Reviews Archives - Allan House

October 6, 2025

The ending of life unworthy of life: could we go there again?

Earlier this year I went to a presentation led by a team from the School of Health Care at my university entitled Finding Ivy: a life worthy of life. The topic was a project that identified and gave details of 13 victims of the Nazi Aktion T-4 programme who were unusual in having been born in the United Kingdom. It was named for a young woman Ivy Angerer who had a learning disability and who was murdered, during the initial formal stage of the programme, along with an estimated 70-80,000 other people with learning disabilities, chronic mental illness or epilepsy as part of a mass killing campaign aimed at emptying the asylums of people with what was called life unworthy of life.

Aktion T-4, described in some detail in Michael Burleigh’s book Death and Deliverance, unfortunately out of print, is now little talked about. The Finding Ivy research project and presentation and the exhibition accompanying it brought the detail distressingly to life by putting real names and real people to the otherwise rather anonymous factual accounts of the matter. There is value in memorialising in the lives and deaths of people otherwise treated as worthless – both for their family’s sake and because it reminds us of an essential human value. At the same time the project raised some interesting and important questions.

What was the relation between the murderous Aktion T-4 campaign and the campaign that involved compulsory sterilisation of people with learning disabilities and mental illness?

What was the relation between the Aktion T-4 campaign and the much larger scale murder of Jews and other groups in the Holocaust? Does any of this have relevance to modern society, either now or for the direction in which society is travelling?

In the first part of the 20^th century sterilisation campaigns were not uncommon in other countries besides Germany – the motivation coming apparently from eugenic theory. There were links also to ideas about degeneracy so that mental illness, epilepsy and intellectual disability could be seen as part of a cluster of genetically determined conditions. Sterilisation was therefore a way of improving the population gene pool.

But other sterilisation programmes did not go on to campaigns aimed at killing members of the same groups. Eugenics could not be evoked as a rationale for this development – the victims were already in institutional surroundings that made reproduction impossible so there was no genetic advantage to the killing. Instead, the argument was mainly economic; the occupants of the asylums were so-called ballast existence or useless eaters. They were drains on more worthwhile members of society – a line of thinking that was most infamously introduced in Binding and Hoche’s 1920 Allowing the Destruction of Life Unworthy of Life. The callousness that made murder possible came perhaps from a certain indifference to violent death brought about by the experience of the Great War.

Although these two rationales feature strongly in arguments of the time and indeed since (see for example Dagmar Herzog’s recent The Question of Unworthy Life) there were other more emotional appeals at play. As well as looking on a group of people as unworthy of life for genetic or economic reasons, they could be presented as people who might themselves welcome release from an awful existence: expressions of revulsion or disgust were not uncommon.

What about the link of Aktion T-4 to the wider Holocaust? Was there an ideological connection or was it more accidental, simply that Aktion T-4 generated a technology that could be used for a completely different purpose? Insistence on the uniqueness of the Holocaust makes it difficult to see or explore links between mass murder (particularly of Jews) and other forms of institutionalised murder, but such links may be there nonetheless.

One pointer resides in the theoretical underpinnings of the national movement that placed those living lives unworthy of life as something more than simply an economic or social problem. They were now, like other enemies of the racial state, a profound existential threat to be answered by an increasing drift from consensus to coercion based upon a preoccupation with racial purity and the fulfilment of a quasi-religious destiny. The mobilising passions of Robert Paxton’s The Anatomy of Fascism.

So there is a common theme in the expansion of choice of victim – all were seen as enemies within: those who could poison the genetic pool; economic parasites; those were different and undermining beliefs and practices (Jews, Roma, homosexuals, communists…). A slightly different way of looking at it is to see the motivation as primarily racist. So-called race hatred (Rassenhaß) is directed at those outside the Volk (Jews, Roma, Blacks etc) while race anxiety (Rassenangst) is directed at those who belong to the Volk but who nonetheless threaten its existence by virtue of some unacceptable pathology (idiots, epileptics, homosexuals etc).

What about the present? Societal attitudes have changed in many ways since the 1940s, but some socially accepted practices may carry the same message today about lives not worth living. The discussion about Finding Ivy, and an associated journal article, have suggested a number of such practices: prenatal screening for Down syndrome with the expectation of termination of pregnancy if screening tests are positive; poor quality healthcare that is leading to people with learning disabilities dying up to 20 years earlier than the average; use of Do Not Attempt Resuscitation notices and delayed prioritisation of vaccination during the recent Covid pandemic all suggest a persistence of ideas about lives that are less valued than others.

A weakness of leaving it there is the non-specific nature of the attribution of “negative attitudes” to people with a learning disability. In aiming to being more specific, I think one clue lies in the rise in recent times of fraught debates about gender, neurodiversity and ethnicity. The vehement politics of identity nod at what has been called “..a sense of overwhelming crisis and victimhood, a fear of the decline of one’s group, a lust for purity and authority…”.

Another example. I went to the Finding Ivy presentation the day before parliament held the third reading and voted to approve Kim Leadbeater’s Terminally Ill Adults (End of Life) Bill. Its aim is to give some people with life limiting illnesses the option of a medically-assisted suicide. Those with learning disabilities are in the frame – with proxy signatories and advocates available to ensure they get full access, and no hint that the Bill’s sponsors understand the risks. But there is a more fundamental point here. The lobby group Dignity in Dying says that these assisted suicides are not about shortening life but about shortening death. So the Bill does not require any exploration at all of why somebody might be asking for help in ending their life – it is simply taken as self-evident that they are leading (to put it bluntly) a sort of un-life, with no value lost from ending it.

This disdain for the un-life comes with an incongruous insistence on the central principle of the Bill being choice, autonomy and the importance of dignity. This is the dignity that is a characteristic of individuals – not innate but made by how they live and die, the latter by suicide, if desired. What PM Keir Starmer, a promoter of the Bill calls “Human dignity. The dignity of the individual. And the respect that goes with it.” The link to the past is the idea of some sort of perfect individual – autonomous, dignified, the ideal citizen – but one who is likely to be undervalued, their wishes ignored, under threat from influences outside their control.

Even if we accept that there are similar psychological forces at play now as there were in inter-war Germany, there is clearly something radically different about where we are compared to the authoritarian or fascist regimes of that time. We lack the prevailing socio-political circumstances that might allow the emergence of a much more virulent form of discrimination. To get there we need two things. One is something equivalent to the extreme economic depressions of the interwar years. For this we can look to climate change and mass migration – even if they are to have their major effects in Western Europe. The other is a genuinely charismatic and effective leader of the extreme right who can exploit the resulting unease. In her recent review of world politics and the threat they pose, Fascism a Warning, former US Secretary of State Madeleine Albright suggested that the rise of such a leader was facilitated by weak and unpopular social democratic alternatives and a degree of complicity with less extremist but nonetheless right wing political groups. Sounds familiar even if, again, we aren’t there yet in the UK .

So, I don’t want to pretend that we are anywhere near Aktion T-4, but neither do I want to pretend that such a thing is unimaginable. In his 1966 radio talk and essay Education After Auschwitz, Theodor Adorno asked how we could avoid a return to the barbarism of the holocaust. He concentrated on the psychological not because he thought social and political factors were unimportant but because he thought the former were more amenable to intervention. He argued for a sustained programme so that “education and enlightenment can still manage a little something”. Perhaps we could hope to see it start on the 60^th anniversary of his talk.

January 1, 2025

The reality of assisted dying – a sober, and sobering, account

A dispiriting feature of the current debate about assisted suicide legislation has been its low quality. Words like autonomy and dignity are used with no definition and the general style tends towards emotive case histories, marketing slogans and celebrity endorsement more reminiscent of the US presidential debates then a serious weighing of pros and cons. When the debate moved to parliament we weren’t served much better. Proposed legislation in the Commons and Lords has taken the form of skeleton bills with numerous so-called Henry VIII clauses that leave most of the detail to later executive decisions, while many of the key challenges are hardly touched upon, never mind carefully elucidated.

Into this space comes a new book – The Reality of Assisted Dying: Understanding the Issues Edited by Julian C Hughes and Ilora G Finlay (Open University Press. 2024) that offers a route to understanding the issues involved. Does it live up to that promise?

The book comprises 34 chapters written by 44 authors: clinicians from the main medical specialties you would hope to see; legal experts; ethicists and religious experts. A risk of multi-author books is wearisome repetition and difficulty in following themes. Helpfully and unusually an introductory section includes pointers to the location of discussion of key topics, and a lack of serious repetition suggests more careful attention to editing than is often the case.

I detect three super ordinate themes. First a careful elucidation of the meaning and relevance of terms such as autonomy, dignity, capacity, coercion and safeguards. These chapters are by no means abstract or over theoretical, instead they help to clarify the complicated issues at stake. In particular I liked the two chapters discussing autonomy, its features and the circumstances under which it should be constrained for the protection of others; they are models of clarity and concision.

A second theme covers the practical experiences in countries where assisted suicide or euthanasia legislation is already in place. Two main messages emerge. The first is a familiar one – there tends to be a move once initial legislation has been passed towards less restrictive criteria for participant eligibility and staff involvement and monitoring is limited, with no serious attempts to understand who is dying in such programmes. Second is a gradual change in culture as attitudes change towards end-of-life care and towards suicide.

A third theme covers the implications for staff and particularly doctors. In the doctor-patient relationship there can emerge a sort of expectation of involvement amounting at times to pressure. On the other hand apprehension from patients can make care more difficult to deliver; evidence suggests palliative care services decline rather than improve in countries where assisted suicide or euthanasia is legalised, while unassisted suicide rates either stay the same or increase.

There are inevitably some gaps in the coverage, reflecting mainly the limited existing evidence. For example there is little or nothing on the implications for staff other than doctors- nursing or care staff – or on the longer term impact on families and close others.

The overall tone of the book is negative towards the idea of legislating for assisted suicide or euthanasia and indeed both editors are well known campaigners in this country. It is difficult to see how it could be otherwise – the more one looks at the evidence from elsewhere the clearer it is that the bland reassurances of campaigners are not supported by evidence about how such legislation works in practice. Nonetheless the book should appeal to all readers. The presentations are well written, factually based and avoid a proselytising style. It is the best book I know about this individually and socially critical question and I recommend it highly.

A version of this review appeared in the December 2024 edition of the British Journal of Psychiatry

August 28, 2023

If you only read one book about identity, class and gender…is this the one?

In 1996 the book shop chain Waterstones launched a poll of the reading public asking for views on the greatest books of the 20th century. They published a list of the top 100 as a pamphlet The Books of the Century, invited Germaine Greer to review them for the house magazine and offered customers the chance to buy titles from the list at four for the price of three. The Waterstones survey was based on an idea from the New York Public Library’s Books of the Century, a list produced in 1995, and perhaps not surprisingly the two lists shared 50 titles.

Since 1996 a steady trickle of similar Lit Lists has come to my attention. In 1999 the French retailer FNAC collaborated with Le Monde in a survey that asked the question “Quels livres sont restés dans votre memoires?” and published a list of the top 100 (this book listing exercise seems pretty much always to produce a list of 100). Of the 16 lists I have before me the BBC tops the charts with four, starting with The Big Read Top 100 and now 100 Books Everyone Should Read, the 50 Greatest Books Of All Time and the top 100 Books You Need To Read Before You Die. Newspapers and periodicals like the genre: Time Magazine’s All Time 100 Novels is joined by offerings from the Guardian, the Daily Telegraph, the Times Education Supplement and Reader’s Digest.

Who gets to choose? Crowd-sourcing has been popular: typical is the Daily Telegraph’s poll of its readers to suggest a top 100 books for World Book Day 2007 and the Modern Library request of its readers to nominate both 100 best books and 100 best novels. Experts aren’t as disdained as you might imagine: Norwegian Book Clubs asked 100 noted writers from 54 countries; in 2002 the Times Education Supplement asked teachers and on the same theme the Guardian in 2014 asked contemporary writers to suggest set texts for English school children. The Modern Library asked its editors as well as its readers and Time magazine asked two of its resident critics for a list, idiosyncratically suggesting titles only from 1923 to the present. The Guardian has published the list of just one person (Robert McCrum) and in 2013 David Bowie published his own list of 100 must-read books later made the basis for an online book club launched by his son Duncan Jones.

The criterion for inclusion in these lists is not fixed – good reads, great books, all-time great books, 20th century books only. Most consist only of works of fiction although Waterstones original list included two nonfiction books – Nelson Mandela’s A Long Walk To Freedom and Delia Smith’s Complete Cookery Course. The Bible appeared along with 99 novels in the in the Telegraph’s top 100 books.

The cinema has a role to play and accounts for some of the more implausible entries. Jurassic Park? Trainspotting? Really? The film link probably also explains why Gone With The Wind features on more than one list including Le Monde’s. On the other hand some famous films were made of books that were already widely read and would have been here anyway – Lord of the Rings, the Harry Potter books, Catch-22, Rebecca. Film doesn’t account for all the outliers: I wonder how many people really voted for Jacques Lacan’s Écrits?

Two entries made me laugh out loud. The teachers list for TES was utterly persuasive and included Pride and Prejudice, Anna Karenina, and the Very Hungry Caterpillar. And in the writers’ suggestions for school set texts I enjoyed Hanif Kureishi’s proposal of his own book the Black Album. I awarded it a Schwartzkopf prize (for which it is the only contender from all the lists) named for the famous soprano who in her appearance on Desert Island Discs nominated seven of her own recordings.

Does a consensus emerge? Nine of the top ten books in the list of Most Begun but Unfinished Books Ever from the Goodreads website also feature in at least one of the 16 best books ever lists. Even so certain books and authors feature across several lists: Jane Austen , George Eliot, the Brontës – you can guess the other recurrent appearances in a predominantly Anglo-centric portfolio.

It is tempting to try and merge all the listings to produce an outright winner but heterogeneity among the lists makes it difficult to manage a pooling exercise. If you are keen to pick a short list you could choose books on the lists that have been written by Nobel Prize winners or that have won the Man-Booker prize; you could go with the wisdom of crowds and select books from the lists that also feature in the best sellers of all time lists, in which case you’re likely to be reading Tolkien, Rowling, Blyton and Dan Brown; you could remove the arrivistes, the fashionably popular, and stick with those that have proved enduring – leaning on the wisdom of crowds without much money or perhaps crowds that use lending libraries.

I’ll save you the trouble. There is only one book that appears on all 16 lists that I have collected. It is a novel, a good read, published in the 20th century, approved by teachers, literary critics, rock stars and the reading and book-buying public. It has been made into a film more than once. It touches on some of the great themes of the long 20th century – identity; the relation between money, social class and respectability; the treatment of women. It is The Great Gatsby. Who knows if it is the book of books but it is the undisputed book of book lists.

July 22, 2023

Who are The Autists?

I was prompted to write this post after reading a review of a book about autism in the Times Literary Supplement – James Cook writing about Clara Törnvall’s The Autists (TLS 23 June). So, it isn’t a review of the book, or even a review of the review. It’s a note about a common problem I see with the popular discussion of autism.

Törnvall is described as a successful journalist and TV and radio producer who has been diagnosed in adult life as having autism. Her description of what that means will be reasonably familiar to anybody who has encountered recent coverage of so-called high functioning autism among people in the public eye – she doesn’t pick up on subtext/banter, she struggles with eye contact, she doesn’t like being interrupted, she has a few (but intense) interests, she has a long-standing proneness to anxiety. Her book is presented as myth-busting but it has to be said some of the myths are rather underwhelming – woman can be autistic; autism isn’t a disease but a (neurodevelopmental) condition; autism’s causes are biological with an hereditary component. Still, apart from the occasional lapse into hyperbole most of it seems uncontentious enough.

What I found problematic, here and more widely, is the merging of two different ways of talking about autism – justified no doubt by the spectrum metaphor. Two because current discussion of autism treats it in two ways – as a disorder, often disabling, or as a manifestation of natural variation in human behaviour. To my mind these require different vocabularies. In the former case it is appropriate to talk about diagnosis and to regret the lack of a cure (as Cook does); in the latter we should use the vocabulary of recognition of (neuro)diversity and regret the inflexibility of modern social life. This distinction calls for clarity about what defines the boundaries of autism as a disorder (qualitatively different manifestations and associated severity of disability), but that is missing from Cook’s review and from much public discussion of the topic. Instead the language of diagnosis is used across the spectrum, and we are invited to be optimistic that more and more people (and especially women and girls) are receiving the diagnosis.

I think this merits pause for thought. Overenthusiastic application of diagnostic labels to historic figures may be merely silly (Beatrix Potter? Really?), but we should be careful not to categorise all sorts of people (especially the young) as so-called Autists on the basis of eccentricity, social awkwardness or a tendency to quirky infatuation with objects. Labels can be damaging; maybe not everybody will benefit when they’re growing up from being told (or others being told) that they’re an Autist. And you don’t need a diagnosis to try noise-cancelling headphones.

At the same time, there is something potentially damaging to the interests of the severely disabled if we appropriate the language of disorder to describe normal variation. The person with a severe disabling autistic disorder – who may be prone for example to impetuous running, persistent hand-flapping or screaming meltdowns – is not recognizable in accounts of people who are, if you like, on the other end of the spectrum. So, there is little evidence that contemporary popular discussion of autism, concentrated as it so often is on those often described as high-functioning, does much for those who have highly disruptive (sometimes called challenging) accompanying behaviours and are unable to care for themselves or live independently. Awareness isn’t raised nor campaigns triggered for those most in need, and as a result it remains the inadequacy of our provision for people with a severe disabling autistic disorder that constitutes our society’s main failing of those with autism.

Postscript: an abbreviated version of this comment has been published as a letter in TLS 21 July 2023.

May 23, 2023

Adult Human Female – a documentary that’s about more than gender.

An unremarkable film that nonetheless raises some far-reaching questions.

I recently watched the documentary Adult Human Female. It gives an outline of the main arguments raised in what we might call the gender critical response to gender identity theory as it is applied by trans activists. I tuned in after seeing an article in the Guardian newspaper reporting on a row taking place at Edinburgh University about whether or not it should be shown on campus. It isn’t difficult to find – it’s readily available on YouTube for those wanting to try and understand what the dispute is about. For me, the film raised three questions, only one directly related to the Edinburgh story.

The first question is, I suppose, why does anybody think the film should be banned? It takes the form of inter-cut pieces to camera from various people with some claim to relevant expertise – in law, medicine, and philosophy for example. There’s nothing here that would be novel to anybody who has taken even a non-specialist interest in trans debates in the last few years. The style is, in places, challenging but there’s nothing remotely illegal in it, or anything that could be reasonably described as aimed at inciting violence or hatred towards trans people. The main objection I can find online is the usual one that any opposition to the gender identity theory proposed by trans activists must necessarily be offensive and transphobic.

Two other questions came to mind while I was thinking about this: neither at all original but prompted, I think, by watching the case being presented on film rather than by reading about it.

One of those questions is – I can see what’s gained by tackling single issues as case studies, but what’s lost? The specific example raised by the film is sexual violence in prisons. For sure, I think most people can see that putting violent sexual offenders with male genitalia into female prisons is not a great idea. But the focus on this issue can easily overshadow a wider problem of sexual violence in prisons. Not long after I watched the film I read a newspaper report indicating that in the past 13 years there have been nearly 1000 rapes and more than 2000 sexual assaults in our prisons. The main lesson is that overcrowding and understaffing mean that it’s all but impossible to make prisons safe for those in them. Rather lost, then, in the furore about the threat from trans women is that sexual violence in prisons is best viewed not through the lens of identity politics but as an indictment of national government policy, and especially that pursued by successive Tory governments in the name of austerity.

And the third question – gender reassignment, sex and sexual orientation are all protected characteristics under the Equality Act 2010, but what exactly is the point of protected characteristics? They are difficult to define (see eg Malleson K. Equality law and the protected characteristics. The Modern Law Review. 2018 Jul;81(4):598-621.) and despite now extending to nine they still don’t include obvious targets for discrimination like body weight, socio-economic status or non-disabling mental disorder. When Diane Abbott MP wrote an ill-considered incoherent letter to the Observer newspaper about racism and prejudice, she was accused of trying to argue for a hierarchy of discrimination where none exists. And yet that feels like the whole point of protected characteristics – they are labels for sorts of discrimination we want to legislate against and therefore implicitly they label by omission states that don’t merit legislation.

Maybe I misunderstand, but it strikes me that these aren’t easy decisions to make, and they are made harder by the style of public debate that involves striking positions and affecting certainty – with the direction of travel seeming to be away from nuance and acknowledgement of uncertainty. What a shame that Edinburgh University students can’t lead the way in modelling what a proper debate might look like.

November 2, 2022

A book about suicide research and a suicide researcher

Rory O’Connor is a health psychologist who has published extensively on suicide. He is also active in discussions about suicide aimed at the general public and about suicide prevention policy, especially in Scotland where he lives and works.

His book When it is Darkest: why people die by suicide and what we can do about it is divided into four parts, covering the main facts (and misconceptions) about suicide, its main causes, what preventive interventions might be effective, and supporting people who are suicidal or who are living in the aftermath of the suicide of somebody close. Further resources are mentioned throughout and there is a list at the end. The emphasis, especially when considering causes, is on the psychology of suicide and includes a review of the author’s own framework for organising the disparate associations with suicide into what he calls the Integrated Motivational-Volitional Model.

O’Connor’s aim is to combine personal and professional perspectives. The style is informal, written in the first person. Interspersed throughout are anecdotes about his personal experiences, his contacts with people who have felt the impact of suicide in another or of feeling suicidal themselves, and his career in suicide research. At the same time it is in parts quite technical and ends with 48 pages of academic references, with a leaning towards his own research.

The book covers a lot of ground without being exhaustive or exhausting, especially of course in its review of prevailing psychological theories. And it offers a sustained attack against fatalism in the face of suicide and the apparent impossibility of eradicating it: we can move to understand more and to develop effective prevention strategies.

No book like this can be entirely comprehensive but there are some important gaps. There is too little on the personal and social impact of drug and alcohol misuse, either as a risk for the individual or as part of the reason people become isolated or alienated from social support. Mental disorder and its treatment may not be the most important part of suicide prevention but even so it deserves more consideration than it gets. Many of those who die have been in contact with helping agencies – GP, the mental health services, university counselling services or whatever – and there is not much here about how such services might do better or what families feel about this aspect of how tragedy might have been prevented. Suicide needs to be seen in social and cultural context if we are to focus public health interventions. Psychology can’t explain the wide regional variation in rates, and some of these wider issues feel undercooked. In a laudable attempt to combat negativism the effectiveness of suicide prevention interventions is overstated.

What about readership? It requires high levels of general and scientific literacy and that will limit its utility. The presentational style will not suit everybody. I personally didn’t like the idea of calling suicide The Big S. I also wasn’t keen on the idea that suicide is not usually about the desire to die but about the desire to end suffering. After all “suicide” means death as the result of an act intentionally designed to end life, so this is a paradox that on close inspection just doesn’t make sense. There are few accessible books on suicide for the general reader (Mark Williams’ Cry of Pain is one, and the Help is at Hand booklet for those bereaved by suicide is excellent); this text will therefore find a place as a useful review for the interested and well-educated non-specialist.

January 17, 2022

Culture wars, economic hardship and disdain for mental illness and learning disability – a dangerous mix.

Germany’s asylums between the world wars housed a mixed population – mainly of people with a learning disability or a severe and persistent mental illness. These people became the focus of Nazi interest for two reasons.

First – and this isn’t as widely known as it should be – residents of the asylums were the first large scale victims of the Nazi’s mass murder programmes. The technologies used later, on Jews, Roma, homosexuals, communists and others, were first developed in what is usually known as Aktion T4 (named prosaically enough for the original HQ address Tiergarten 4). That is, T4 developed gas chambers as an efficient method of killing, purpose-built crematoria for disposal of the bodies, and an associated propaganda programme that is hard not to see as enabling a sort of collusion with the general public. An estimated 200,000 people from the asylums were eventually killed in T4 and its sequelae. This history is covered in some detail in Michael Burleigh’s extraordinary 1994 book Death and Deliverance: “euthanasia” in Germany 1900-1945 (Cambridge UP, listed unbelievably as out of print now).

An apparently separate campaign waged by the Nazis took the form of what we would now call culture wars, with modern art as a particular target. The infamous Entartete Kunst (Degenerate Art) exhibitions curated by party members and promoted by Goebbels are well known, but less so is the link to asylum art. A number of key modernists had been intrigued and influenced by the work of apparently mad people – so-called art brut – a significant collection of which had been accrued by Hans Prinzhorn at Heidelberg and valued as being artistically important in its own right, not simply as a window into the mind of the insane.

The Nazis exploited this association in carefully managed presentations associated with the message – look how modern art is no different to the art of lunatics and imbeciles and yet you are duped into paying huge sums for the public galleries to own it. With the related message of course – it’s all part of a (Jew-orchestrated) conspiracy to undermine true Germanic society through undermining its culture.

The two stories inevitably intersect, with many (amazingly not all) of the asylum art works destroyed and the artists who made them perishing in the mass euthanasia programmes. This story is well told in a new book The Gallery of Miracles and Madness by Charlie English – unlike Burleigh a journalist rather than historian, with a predictably different but nonetheless well researched and engaging style.

The asylum artists who died in the T4 programme were caught in a perfect storm – of culture wars used by an authoritarian government to garner support for their wider political project; the motivating force of economic hardship coupled with the idea that alien enemies are to blame; the promotion of “euthanasia” as a solution to the societal problem of burdensome lives. Sound familiar?

January 9, 2022

Two excellent books about psychosomatic illnesses

There’s something both familiar and unfamiliar about neurologist Suzanne O’Sullivan’s book It’s All in Your Head:stories from the frontline of psychosomatic illness, which discusses her experience of psychosomatic illness while working as an NHS consultant.

The familiar first: O’Sullivan describes typical cases that come up in her clinical practice – seizures that aren’t due to epilepsy; weakness or paralysis when there is no identifiable neurological disease; persistent symptom states like chronic pain or fatigue when there is no apparent explanatory pathology. She is not talking about neurological diseases waiting to be diagnosed but about presentations in which “no disease is found because there is no disease to find. In those people the medically unexplained symptoms are present, wholly or partially, for psychological or behavioural reasons”. Refreshingly uninterested in worrying about terminology, she calls these conditions psychosomatic.

The book’s case histories contain some familiar details – responses to the diagnosis range from bemusement to downright hostility and rejection. And contact with a close family member or friend can provide revealing detail about likely causes or perpetuating influences.

And the unfamiliar? Like most doctors, O’Sullivan sees the cause of psychosomatic conditions as being primarily psychological and in her own practice she regards psychiatry as a part of the management plan. However, she is (far) more than usually willing to state this unambiguously and is interested herself in understanding what are the underlying problems. Here she encounters such a variety of stories – complicated bereavements, family and other interpersonal predicaments, gender discomfort, loneliness and more – that although she sees their relevance she cannot really discern a common theme.

O’Sullivan has clearly read more widely than many a clinician, for example in the history of psychosomatics and psychodynamic theories, and she is comfortable with the idea that the mechanisms driving psychosomatic presentations are unconscious and often involve a sort of dissociation – that is a disorganisation of usually-integrated mental processes. She sees the symptoms as having a function, perhaps defending against emotional breakdown or in some other way helping the patient adapt to the otherwise intolerable.

The book throws down a gauntlet in the form of a question: “If psychosomatic symptoms are so ubiquitous, why are we so ill-equipped to deal with them?” It is picked up in O’Sullivan’s second book on the topic The Sleeping Beauties and other stories of mystery illness, which describes her exploration of a number of “mass” episodes of psychosomatic illness. This could be a horrid parade of grotesques but it isn’t, instead providing a sensitive exploration of external social influences on illness and its course. Everywhere there are “…moral dilemmas, inconceivable choices, inequality” and the unenviable role of women in society.

The answer to the gauntlet question comes at least in part from the medical and other social and official responses, which do not come out of it well. They are often disparaging or dismissive, and mistrust of officialdom plays an important part in the difficulty of forming a shared therapeutic response. An important observation is made about the part played by official responses that simultaneously confirm the absence of underlying disease while at the same time downplaying or ignoring the psychological and social. This loops back to the first book with a comment about the currently favoured label of Functional Neurological Disorder which is “…used to imply that the brain is not functioning – therefore (rather ham-fistedly, I would say) placing the source of psychosomatic disorders firmly in the biology of the brain” – where O’Sullivan believes it does not belong.

Again, psychosomatic illnesses are seen as serving a purpose: “…perhaps we need release valves and coping mechanisms, face-saving ways of addressing conflict and grappling with ambivalence. Sometimes, embodying and enacting conflict is either more manageable or more practical than articulating it”.

Where next? There is work left undone by these two books. One task is that more work is needed to link lessons about the causes of what we might call the epidemic cases in Sleeping Beauties to the sporadic cases in All in Your Head: in particular to ask – is there really no common theme to the apparently disparate adversities that lead to onset of psychosomatic illness? This links to the need to consider other explanations for the onset of symptoms in the face of such adversities. We accept that depression can follow loss, anxiety can follow threat and PTSD can follow trauma, and we usually see such conditions as symptomatic breakdowns rather than adaptive responses. Perhaps we could look at psychosomatic illnesses in the same light, as manifestations of how we break down when faced with adversities that represent (the common theme) persistent and seemingly unresolvable conflicts, challenges and dilemmas.

August 12, 2021

Helpful words for people who self-harm

Emergency Departments and their associated mental health services don’t always get good press when it comes to feedback about how they respond to people who repeat self-harm and attend for help: this leaflet which has just become available online is a positive contribution and a good example of collaboration between statutory services and the people who use them. Just the fact that there is such a leaflet is itself a positive message – saying that the service takes the problem seriously. And the content is supportive and practical – it certainly bears the hallmark of having been written by people with personal experience. Maybe a small step but nonetheless a step in the direction of building bridges and improving mental healthcare. To be emulated!!

June 27, 2021

Searching for meaning in a book “about” mental illness.

I detect a drift into the mainstream of the idea of personality disorder, and in an attempt to understand why I have been reading some pop books – perhaps the best known being Ronson’s The Psychopath Test.

The book is subtitled “A journey through the madness industry”: it’s never clear what Ronson means by the madness industry but it’s true that the main structuring device is a journey, although it’s from one person to another rather than (unfortunately) from one idea to another.

We start with Ronson meeting a neurologist in a café in London, and an anecdote about an anonymous incoherent book she has received. There are warning signs here about this careless superficial book – the person he’s meeting isn’t a neurologist and even a casual conversation with a few mental health clinicians would have marked his card about how common it is, if you work in that world, to receive unsolicited books and articles from people hoping to interest you in their idiosyncratic view of how things work, and how little such gifts really tell you about either mental illness or mental health services.

It’s difficult to identify a theme in what follows. To start with it seems to be an exploration of psychopathy, which Ronson has been persuaded is routinely diagnosed in clinical and forensic practice on the basis of Hare’s Psychopathy Checklist and as an explanation for which he mentions repeatedly a half-baked idea about amygdala function. So we get a visit to a special hospital, a skimmed review of some aspects of the Oak Ridge scandal, and an interview with a ruthless businessman, but half way through he seems to lose interest in that line of thinking and we get an account of David Shayler’s mental illness, an interview with a guest-booker for (among others) the Jeremy Kyle show, and a drift off into stuff about DSM and the overdiagnosis of bipolar disorder in children in the USA.

All this is sketchily researched. The piece about the Oak Ridge scandal doesn’t mention the Class Action lawsuit started in 2001 against The Ontario Government and Drs. Elliott Barker and Gary Maier for breaching the basic human and civil rights of participants. The account of Shayler’s mental illness has no obvious point in relation to understanding ideas about psychopathy and the egregious picture of Shaler dressed as a woman suggests the main aim is to invite sniggering. In his report of an interview with Hare himself, there’s a recycled anecdote that comes from the introduction to Hare’s 1993 book about psychopathy. The interview with Charlotte Scott (the Jeremy Kyle producer) is mainly a rewarmed version of her earlier mea culpa published in the Guardian.

The people Ronson interviews have a habit of speaking in odd tabloid journalese, issuing stupid one-liners like if you’re worried about being a psychopath then you’re not one. Adam Curtis asks him – what does all this say about our sanity? – one example of recurrent cod philosophy about the difference between sanity and insanity that reminded me of nothing more than Rosenhan’s fraudulent paper On Being Sane in Insane Places.

Reviewers, at least those quoted in the book, apparently find it all hilarious. Will Self says he found himself “laughing like the proverbial loon” for page after page. And this coupled with a comparison one of them makes between Ronson and Louis Theroux provides a clue about what is going on. Ronson tries disarming mentions of his own tendency to anxiety and of the intrusive and disabling nature of mental illness, but in truth this is Barnum and Bailey psychiatry, a parade of grotesques (people and ideas) at which we might laugh or shudder depending upon our disposition. Its appeal is to Hollywood stereotypes – Gordon Gekko meets Michael Corleone – and doesn’t offer anything interesting about the contentious diagnosis of personality disorder (antisocial or otherwise) or sympathetic to the popular understanding of mental illness or the people who try to treat it.

I guess it’s that appeal to the familiar that accounts for the popularity of this grim book – the offer of a reassuring romp through a landscape populated by really odd people who aren’t like us. I didn’t find it remotely funny, just rather unpleasant.

Allan House

Category: Reviews