Without schizophrenia there would be no psychiatry. Yet – whether because of underfunding, lack of a coherent treatment philosophy, post-modern instrumentalism, the malign influence of Big Pharma, the intractable nature of the condition, or scientific ignorance – it is hard to deny that things are far from even good-enough in services for people diagnosed with schizophrenia and their families. Most psychiatrists will have had calls for help from distressed relatives or friends about a loved one behaving oddly or clearly mentally unwell, for whom no satisfactory treatment seems forthcoming: no psychiatric beds, professionals who do not answer the telephone, a psychiatrist unconcerned or on leave, ineffective medication producing bad side-effects. At times it is hard not to feel angry, ashamed and impotent about the failings of one's profession.
The International Society for the Psychological Treatments of the Schizophrenias and Other Psychoses, whose summation and manifesto this book is, takes as its starting point the limitations of a narrowly biomedical approach. In place of – or, from your reviewer's position, ideally alongside – antipsychotics, genetics and brain science, there is a need for a humane, person-centred, relational, family-oriented approach, offering de-stigmatisation, continuity, optimism and understanding. The roots of this come from two main sources, both of which are traced in the historical section of this compelling compendium. First is the psychoanalytic perspective, however questionable in its details, brilliantly expounded here from a Kleinian position by Murray Jackson and ethnographically by Lyn Chua. The second is the ‘needs adapted’ approach to mental illness, described by some of its leading practitioners – Alanen, Rosenbaum, Cullberg – a manifestation of Scandinavian social democracy miraculously managing to finesse the oxymoron of institutional yet personalised care.
Inevitably there are some reservations about this book. It suffers from the unevenness of tone and quality endemic in multi-author tomes. Conspicuously absent are psychosocial psychiatry's big beasts – Leff, McGorry and Burns come to mind – who might have lent academic gravitas. Although its critique of conventional services is stringent, the alternatives offered are in the main merely vaguely humanistic. Little attempt is made to delve into the complex relationship between genes and the environment, the exact role of trauma in psychosis, or ways of devising services that meet both psychodynamic and scientific and economic criteria. Silver and her colleagues argue that the tide is turning and that the psychotherapeutic relationship is once more moving to the mainstream of mental health services. Let us hope that she is right, and that this book will play a full part in that shift, not drowning but waving.
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