On ‘Lost Connections’: Must we return to the era of ‘Psychiatry in Dissent’?

On 24 January 2018, the journalist and author Mr Johann Hari came to the Sean O’Rourke Show on RTÉ Radio 1 to talk about his recent bestselling publication.

Lost Connections- Uncovering The Real Causes of Depression - And The Unexpected Solutions, published by Bloomsbury, has been the subject of much praise and some controversy.

RTÉ invited me to read the book and to share my comments with Mr Hari in the studio.

Mr Hari’s book tells us that across the world he has found ‘social scientists’ uncovering evidence that ‘depression and anxiety are not caused by a chemical imbalance in our brains’, but ‘are largely caused by key problems with the way we live today’.

In the studio, Mr Hari spoke about his own history of depression. He recalled being told by his doctor that he had a deficiency of serotonin necessitating medication. He had been prescribed the specific serotonin reuptake inhibitor (SSRI), Seroxat. He told the RTÉ interviewer Richard Curran that he had remained on this treatment for 13 years, only subsequently to find out that the story told him by his doctor is not true.

In his book Lost Connections, he quotes from interviews with various experts telling him ‘that the serotonin theory is a lie’ and that ‘almost everything he had been told was ‘bullshit’. He attributes this statement to Dr Lucy Johnstone (see Lost Connections, page 30).

Having read many lived experiences by various authors (my favourites include Darkness Visible: A Memoir of Madness by William Styron and Triumphs of Experience by George E Vaillant), I came to Lost Connections with high hopes. As I read it, I became increasingly concerned about many of its definitive claims, and so I was critical of the book on air.

I listened as Mr Hari responded to questions from the presenter, Richard Curran. When I was asked for my view about Lost Connections, I began by emphasising that Mr Hari’s work deserved respect, but I went on to say that his selective use of conversations with various experts about their work does not amount to scientific evidence. He acknowledged it was a work of journalism. I said that I feared that the book’s apparent derision for medication might jeopardise patient care, and so we continued by trading opposing points of view.

Then it got worse. I said his work lacked empathy for those who had made different choices including the choice to take medication. At that stage, the broadcast descended into a babble as we talked over one another to no good effect. Richard Curran reminded us both that by now no one could hear what either of us was saying.

The discussion reminded me of my early years in the 1980s, training under the late Professor Anthony W Clare, a great psychiatrist and a consummate broadcaster. He trained in the 1960s and 1970s, when fiercely confrontational debates were common in the world of psychiatry. Prompted by anti-psychiatrists, such as RD Laing and Thomas Szasz, and philosophers such as Michel Foucault, the ‘myth’ of psychiatry was being exposed and harmful medical ‘treatments’ were rightly discredited. Barbaric interventions such as Insulin Coma Therapy and Frontal Lobectomy (lacking any proper evidence base) were finally abandoned. At the same time, the asylum system was also collapsing largely under the weight of its own numbers.

Throughout the 1960s and 1970s, these fierce disputes, known as the ‘Psych Wars’, pitted medical antagonists against each other in increasingly personalised and bitter ways. Very few people were able to rise above this hostility or to find any reasonable middle ground. In this case, Professor Anthony Clare was a rare exception. His dialectical work, Psychiatry in Dissent, published in 1976, is a classic and it is still relevant to contemporary debates. With peerless fluency, Clare balanced the scientific case for and against controversial treatments such as psychosurgery, electroconvulsive therapy (ECT) and others. His rationality made scientific truths accessible to the general public. While Clare could still be a trenchant critic of methods he opposed (he was particularly critical of psychoanalysis), he respected his opponents’ arguments. In Psychiatry in Dissent, he produced a genuine synthesis, an enlightened rational way forward. It was deservedly a best seller.

When I first knew Anthony Clare, he was already a legend. His return to Ireland and to St Patrick’s Hospital was fortunate for me and for many others who trained there, as well as for the hospital of which he was an inspiring Medical Director, but these years were associated with more clinical events than literary or scientific ones. He remained a magisterial teacher and an imaginative clinical director, but he rarely talked about that challenging time when he had become the voice of reason amongst the noise of the ‘Psych Wars’. If he ever referred to it, it was generally about to reiterate his respect and sympathy for the people he disagreed with. He became particularly concerned for the welfare of some anti-psychiatrists whom he had opposed, most notably RD Laing who died in 1989 age 61.

So, why is it important to respond today to the claims of Lost Connections? Perhaps because so much has changed (even if much has remained the same).

Communicating a rational view may not be easy, but is it too much to hope for that we might one day achieve a more kind, compassionate, respectful debate? Must we accept that psychiatry will always remain ‘in dissent’? Perhaps divisive contest is an inevitable manifestation of mental health ‘stigma’? Who knows?

There were some things Mr Hari said in the studio that cannot be disputed. He said the data about ‘lost connections’ was new to him and so he needed to communicate it. He’s right. There is a need for more communication.

Many people, from Virginia Woolf to Sylvia Plath to the modern-day bloggers, have written extensively about their lived experiences and, in this tradition, Mr Hari’s personal story still needs to be acknowledged and respected.

Notwithstanding his own bad experiences some years ago, the reality is that many things have changed and for the better. Modern mental healthcare is no longer plagued by disputes between the ‘mindless’ and the ‘brainless’. When today’s psychiatrists and psychologists work together constructively, engaging with individuals in mental health distress and with other highly skilled members of multidisciplinary teams, they can provide genuinely effective care.

These ‘Psych Wars’ should be over. Recovery isn’t just about medication. Today, there are many more psychotherapeutic ways to restore ‘lost connections’. These include modern evidence-based psychotherapies such as Marsha Linehan’s Dialectical Behaviour Therapy or Paul Gilbert’s Compassion Focused Therapy. These and others have advanced recovery in more mindful, structured and reproducible ways.

Nowadays, people who use mental health services are better informed than ever before. They know they have choices and rights and many have highly informed preferences. We try to work together with everyone in distress. We do not sell snake oil. Our core mental health disciplines work together within a proven evidence-base. Robust quantitative and qualitative research is enhancing every aspect of clinical practice in mental healthcare. This progress should distinguish today’s mental healthcare from many of the discreditable practices of the past.

Whilst many people, including Mr Hari, have had negative experiences, over the past three decades, the reality is that millions of people have benefited from combined treatments for depression and anxiety. Obviously, recovery means putting things together and so restoring ‘lost connections’ is an important part of that recovery. There is nothing new or disputable in this.

Forty years on from Psychiatry in Dissent, we still need to articulate a more balanced view. To achieve reconnection and in order to remain well, many people choose to take medication at least for a time. They do not need to be made to feel ashamed. They should not be judged and their experience should not be dismissed. Their recovery journeys have truth and validity and they deserve respect, just as Mr Hari’s journey does.

Tags:   depression   RTÉ Radio 1   Prof Jim Lucey   Book review   Today with Sean O'Rourke