In 1973, an American psychologist called David Rosenhan published the results of a bold experiment. He’d arranged for eight “pseudo-patients” to attend appointments at psychiatric institutions, where they complained to doctors about hearing voices that said “empty”, “hollow” and “thud”. All were admitted, diagnosed with either schizophrenia or manic-depressive psychosis. They immediately stopped displaying any “symptoms” and started saying they felt fine. The first got out after seven days; the last after 52.
Told of these findings, psychiatrists at a major teaching hospital found it hard to believe that they’d make the same mistake, so Rosenhan devised another experiment: over the next three months, he informed them, one or more pseudopatients would go undercover and, at the end, staff would be asked to decide who had been faking it. Of 193 patients admitted, 20% were deemed suspicious. It was then that Rosenhan revealed this had been a ruse as well: no pseudopatients had been sent to the hospital at all. Not only had doctors failed to spot sane people in their midst; they couldn’t reliably recognise the actually insane.
Rosenhan’s gambit seized the public imagination. Were the men in white suits just quacks? Was mental illness even real? Two years later, the film One Flew Over the Cuckoo’s Nest added to the sense of reputational meltdown, and the psychiatric establishment responded with a major tightening up of diagnostic criteria, squeezing disparate symptoms into even tighter boxes. A freewheeling challenge to psychiatry ended up provoking a kind of counter-reformation, making the profession more medicalised than it had been for decades.
The whole affair is a neat example of the ideological switchbacks Edward Bullmore maps in his fascinating, personally inflected history of psychiatric ideas. It is all the more mind-boggling – pun intended – when you find out Rosenhan’s paper was largely made up. Research by journalist Susannah Cahalan in 2019 concluded that most of the pseudopatients were invented; one colleague remembered the psychologist as a “bullshitter”.
Whether or not he lied, though, Rosenhan exposed a faultline that has run through the field almost since its inception. Bullmore, a professor of psychiatry, blames it on a bogus divide between the body and the mind. He calls this the “original schism”, bequeathed to us by Descartes, and before him Saint Paul. It falsely suggests that our thoughts and any psychological distress we experience exist in a separate domain, detached from the flesh. Diseases are either “organic” (like cholera or Alzheimer’s) or “functional” (like depression or schizophrenia), emerging mysteriously from an entirely healthy body.
Practically speaking, this schism cleaves psychiatry from the rest of medicine, meaning the physical health of patients with mental illness is often badly neglected. But it also sets up a division within psychiatry itself, between what has been referred to glibly as the “mindless” tribe, which believes biology explains everything, and the “brainless” one, which ignores neuroscience and looks for answers in a person’s upbringing and way of relating to the world.
We’re all familiar with Sigmund Freud, patron saint of the brainless contingent (though the founder of psychoanalysis started out as a neuroanatomist, and – unlike some of his disciples – found it easy to imagine that advances in biology might one day replace “the whole of our artificial structure of hypothesis”). But his mindless contemporary, Emil Kraepelin, is far less well-known, “the most important psychiatrist you’ve never heard of”, according to Bullmore.
Kraepelin led a German school of thought that saw mental illnesses as manifestations of physical disease, and imagined that, as with tuberculosis, a causal factor or “germ” would surely one day be found to explain them. His focus – and Bullmore’s – is the pattern of symptoms we know as schizophrenia, which Kraepelin called dementia praecox (“early dementia”). For him, the contents of any given psychosis – delusions, paranoid fantasies – were only relevant insofar as they suggested a diagnosis. Interpreting them would not help.
When, after Rosenhan’s antics, a new diagnostic manual was issued by the American Psychiatric Association in 1980, it was labelled “neo-Kraepelinian”. But before that, the pendulum had already swung several times – from the first murmurings of dissent by Freud and his followers, to the genocidal overreach of the German school under Nazism, to the “victory” of the refugee psychoanalysts in the aftermath of the second world war. Bullmore is excellent at showing how our understanding of mental illness has not blindly “followed the science”, patterning instead with the tides of history. The brainless tribe won the literal war – and, as a result, the intellectual one as well.
But science does march on, and in the last four decades there has been loads of it, which Bullmore charts from his vantage point first at the Maudsley in London, where the tribes clustered in different parts of the canteen, and then at the University of Cambridge. One of his touchstones is Susan Sontag’s essay Illness As Metaphor, which showed how any “intractable and capricious” disease becomes a container for morbid fantasies until such time as we have a better explanation. Now we know that TB is a bacterial infection of the lungs, we don’t tend to think that sensitive poets are naturally more prone to it, as we once did.
Schizophrenia may finally be on the cusp of that transformation – something truly momentous, given the puzzle this strange and brutal disease has posed for so long. As Bullmore carefully explains, advances in scanning, maths, genomics and immunology have piled up to give us a clearer understanding of the illness. It is probably caused by the abnormal development of brain networks in childhood and adolescence; this, the evidence suggests, happens under the influence of immune dysfunction, and the cause of that is variation in a broad range of genes, interacting in particular ways with the environment. Triggers can include infections, abuse, social stress or drug use.
The emerging picture marries biology and experience in a way that was always inevitable, since they are not really divided at all – and offers promising new avenues for prevention. The task for the next generation is to translate the science into better outcomes in the real world. Given what we now know, prevention, including better health and social services for mothers and young children, should play a major role.
And what about those colourful types, the anti-psychiatrists? In the 1960s, the shaman-like figure of RD Laing captured the zeitgeist with his idea that psychosis was simply a rational person’s attempt to “live in an unliveable situation” – of which the modern world provided plenty. Bullmore admits that the anti-psychiatrists “have a lot of the best tunes”. I imagine that many of Laing’s insights could survive the new model of schizophrenia as descriptions of social stress, but despite being sympathetic to him in a romantic kind of way, Bullmore doesn’t really make an attempt at salvage. Nor does he examine the adverse effects of powerful, chronically administered psychiatric medication, and how these might confound some of the evidence of biological differences in people with schizophrenia – something contemporary anti-psychiatrists will doubtless take issue with.
But he is emphatic about the need to reckon with psychiatry’s dark past. When he started to research the Nazi programme to exterminate psychiatric patients, he was surprised to find “remarkably little” material in any language for him to consult. This is despite the fact that about 260,000 asylum inmates were murdered, something that followed directly from the theory of dementia praecox as a disorder of one or two defective genes that could be expunged from the volk. This violence continues to cast its shadow, and he notes that most psychiatrists, regardless of tribe, would agree that “to recover from trauma it is important to talk about it, somehow, at some stage in the recovery process”.
Bullmore’s writing has flair and occasional flashes of anarchic humour; as with his 2018 study of depression, The Inflamed Mind, this book is both intellectually exciting and highly readable. Like the best of his psychiatric forebears, he is far from the stern megalomaniac of caricature, animated instead by a desire to do right by his patients, to cut through the ideological commitments that slow down progress, and above all, to understand.
• The Divided Mind: A New Way of Thinking About Mental Health by Edward Bullmore is published by New River (£20). To support the Guardian buy a copy at guardianbookshop.com. Delivery charges may apply.
