive behaviour therapy. Pschological Medicine, 32, 763-782).

      Second, as the example of family therapy shows, CBT isn’t the only psychological therapy in town, and even CBT is evolving. Hence, two recent trials have reported impressive effect sizes for interventions that might or might not be considered CBT, depending on how CBT is defined: a worry intervention targeted at paranoia (Freeman, D., et al. (2015). Effects of cognitive behaviour therapy for worry on persecutory delusions in patients with psychosis (WIT): A parallel, single-blind, randomised controlled trial with a mediation analysis. Lancet Psychiatry, 2, 305-313) and an eye movement desenitization and reprocessing therapy for comorbid PTSD symptoms (van den Berg, D.P.G., et al. (2016). Prolonged exposure vs Eye Movement Desensitization and Reprocessing vs waiting list for Posttraumatic Stress Disorder in patients with a psychotic disorder: A randomized clinical trial. JAMA Psychiatry, 72, 259-267).

      Finally, there is the question of whether specific techniques are required for psychological treatments to be effective, or whether more general psychotherapeutic skills – an ability to establish an effective therapeutic alliance – are more important. Using new statistical techniques, my colleagues and I recently reanalysed the data from a large CBT trial and the results pointed strongly towards the latter conclusion (Goldsmith, L.P., Lewis, S.W., Dunn, G., & Bentall, R.P. (2015). Psychological treatments for early psychosis can be beneficial or harmful, depending on the therapeutic alliance: An instrumental variable analysis. Psychological Medicine, 45, 2365-2373). There are many ways of interpreting these findings – perhaps we would not have gotten the same results if we had carried out similar analyses on data from the recent worry and EMDR trials, for example – but it does suggest that it would be foolish for services to ignore the human aspects of care. And in a way, that was the point of my letter – it is probably possible to practice hard line biomedical psychiatry whilst maintaining a strong therapeutic alliance but, in general, that is not how it is done; indeed, in my view a narrow medical conception of severe mental illness discourages this kind of alliance.

      Let me add one further thought. However we intrepete the data from clinical trials, the more global epidemiological data referenced in my letter shows that modern psychiatric services have had a negligible effect on population mental health. In my view, it would be foolish to ignore this evidence. Clearly, we all – psychiatrists and psychologists – need to be modest in our claims about what is effective. In these circumstances, it is vital that we offer service users a range of choices and avoid the assumption that any particular type of therapy – pharmacological or psychological – will suit everyone.

      Best wishes

      Richard

  28. This article hits the nail firmly on the head. If instead of the term ‘mental illness’ (or even the increasing and strange practice of referring to problems as ‘mental health’!) we instead talked of ‘extreme unhappiness’, we might access the wisdom of therapists, priests and wise friends, as well as the social factors, a holistic approach which might get much further in restoring happiness.

  29. Richard: I am a cultural anthropologist that had the opportunity to work with psychiatric populations for 15 years first hand in Residential Community settings in NY State, USA. At the start the “disease” concept and behavioral psychology dominated. The idea that there were “adaptational” responses or reactions was not a favorable consideration when I approached theory in this perspective, and the dominant operational ideas were decomposition and compensations. It was surprising how hostile and controlling the world of psychology was from the “other” side of the spectrum of care giving. Theorists rarely actually “lived” with psych populations and the distance was clearly a factor in their rationale and reasoning.
    I would say generally that the “disease” concept itself is faulty in dealing with distressed populations. Trauma of one sort of another along a wide spectrum of developmental to physical/environmental does impact of a great deal of what becomes relative distortions. The notion or signal to noise ratio is helpful in grading these responses. What I also recognized is that the great majority of “symptoms” are similar to computer troubles. They either block, overwhelm or deny actions that result in proportionate behavioral contests and context. Finally it is absolutely true that ALL of us utilize many of these same mechanisms. The distinction is that for the average functioning individual it is more like a “foot note” in our working narrative and mental text, whereas for distressed populations it has become more of a “headline” in their daily coping skills.
    One positive note from the community base findings was that successful succession of some qualitative improvements were directly correlated with “family” support, but that also the characteristics of certain features (affect) were possibly epi-genetic more than genetic, and that synchronicity was a factor in both healing and regressive expressions in cognition & behavior itself. I hope this is useful to someone and all. Bruce E. Woych

  30. Thank you for this article, Richard. I too dislike the idea of biological determinism – it can be a recipe for throwing one’s hands up and giving up. Social factors are far more challenging because they suggest change is possible but that requires both political will and consensual public support. I was surprised to read that “those countries which spend the least on psychiatric services have the best outcomes for severe mental illness whereas those that spend the most have the highest suicide rates”. That’s the sort of information you wouldn’t want to get into the wrong hands – I’ve Jeremy Hunt in mind.

  31. Yes, I agree with the narrative of Professor Bentall’s letter. Alas, too often still mental ill health is explained in biomedical terms. For me, the most compelling research that links psychosocial adversity to mental difficulties is the seminal work of George Brown and Tirril Harris in 1978 in their book The Social Origins of Depression. This important study showed that stressful life events, particularly ones involving loss of various kinds, when combined with the vulnerability factor of an absence of social support from others (eg lack of a close confiding relationship) produced a significantly raised risk of depression. The book was reprinted in 1993, such was/is its on-going import. I have taught this work to undergraduate students repeatedly since I became a psychology lecturer 25 years ago. And there has been plenty of other wonderful work that illustrates the effects of psychosocial adversity on `physical’ ill health (if you’ll pardon the false Cartesian dichotomy for a moment) – see for example the brilliant research of Janice Kiecolt-Glaser (the BBC featured her work in one of its Horizon programmes some years ago now). The challenge for us is to fully understand and represent the complexity of the `dance’ of nature with nurture, and to resist portrayals that focus on one to the relative exclusion of the other.

  32. Good article, I can see how poverty, bullying, etc., can trigger mental illness, but the vast majority of people who have miserable childhoods do not become mentally ill. Why do some do? They must have a biological sensitivity. That would also explain how someone who has grown up in ideal circumstances with no trauma can become mentally ill. What, then, is reason why we can find two people in exactly the same circumstances, with one who becomes ill and the other not?

  33. I’m concerned about the straw-man argument that psychiatrists are disinterested in their patients’ life-experiences. Quite simply this isn’t true. Just because there is a lot of research in psychiatry about bio/pharma/genetics doesn’t mean that clinical psychiatry (or even general practice, especially where there is continuity of care) is indifferent to patient-narratives. For many patients with mental illnesses, a psychiatric history is the first opportunity they have to spend as long as an hour with a doctor giving a detailed account of their lives. I’ve read thousands of detailed psychiatric reports and written a few myself. Our clinical psychiatry services in Hackney (at least) also integrate psychology and psychotherapy which gives our patients the opportunity to discuss their experiences even further.

  34. Thank you so much Richard. I watched the documentary and was very upset by the unbalanced view it projected. I felt despondent as the end credits rolled. These views damaged me for years and were continuing here. I suffered emotional trauma/abuse as a child and subsequently in adulthood – I knew nothing else! If i acted differently, even disturbed it was because I was odd or wrong not the situation. This continued – after a sexual trauma in my 20’s left me ‘depressed’ I went to the doctors where the events of the life that had put me there were ignored, symptoms only please. I was told tablets would make me all better. I felt a little better (numb anyway) but those tablets wore off, so more were given, then different, then more of those.
    My circumstances were getting worse but tablets and more were the only answer I was given. from one abuse, one trauma to the next – this is how I lived and I entered an emotionally abusive marriage I went from down to up and into psychosis. I was trying to escape, i had no other way but through my mind. I had no power so I found it as God. I was sectioned and given a new stamp of ‘Bi polar disorder’ told it was life long, genetic, a brain disorder andI would be on drugs forever – hard core zombie makers. Much like some of the sentiments in the documentary. I felt hopeless, all the odd and the wrong I had been called in my early years was back. In my eyes I was bad brained and all the experiences that I had gone through meant nothing. I remember feeling like i was not even human. All the hurt was numbed, but for me the pain and the hurt was there for a reason- for a while it stayed frozen. I was frozen. Then I was very lucky and found light, first in the community psy nurses i was gifted with and then because of them from a psychotherapist. I went on a talkabout with her for 5-6 years and I defrosted and became human again. I felt every feeling, told every story I needed to tell. By the end of my time with her I was off meds- I had been on anti psychotics, then high dosages of lithium and sodium valporate. I was out of services. I have been so for over 6 years now- no relapse. I found abusers and abused myself – with circumstances and people- I don’t anymore. i changed the pattern. i have a daughter and she was heading towards something similar or worse, she is not anymore. Heal one member of the family and you can heal the generations.
    When I watched that documentary I felt alone, I felt hopeless for others and anxious about the message that came across until you sent that important letter. Thank you so much for this and all the other work you have and continue to do to in this field. I teach and tell my story now, work in helping others using my own experience. Having people like you speak out for me and my peers in the way that you do helps me to hold faith. The group I am with call ourselves freedom fighters – you are one too!

  35. Hi Richard,
    Thank you for your letter. I think it is great that mental health is being normalised, but as a mental health professional I was quite disappointed by the bio-medical message from the documentary. What you have written about is very well balanced, history and social circumstances do play a larger role than was implied in the documentary. Thanks again, Katherine

  36. surprise surprise, once again bi-polar and schizophrenia is mentioned again. but what about the little known illness called borderline personality disorder. which up to roughly 15-20 years ago you could not be diagnosed with unless you had either bi-polar or schizophrenia. but around 15-20 years ago you could be diagnosed with borderline personality disorder, as a illness in it’s own right. but this illness cannot be treated with meds, as you do not have that chemical imbalance like with other illnesses. there is also people out there could still be carrying around a label of mis-diagnosis of bi-polar or schizophrenia, when actually they are bordrline as all three of these illness are so close in the traits. there is only a few that is different.but this unknown illness never gets a mention.maybe one day when a big a list celeb comes out and says i have bpd. but untill then people will suffer gp will play the ignorance card and the suffer is left to fight it themselves.

  37. The broadcast was sloppy: four unfortunate (two articulate tragic) people conducting themselves with great honesty and dignity, then placed inside a “docu-soap” collage & intertwined with Mr. Fry’s musings. I didn’t see what point it was trying to get across other than “isn’t this awful?”. As a consequence will people have a better appreciation of the disease and be more understanding? I very much doubt it. A great opportunity wasted.

    I’m a layman, and certainly not a psychiatrist or a psychologist. However my personal experience with a close family member is that nurture and nature have played a significant role. There is a history of mental illness in my family (not identified as bipolar, but certainly erratic). And my family member was bullied at primary school. Eight years (on and off) of hypnotherapy (Human Givens “Rewind”) proved extremely effective, and they are no longer carrying any mental baggage from the past. I was cynical about such approaches but that is no longer the case. Add to that iron-willed self-discipline and meditation (“The Power of Now” by Tolle has been particularly useful) and you have someone who’s got through the last 15 years without any drugs (whether prescribed or “self-medicated”). But recently it got worse, much worse – even meditation has it’s limits when you’re at level 1 on a mood chart and you’re rapid cycling every 2-3 days.

    So they’ve found a psychiatrist to act as a guide and mentor while they record meticulously what’s happening to their body, are very disciplined about their daily activities, and decide what they want to do. And the pair of them have got lucky with their “mania led” hypothesis straight away: 7.5mg a day of aripiprazole has transformed their life over the last six weeks (5-5.5 on a mood chart). They are smiling, radiant and getting on with their life. Yes, there are adverse side effects around sleep patterns, anxiety and difficulty eating full portions – but this is regarded as a very small price to pay. It’s early days and the condition will always have to be carefully managed, but early signs are promising.

    Nurture or nature? Psychology or psychiatry? In this case I’d say both – the hypnotherapy and meditation provided a “clean slate” so that they knew what was left needed addressing through medication.

  38. The extent of personal and/or social invalidation determines the extent of distress. Problems with living can make life unlivable. The antidote to invalidation is to create validating conditions that help people find their own way forward to build and live healthier and happier lives. Love not pills…

  39. Dear Richard – I am interested in what you mean in your letter by the latter part of “Patients are routinely offered powerful drugs…but very rarely the kinds of psychological therapies that may help them to come to terms with these kinds of experiences…”.
    As others have remarked, your letter is well-referenced with supporting research, but I notice that no empirical research is cited here regarding the latter claim. I am genuinely curious if you know of any published empirical work showing that psychological therapies help people with such diagnoses (schizophrenia, bipolar disorder) ‘come to terms with their experiences’?

  40. Whilst I’m sure what Professor Bentall says is true, I do not agree with his stance that mental health disorders being thought of as genetic by the general pubic is detrimental to the campaign to destigmatize mental health. I have suffered with depression since childhood. I have none of the environmental ‘risk factors’ that his article mentions. I struggled for years before finally turning to medication as I didn’t think it would help. When, in my late 20’s I finally took anti depressants it was as though a weight had been lifted and I was finally free. When I have stopped to meds the depression has come back and I am fairly certain I will take medication for life. While I know this is not the case for everyone I want people to know that this is just the way my brain works. I don’t need counselling, as there is nothing wrong with me emotionally. The problem is physical, not emotional. Most people don’t seem to realise that depression can be caused by physical problems. The general opinion seems to be that depression is caused by something and you should be working through that problem, not taking medication. Stephen fry’s documentary showed that this wasn’t necessarily the case and helped to destigmatize taking medication.

  41. It occurs to me that the emergent focus on mental health issues and illnesses is indeed positive, whether it be viewed as the wrong focus or not, as it is this very focus that has driven this conversation initiated by Dr Bentall’s letter. I am a psychology student, a person with a mental health disorder, and someone who has seen my mother suffer severe psychotic breaks twice, and it appears that one of the issues is the apparent need to ‘medicalise’ mental health. If a person has a medical disorder, diabetes, cancer, etc, they are treated with chemical solutions, where possible. Due to this being what we as humans have evolved to see as curing disease. However this does not mean that mental issues require the same.

    I have OCD and take medication at a high dose daily and will for the foreseeable future. When I was diagnosed, I was told by both psychologists and psychiatrists that my particular condition was unheard of, I would have it for life, and therefore the only treatment was medication. Unfortunately 18 years later after numerous horrific medication trials and two failed attempts at therapy, I am told that it is now so well established and covert in nature that it is unlikely that I will ever be fully rid of it. So currently I rely on the medication to enable me to study and pursue my career. So did therapy fail me? I don’t believe so, I believe that I didn’t find the appropriate therapy that would have enabled me to defeat this condition earlier. Had the approach to mental health been more multifaceted, rather than directed towards medication as an answer, then it is likely that I may have found the correct therapy.

    In a separate example, my partner took his own life in 2013 due to a lengthy depression. Despite seeking help from a number of GPs, he was simply placed on anti-depressants and sent on his not so merry way. Having dealt with depression personally and with family and close friends, I felt this level service was not sufficient. Not once was he asked what he believed had led to his depression, when it had begun or how he would like to deal with it, what options he had, nothing. After my persistence got him on a counselling waiting list, he had his appointment cancelled twice and then it was too late.

    The reason I share this now, is to illustrate the determination these experiences have bred, I believe that our NHS is failing drastically those who need it most. Multiple medical issues can be in part attributed to mental health issues; alcoholism, drug addiction, obesity, anorexia, to name a few. However people with these issues are shunned, criminalised or criticised for poor life decisions. Is it not clear that these conditions themselves are often symptoms of more serious underlying issues? Issues that are not treated until the symptoms become troublesome. How many people are harassed in the street because they have a broken leg, or a hearing aid? Now compare that to the number of times alcoholics, addicts and obese individuals suffer jaunts and insults.

  42. Not all people that are experiencing bipolar disorders have “bad childhoods”. A lot of People have, that is correct, but many people also experiences that the illnes is triggered by Things that “normal People” would not take particulary notice of. Most People, for example, do not take damage of exstensive travelling. So why do some People do? And as in Frey’s case, speaking With an extreame homofob would probably make you upset, but most Peoples Wold not get sick of it! Of course, mental disorder is often a complex disorder, but somtimes it is not. Taking my selv as an exsample: It is no doubt that I have a bipolar disorder, but I can not reafering it to anything else than that about 25% off my, quite big, Family suffers from the same disease, speaking of aunts, oncels and cousins. I have been brougth up in the countryside, by relatively resours-Rich parents (who not them selvs are ill), I am not drinking alchol at all or taking illegal pills and stuff (never have!). All my life I have been routinely praktising sports, and all my life I have also attended a normal healty varieted diet. The only thing that I migth not have been so good at, is to get the rigth amount of sleep. Fare too littel in some periods, and fare too much in others.
    Despite some few signs of mental problems of minor grade (which seem to just suddenly turn up without any particular reason) through my childhood, my more seriously problems With the disease first turned up the same year as I attended highschool. I think the reason must have been the shift of environment in it selfs, because I did’n actually have problems With attendig School (my marks was quit great), and I had a lot of friends. So the only thing I can point of that triggered the disease, was the shift of environment itselves., and onestly speaking, non of my classmates responded in, something even near, that way too the change of environment! To day I, have finaly, got medicination, and is mostly quit well. I had some counsultations whith a psycaietrist in the start, but that was mainly to deside what drugs that would be right for me, and a bit of advise of what to do an not to do as a bipolar. Notingh else! And to day I woork as head of a Department in a University hospital and is doing quit well. So how would you explain this if it was not because of my Genetics? I am, of course, not doubting scentific results, but I have a strong belife in that bipolarity is mainly a Genetic disease which is triggered by, sometimes bagatelly , experienses in the pasients life. And, offcourse, “big events”, like some kind of “bad childhood”, is even more serious for a person which is predisposed for the disease. I have also heard that bipolar disease always has a Genetic Component, while conditions like Shizofrenia and autism not nesesarey have. You might have rigth in that Frey’s documentar migth be a bit “polar in one direction of the disease”, if I could put it that way, but in the other hand, this is how Frey is experiencing his disease, and I do not think it is anything in his dokumentar that is directly wrong. But that was maby not Your intention to point out either…???
    (PS: sorry for some bad English; English is not may primary language)

  43. As a mental health nursing student I feel Richard Bentell has attempted to capture the psychosocial perspective which was missing in the television documentary. Too often the biomedical perspective of mental illness gets all the attention so kudos to Bentell for this timely response.

  44. I welcome this open and compassionate discussion. I am a retired Embodied Relational Therapist and a survivor of a disturbed mental health history. For my own recovery I used a generous mixture of medication, psychotherapy and self- help. I have no idea which of the interventions “worked” and I recovered and re-gained a balanced sense of emotional well being. My recovery was good enough to train as a therapist and find myself able to work with others who were in pain and turmoil as a result of a mental and emotional imbalance. I was concerned that Stephen seemed to me to be sharing a more limited strategy for recovery than is my experience with myself and my brave and courageous clients who have walked their own paths of recovery with my support. When despair and confusion is all that seems available in life I believe the most crucial intervention is for us to feel the support and encouragement of the people around us, friends, family and most of all the professionals that we seek to help us. Let us keep our hearts and minds open to all that we know about being a human and generously and compassionately use anything that works. I value the research that continues to be carried out that validates the experience of many people who recover from this tragic form of human pain and lead useful and worthwhile lives.

  45. Stephen Fry is very fortunate to have had the services of such an attentive psychiatrist. For most of us it is a struggle to even get to see one. Even then the outcome as seldom as pleasant as portrayed in the film. The reality of living with bi-polar disorder or any other serious mental health problem is that not enough active help is given. Whatever the cause is the important thing surely should be what is going to provide the most help to the individual.

    More often than not a person is given a degree of help but this is not followed through to completion because of funding cuts. This leaves people floundering and resentful. The best results seem to come when encouragement is given to meet with others in group arrangements. The value of human interaction and shared experiences is invaluable. If more funding were given for this type of ‘therapy’ both by government and private sources there would be much improvement amongst sufferers.

  46. This is a breathtaking response to Stephen Fry – fundamentally important arguments, respect for Stephen Fry’s intensions, and education in succinct form that could reach anyone from the highly to less informed. Wouldn’t it be wonderful if Stephen Fry invited Richard Bagnall to join him in persuading the bbc to enable them to make a follow up programme together exploring some of this ground? This could help bring what is disgracefully unpublicised knowledge on mental health to the public and, if we’re going to be ambitious, contribute to the seriously needed breakdown of current misconceptions around mental health.

  47. As someone who has put their mental health into the public domain I appreciate the thinking that goes into the decision to go public. For me each person is entitled to describe their own mental health in the way they choose. Becoming the subject of debate has its benefits – it raises issues. But it can feel as though a persons health, treatment choices and life becomes a battle for territory between different factions within the mental health world. As someone who has used mental health services I am all too aware of the ownership that professionals can take of the recovery journey, when in actual fact that journey is taken by the person who has the mental health problem.
    For me there are other battles to be fought which might begin with a change within secondary schools to the idea of studying abnormal psychology. If we really want to change the way we all see mental health problems then let’s move away from this perjorative term. Let’s teach young people something about the normality of distress within human life, this way we might enable less stigmatising and more helpful conversations.
    In the mean time, thanks to those who share their experience to change the debate and normalise mental distress within human life.

    Laura Lea- Co-ordinator of Service User and Carer Involvement Canterbury Christ Church Clinical Psychology Doctoral Programme.

  48. I have read through many of these comments and am struck by the difference between the treatment of “mental illness” and the problems caused by adoption. I have adopted three children and have a lot of experience of the support given to adopted children and their parents. Adopted children are recognised as having many behavioural problems related to their experiences. However these are not medicalised by professionals and are generally treated as related to attachment problems or post traumatic stress. Adoptive parents are taught that their children can be helped by the way that they treat them. The children are given play therapy and talking therapies. Perhaps because there is such an obvious external source of trauma – i.e. being taken away from your parents, professionals are happy to accept that problems have not been caused by the genetics of the child. I am not a medic or a psychologist so am not sure if I have misunderstood the difference between the problems my kids have and “mental illness” but thought it interesting that most adoptive parents I know have not been prescribed drugs to help their children.

  49. Dear Professor Bentall

    Thank you for this letter. I have had depression and anxiety for a decade and been on several different medications and have come to the conclusion that the answers lie outside the brain, well at least “brain” in the way the word is generally employed. I am also a lecturer in psychology. I had a go at trying convey these things in a TEDx talk… it would be great if you were given a platform like TEDx to express your views given the dominance of the neurobiological account in both society and academia.

    Best wishes,

    Damian
    https://www.youtube.com/watch?v=cbHBZWbEk8A

  50. Thank you Richard for your informed communication.

    I am someone who is managing their mental health issues and as an educated man from an evolving analytical background I have asserted some of your observations and views for many years when speaking to my psychologist and on occasion in response to social media commentary.

    In my personal view I have maintained for years that as well as the hereditary and gene based precursor relationship to mental health issues time and time again the following areas seem to present themselves relative to the sensitivity of any given individual in variable intensities and combinations:

    1. Environments where social conditions are deteriorating whilst inhabitants have recursive visibility of unattainable class driven ideals projected as progress.
    2. Childhood trauma, abuse (witnessed/recieved), racism or having to prematurely support uneducated non integrated parents or lack of patriarchy/matriarchy and non existent role models.
    3. Poor Diet where processed sugar in all its forms is a large percentage of the diet and individuals are unaware of other food markers which may cause inflammation and also trigger and heighten the intensity of mental health issues and episodes.
    4. Uninformed patients across a spectrum of intellectual capacities who are unaware that for allergies a blood test, food intolerance test and skin prick test can produce inconsistent results for the same test sample which may be adversely affecting them and exacerbating symptoms.
    5. An individual’s constitution and how dietary factors, biological factors or simply neglect effects their uptake and the availability of key vitamins and minerals that support mental health.
    6. Self medication using alcohol, tobacco and recreational drugs from an early age initially as an environment/cultural social support mechanism which is casually overlapped into adulthood.
    7. Religious or cultural indoctrination that the evolving intellectual mind of certain individuals fights against after years of programming has been embedded in their neural pathways.
    8. A sudden change in the long term habitual familiar activity like that of a career/job and subsequent work life routine when faced with retirement or redundancy.
    9. The loss of a figurehead such as a mother or father without the appropriate social support or knowledge of the stages of grieving and sudden realisation of mortality however remote or local the deceased was.
    10. Mentally or physically abusive adult relationships born of a distorted or non existent relationship to social interactions during key formative years of childhood and adolescence.
    11. A Dark Night of the Soul episode being misdiagnosed as a mental health issue and an individual being led down a allopathic based diagnosis due to an inexperienced support mechanism where the possible side effects of neuroleptics have not been explained.
    12.The residual symptoms of viral activity or neurotoxin activity whether administered maliciously as a control factor or accidentally into the body of a vulnerable individual.

    For this reason I have argued that bipolar and relative mental health issues would be better dealt with on a case by case basis since the above point to a multifaceted habitually fluctuating model of mental illness precursors in any individual’s mental health equation.

  51. Pingback: Document Moved
  52. Fantastic article! Thank you. I am a music therapist who first hand experience of the highly biassed ‘medical model’ of mental health system. Although I acknowledge there is much good work in the medical world researching drugs etc.. there is also a lot of profit to be made!!! I believe that trained therapists helping people through their personal life struggles can be far more individualised, effective and safer than medicalised alternatives..

  53. Seems to me that there is much in-fighting regarding the meaning of mental ill-health. In my mind, compassionate care is the shortest pathway to inner peace. Compassionate care is difficult to provide in a war zone and so I am no longer wanting to be part of this war.

  54. I am delighted to have read your open letter, so much more eloquently put than I could have managed. I have wanted to say exactly the same for some time, especially to the highly revered Mr Fry who I honestly feel is doing more damage than good by blaming his symptoms on an “illness” rather than linking it to the misery he has experienced at a deeper level throughout his life.
    Having experienced these symptoms myself I trained to become a psychotherapist and find that it is so much more effective than medication to all my clients.
    Stephen sadly rejects and despises anything of the spirit ( by that I do not mean religion but that spark inside that we need nourish before we can heal ) and thus seems unable to be open to any change or non medical intervention. I feel doubtful of his ability to become autonomous and experience a return of equilibrium and ability to thrive.

    I will share your letter far and wide.

  55. Thank you for these valuable information Professor Richard Bentall.

    It is a great joy to see academics succeed that want and can contribute to an improvement over the old models and ways. As a former student of biology and diagnosed schizophrenic for nearing 17 years, i am more interested in the scientific citations provided and the benefit they might bring to discussions elsewhere, than criticising my benefactors, but i am very sure my schizophrenia is not dependent on genetical vulnerabilities and i had a very nice childhood and life until being introduced into forced psychiatry.

    Unfortunately, i have many personal problems, now and probably will not be able to do much more than share this blogs post to my facebook wall but most newer scientific papers on the validity of the biological model seemed easily disprovable to me and some colleagues. I cannot guarantee that my eMail will suffice for the intention to contact me here, so i want to state that i found your open letter in the facebook group “Drop the disorder!”.

    Thanks again for your work and honesty.

    Christian Thorsten Helge Mayer

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