Bryan Caplan  

Has Bentall Explained Madness?

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I finally got around to reading Richard Bentall's Madness Explained. It's a fun book, but as expected, it falls short of its ambitious title.

Bentall's been criticized as a Szaszian, and it's easy to see why. Like Szasz, Bentall is highly critical of the official DSM classifications of mental illness, and notes that many people who fit the textbook definitions of mentall illness lead productive and independent lives. He even holds the revolutionary view that apparently incoherent psychotic babbling often turns out to make a great deal of sense - so-called "word salads" are closer to poetry than they are to radio static.

In the end, though, to call Bentall a Szaszian is unfair to both. For all his disagreements with mainstream psychiatry, Bentall is not ready to say that the "mentally ill" are just people with extreme preferences - and he is certainly not ready to declare that mental illness is a pseudo-scientific excuse for being a permanent parasite on family and society.

So what is Bentall's deal? He thinks that we learn as much or more about mental illness with old-fashioned empirical psychology (both experimental and field) than we do with biochemistry. For example, he finds that West Indian immigrants to Britain have unusually high rates of paranoia. Bentall argues that an old-fashioned psychological explanation - immigrants find it harder to trust (and be trusted by?) people from a different culture - fits the facts well.

To take another case: Bentall argues that people who claim to "hear voices" are just misinterpreting ordinary silent speech. Most people who do this live normal lives: "as many as ten times more people experience voices than receive treatment for psychosis." Hard to believe? Here's more:

When Marius Romme compared voice-hearers who had been diagnosed as suffering from a mental illness with others who had not, he found remarkably few differences in the experiences of the two groups. Both patients and non-patients experienced a combination of positive and negative voices, but the proportion of positive voices was greater in the non-patients. The non-patients in contrast with the patients often felt that they had some control over their voices... A majority in both groups reported that their voices played a role in regulating everyday activities, for example by issuing instructions.

Bentall is full of interesting observations like this. But in the end, I don't see that he's "explained madness" in any deep sense. A minority of people are weird, and a minority of this minority are so weird that other people wind up supporting them while desperately trying to change them. What's Bentall's explanation for why people belong to either group in the first place? I still don't know.

At the end of the day, Bentall sees little point in figuring out which official mental illness a troubled person has. Instead, we should find out what symptoms, if any, are bothering him, and work from there. In his conclusion, he even writes that:

If people can sometimes live healthy, productive lives while experiencing some degree of psychosis..., if the boundaries between madness and normality are open to negotiation..., and if our psychiatric services are imperfect and sometimes damaging to patients, who not help some psychotic people just to accept that they are different from the rest of us? Fear of madness may be a much bigger problem than madness itself.

Great rhetoric, but what a blind spot! Bentall ignores the fact it's often family members, and not the mentally ill themselves, who refuse to "accept" the symptoms. So what does Bentall recommend if the patient says he's fine, but his family wants to drug him until he behaves? I say: Respect the rights of the mentally ill, but don't let them take advantage of you. What's Bentall's alternative?

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COMMENTS (3 to date)
Rochelle writes:

This is very interesting. My brother is schizophrenic and while he prefers not to discuss the voices he has heard during psychotic breaks, the voices were basically negative, saying things like "You can only kill when I tell you," along those lines. I'm not schizo, but I too, hear voices in the form of my own conscience, discussing my day, what's going on, kind of like a running narration. I imagine that having a running narration full of negativity would be enough to make one fear for one's sanity. Losing control of those voices would be enough to drive anyone over the edge.
You can also tell when he's on medication that while the voices have been deadened, so has a lot else inside him and he seems to be a lot less focused, almost as though all the voices inside of him have been silenced, and not just the negative ones.
The only explanations I can see for why some end up having more negative voices instead of positive ones would be: 1) genetics (my family has a history of anxiety disorders), 2) Personality--some people have personalities that are very self-criticizing, and 3) experience. Negative experiences re-enforce negativity, which increases self-criticism. When you have all three, I think it would be difficult to avoid mental illness.

Bruce Charlton writes:

Bentall has rather similar views to my own, except that I am more interested in psychopharmacology and human evolution.

I wrote a book on this in 2000 called Psychiatry and the Human Condition, which I have now put online:

I'd be interested in any comments.

Randy Yniguez writes:

Hmmm...sounds like an interesting book that I might consider reading as long as it doesn't have too many big words, too many pages, or if you can let us know exactly what you mean by "It's a fun book..."

"Bentall ignores the fact it's often family members, and not the mentally ill themselves, who refuse to "accept" the symptoms. So what does Bentall recommend if the patient says he's fine, but his family wants to drug him until he behaves? I say: Respect the rights of the mentally ill, but don't let them take advantage of you."

Being a veteran of the mental healthcare field, my experience has been that it is, for the most part, family members that bring in the patient for "treatment." The patient is usually unaware of his behavior and lifestyle, but the family is generally annoyed or embarrassed. Further, family members usually are reluctant or confused as to why they should participate at all in the patient's treatment.

But I also agree that boundaries must be developed where a mentally ill person doesn't take advantage of you. Boundaries not because they are mentally ill. Parents must help foster boundaries in their children regardless of mental health status. It's what good parents/family members do. Anyone who is mentally ill can learn. They might be odd or eccentric, but they're not stupid.


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