James Patrick Watson MD, FRCP, FRCPsych

The Other Side of Silence: A Psychiatrist's Memoir of Depression By Linda Gask Summersdale 2015, £9.99, pb, 272 pp. ISBN: 9781849537544

Linda Gask is an eminent academic psychiatrist with an outstanding international reputation. I state this upfront because it is none too obvious from this book

James (Jim) Watson, who died after a stroke on 3 August 2016 aged 80, was among a small band of British psychiatrists who trained in the 1960s and 70s to take psychiatry out of the asylums and establish robust services in general hospital and community settings. They were also responsible for developing a wide range of specialist mental health services. Jim was deeply committed to improving the standards of clinical care, from early implementation of behavioural therapy through inpatient group therapies and the understanding and management of behaviour on hospital wards. He championed the relationship between staff and patient as key to recovery in psychiatry, deploring the move to ever fewer acute beds, reductions in staffing levels and organisational changes that resulted in fractured continuity of care and consequent erosion of the essence of good mental healthcare.
His clinical interest was reflected in his research, which included evaluations of community mental health, telemedicine and treatments for psychosexual disorders, for which he established one of the earliest specialist multidisciplinary clinics and training programmes in Britain. With his personal style, he led a vibrant, outward-facing, creative and very happy department, in which a serious commitment to excellence went along with a refreshing lack of pomposity and a keen sense of work being enjoyable. This was in no small part due to Jim's dedication to improving the quality of psychiatric services, not least by ensuring excellence in the education and training of psychiatrists and by making sure that medical students had a varied and stimulating exposure to psychiatry.
Under his leadership, Guy's Hospital Medical School had the enviable reputation of having the highest proportion of medical students opting for a career in psychiatry. In the postgraduate field, he was an inspirational leader of the South East of England training scheme for psychiatry, chairman of the Royal College of Psychiatrists' Specialist Training Committee and chairman of the Association of University Teachers of Psychiatry. In the mid-1990s he launched an MSc in mental health studies -a programme directed at professionals from all disciplines involved in delivering mental health services. This course was extraordinarily successful: consistently oversubscribed, with unprecedented numbers of applicants. Its success spawned further collaborations with university departments overseas, notably in Egypt and the Middle East, where he worked with colleagues to develop a diploma in psychiatric practice for wider dissemination across the region. His determination to improve mental healthcare led him to a lengthy involvement with mental healthcare in Pakistan. From the early 1990s, he collaborated with colleagues there, visiting regularly and helping to train staff for mental health clinics in rural settings that have now expanded to more than 15 centres, some of which are co-located with a mosque and madrasa. Jim was also connected with several other international projects involving, among other countries, Greece and the former Yugoslavia.
Jim was the eldest of three sons. His father was a teacher and his mother a doctor. He attended the Roan School for Boys in Greenwich, where he excelled academically and in sport. After retirement, Jim continued to contribute actively to the field, providing teaching and mentorship to psychiatrists in the Sussex Partnership NHS Foundation Trust. He maintained his collaboration with colleagues in Pakistan, advising on setting up a new School of Nursing as well as the development of a service and training resource for children with learning disabilities and autism. He took part in continuing education meetings with colleagues in Cheltenham, chaired a patient support group in a local general practitioner practice and was trustee of the Soundwell Music Therapy Trust which provides music therapy for people suffering from mental ill health.
Jim enjoyed a very happy family life, having four sons whose diverse careers in music, international school teaching, hospital medicine and clinical psychology were a great source of pride and affection. In 2002, he and Christine exchanged London life for a Cotswold home where he could indulge his enthusiasm for vegetable gardening -a throwback to his maternal ancestors who had traded as market gardeners, supplying mustard and cress to Queen Victoria.
Jim's passing will be felt as a great loss to psychiatry and by the many clinical and academic colleagues who had the privilege of knowing and working with him.
Tom K. J. Craig and Nick Bouras

Irving Gottesman
American psychologist and behaviour geneticist who radically changed traditional views of schizophrenia The research and writings of the clinical psychologist and behaviour geneticist Irving Gottesman, who has died aged 85, radically changed the way psychologists and psychiatrists think about schizophrenia and, more generally, about what Irv called the 'origins of madness' (which was the subtitle of his 1991 book Schizophrenia Genesis). His path to becoming a dominant figure in psychiatric genetics began at an international conference in 1961 when, as a psychology lecturer at Harvard University, he was introduced to Eliot Slater, director of the Medical Research Council (MRC) psychiatric genetics unit at the Institute of Psychiatry in London, and the doyen of psychiatric genetics of his day.
Slater agreed that Irv might join his unit provided he brought his own funding. Irv duly won a three-year grant from the US National Institutes of Health (NIH) and arrived in London in 1963. Slater was an austere and imposing figure and the building that housed his unit was equally austere, a makeshift postwar prefabricated building, affectionately known by staff as 'the hut', on the fringe of the campus of the Maudsley hospital in Camberwell. Although its physical environment was poor, the unit had much intellectual capital, provided by Slater himself, his deputy director Valerie Cowie, a psychiatrist trained in the new techniques of cytogenetics, and a brilliant if self-effacing senior research assistant, Jerry Shields.
The hut also housed another world-class asset, the Maudsley Twin Register. Begun by Slater in 1948, it contained the names of all patients entering the Maudsley and Bethlem Royal hospitals who had been born a twin. Irv's successful NIH proposal was for a study of schizophrenia using the register and Slater paired him with Shields to carry out the work.
The principle of the classic twin method is straightforward. Identical or monozygotic (MZ) twins share all their genes, whereas fraternal or dizygotic (DZ) twins share half their genes. MZ and DZ twins usually share the environment in which they are raised. Therefore if a disorder such as schizophrenia shows greater co-occurrence ('concordance') in MZ versus DZ twins this is evidence of a genetic effect. Similarly, absence of 100% concordance in MZ twins is evidence of environmental effects. The Gottesman-Shields Twin Study (1967) clearly confirmed the proposition that both genes and environment play a role in schizophrenia (at a time when theorists in the US and Britain were blaming parents, particularly mothers, for 'causing' the disorder).
One of Irv and Jerry's major contributions was to propose a plausible mode of inheritance for schizophrenia. One of the big puzzles about familial common diseases at the time was that none (including physical disorders such as heart disease, diabetes, some cancers) showed the simple ratios of affected:unaffected within families predicted by Mendel's laws.
The most widely accepted solution for schizophrenia was Slater's model invoking the idea of a dominant gene with 'incomplete penetrance' (some people carry the gene but do not show the disorder). Irv and Jerry boldly proposed an alternative polygenic model, derived from the work of the Edinburgh mathematical geneticist DS (Douglas) Falconer, in which liability to develop schizophrenia has a normal 'bellshaped' distribution in the population (like height or weight) contributed to by many genes. But, unlike height or weight, there is a threshold effect, so that only the 1% or so of the population with the highest liability show the disorder.
The Gottesman-Shields polygenic model of schizophrenia eventually gained ascendancy, even though the final clinching piece of evidence emerged only in 2014 with the publication of a huge genome-wide molecular study of tens of thousands of subjects showing that more than 100 genes are involved.
Another far-reaching conceptual innovation was their idea of 'endophenotypes'. Irv and Jerry proposed in their 1972 book, Schizophrenia and Genetics, that the genetic basis of psychiatric disorders could be better understood, and specific genes more readily identified, by the discovery of biological COLUMNS Obituaries Irving Gottesman used a register of twins at the Maudsley and Bethlem Royal hospitals in London for his study of schizophrenia. Photograph: Lisa Miller, University of Minnesota/theguardian.com characteristics that lie a step closer to DNA than the clinically observable symptoms and signs, the 'exophenotypes', by which disorders are defined. Irv continued to elaborate the endophenotype concept over ensuing years and it provoked thousands of papers by others, a sort of Higgs boson for biological psychiatry. Unlike the Higgs particle, the existence of endophenotypes has yet to be proved experimentally for any of the major disorders.
Irv was born in Cleveland, Ohio, to Hungarian-Romanian Jewish emigre parents, Bernard, an insurance agent, and Virginia (nee Weitzner). He was a science enthusiast from an early age and began a physics degree while serving as an officer in the US navy, later switching to psychology. He completed his PhD at the University of Minnesota on the genetics of personality but initially had great difficulty in getting his findings published because of the prevailing orthodoxy in US academia in the late 1950s that behaviour was entirely due to nurture and nothing to do with nature.
After his postdoctoral fellowship in London, Irv returned in 1966 to the biology-friendly department of psychology in Minneapolis and set up one of the first behaviour genetics training programmes in the US. He thereafter held chairs in Washington University in St Louis  Linda Gask is an eminent academic psychiatrist with an outstanding international reputation. I state this upfront because it is none too obvious from this book -owing to her self-effacing style -and in my opinion, it is very relevant. I should also declare an interest as Linda and I were in the same year at Edinburgh University's medical school and I have heard small snippets of this story from her over the ensuing years.
In this excellent book Linda Gask shows what may be achieved despite living with a recurrent depressive illness; hope emerges even from her darkest moments and this work should encourage many. It is striking for its frankness and honesty -no small achievement given that she clearly must have known it would be read not only by colleagues, but by patients past and present, some of whom would have known little about her. She even mentions her failure to pass the MRCPsych exam at the first attempt and describes hersurprising to some! -experience of how sensitive and supportive a very senior academic colleague was at this time.
The book chronicles her life and career and the impact of her illness, including thoughtful reflections on its roots (in her early life). She teaches us about depression through the mirror of her own illness and that of her patients, and brings this to life through the use of clinical vignettes. She emphasises the importance of both biological and psychosocial factors in the origins of this illness and her description of treatments is both fair and accurate. Her accounts of her interactions with patients are particularly helpful and should be of value to any doctor, whether trainee or senior. I especially valued her comments on those whose failure to improve is ascribed to personality disorder, which is, alas, an all too common tactic of many psychiatrists. This is an exceptional book and should be read by many, both doctors and patients. The high-profile endorsements on the cover are entirely deserved. Some years ago Linda wrote another excellent book entitled A Short Introduction to Psychiatry. I gave it to many medical students to read. I will give this to many more.
one of this book's functions is to assist supervisors of MBT-G in rating therapists on quality of technique and adherence to the MBT-G guidelines. So, at first sight, you might not be drawn to this publication unless you are a group therapistand trained in MBT-G.
However, I encourage people who are not psychotherapists or trained in MBT to consider this manual as a useful introduction to the concept of mentalising. Mentalisation is an old concept in psychology and refers to our human ability to understand ourselves as agents who make choices and form intentions. This ability includes an understanding and perception of other people as having minds that form intentions, which are real and distinct from our own.
All psychiatrists need a valid and reliable model of mind with which to work clinically, and the concept of mentalisation fits the bill. Mentalising capacities are crucial to our social existence, across the lifespan; failure to mentalise successfully is a feature of all mental disorders. The healthy mind is constantly mentalising, with odd lapses in reasoning and dialogue that are neither too severe nor too frequent. When the mind is disordered -through any cause -mentalising fails and immature modes of thinking dominate, often with catastrophic results in terms of social identity and function. The restoration of mentalising then becomes a crucial aspect of all psychiatric treatment.
There are several books on mentalising and mentalisationbased therapy by Karterud's collaborators in the UK (Peter Fonagy and Anthony Bateman) and the USA (Jon Allen). I found this particular book of interest because it approaches mentalising from a philosophical perspective: that of hermeneutics and how we interpret the world. Karterud suggests that the way we interact with and interpret others comes before our experience of our own minds; that the social self is primary in developmental terms. Such a relational approach to mind is a vital complement to models of mind that are either atomistic or mechanical. We have no evidence that the mind works like a machine, but there is growing evidence that the mind is organic and dynamic, responding, developing and evolving in response to the environment -which, for human beings, is the experience of other minds.
MBT is recommended by the National Institute for Health and Care Excellence for the treatment of borderline personality disorder and treatment trials of MBT for antisocial personality disorder are ongoing. But understanding mentalising is a broader objective which all psychiatrists need to achieve. This work is obviously essential reading for trained MBT-G therapists, but it is a useful introduction to mentalising in its own right.  I find myself split in my thinking about this book. On the one hand, I can see its appeal as an airport read; requiring little effort to get through, and full of celebrity and political commentary as well as easily digestible chunks of scientific evidence.
At that level, it's enjoyable. Especially so when it allowed me to neatly project all my ugly narcissism into reports about Kanye West and Sarah Palin. Perhaps a first for them to be mentioned in the Bulletin, no doubt adding to their narcissistic satisfaction, should they or their agents be subscribers.
At another level -and this is where I'm split -it is an exercise in quite contemptuous character assassination. Kluger's portrayal of his example subjects is cold and sneering at times. Furthermore, he often seems to conflate the concepts of narcissism and psychopathy, leading to a sense that the more narcissistic of us are one step away from becoming serial killers or workplace tyrants.
There are only brief mentions of how the presentation of narcissism might be related to inner vulnerability, and this left me wondering if Kluger might have been looking at the mirror crack'd. Even as I write this I wonder if I too am succumbing to the narcissistic appeal to feel superior to what we read -this is hard to contain when I am a UK reader and the author mentions former prime minister 'Malcolm Browne' (referring to Gordon) and the football team 'Aston Vista'. Such mistakes feel sloppy, arousing my narcissistic contempt; perhaps a response to feeling as though the author does not care enough about the UK to check facts properly.
Coming from a psychoanalytic tradition, where this subject has been a preoccupation of clinicians since Freud's 1914 On Narcissism: An Introduction, Kluger's view on the dilemma of the narcissist saddened me. We are all narcissists to some degree; it's what allows us to get out of bed in the morning and feel like we are good people who might be loved. The pathological narcissist is someone who has found their early experiences to be lacking and who has lost their trust in acceptance by others. To manage this insufferable situation, they create an outer self that is contemptuous of need and full of itself, and project away their dependent, vulnerable selves onto others. Sometimes, they are contemptuous and dismissive of needy people. Sometimes, if society is lucky, and the person more creative, they will look after others who are vulnerable -to repair the damage they feel inside themselves.

The Vegetarian
By Han Kang Portobello Books, 2015, £7.99, pb, 160 pp. ISBN 9781846276033 This short novel, winner of the Man Booker International Prize 2016, is translated from Korean and tells the story of Yeong-hye, a young woman in modern day South Korea. It is a fascinating and thought-provoking narrative that starts with Yeong-hye choosing to become vegetarian. This seemingly unremarkable and straightforward choice turns out to be nothing of the sort -vegetarianism is almost unheard of in Korea but, more importantly, Yeong-hye is on the verge of serious mental illness. Yeong-hye's stance is challenged by all of those around her, but she remains steadfast. It transpires that becoming vegetarian is the prodromal seed of an all-encompassing psychosis which will take Yeong-hye on a journey from being vegetarian to believing that she is vegetal in nature and therefore food is superfluous to her needs.
Clinicians will be acquainted with the somewhat perplexing process by which this intricate and emotive story develops. Information appears not in neat chronological order but in a tangle that needs some work to unpick. Yeong-hye's story is told in three parts. We hear first from her husband, then her brother-in-law and finally her sister, all the while following the unravelling of Yeong-hye's internal and external world, in a tale that deepens in complexity and darkness as it unfolds. Interspersed italicised monologues allow us a brief glimpse of Yeong-hye's muddled (and muddling) mind. By portraying thoughts that mingle with dreams and memories in a way that confuses the reader as to what is real and what is not, Kang elegantly conveys something of Yeong-hye's mental state. We don't hear much about Yeong-hye's premorbid adult life, other than through her husband, who says she was 'ordinary' and functioned to his liking. We can, however, sense the weight of the oppression she is subject to and guess that although becoming vegetarian may have marked an important transition point in her illness, it is unlikely to have been the beginning of it. The husband's account of Yeong-hye's condition reveals, through the lens of his own narcissism, a shocking lack of concern for his wife beyond her role in satisfying his immediate needs. He views Yeong-hye as an object and a possession, and this is most apparent in his remorseless and matter-of-fact description of raping her. A meal with her husband's boss tells us something about society's inflexible expectations and demonstrates that the lack of compassion experienced by Yeong-hye is multifaceted. We see Yeong-hye's father in action and learn a little about her upbringing; as a result, the degree to which she has been repressed and forced to endure throughout her life becomes clearer, and the powerful, subversive resistance enacted through her illness begins to make sense.
The second part of the book is equally disturbing and leads us to the brother-in-law, a less than successful videoartist who becomes obsessed with Yeong-hye's pre-pubertal appearance and whose paraphilic behaviour uncomfortably exposes her vulnerability.
In the final part of the book, several years later, we join Yeong-hye's sister In-hye as she visits her in a psychiatric hospital. In-hye now faces the repercussions of preceding events and the resulting family disintegration. We hear more about the sisters' childhood and the abuse which they experienced; we learn that In-hye continues to suffer her own anguish as a corollary and that she in some way envies her sister's position. This is an astonishing book. Strange, surreal and beautifully written. The idea that people could find themselves surrounded by such brutal inhumanity and lack of connection that they reject their current existence and instead opt for transformation into a life form that does not involve thought or feeling is indescribably sad, but probably not beyond imagination for most psychiatrists. Readers will find that they must piece together the jigsaw of Yeong-hye's life, and as hard as they try, the image is not clear and the final pieces can never be found -an experience to which most of us surely relate. The resurgence of psychedelic research has opened up a new realm of possibilities in consciousness research. However, public policy surrounding the use of psychedelics has struggled to acknowledge that they may be effective therapeutic treatments or tools for enhancing self-awareness and exploring consciousness. Highlighting the need for redress, this anthology argues that current international public policy is not scientifically or culturally informed and is thus divorced from the empirical evidence that is supposed to inform its construction and implementation.
The book examines the complex policy issues surrounding psychedelic-based healing modalities and calls for an urgent shift in policy regulating the research and application of psychedelic substances. At its core, it is a scathing criticism of legal frameworks and regulatory policies that control the use of and research on psychedelics, and goes so far as to suggest that current structures and mechanisms impose a status quo of consciousness, thereby preventing people from fully enacting their right to freedom of religion, thought and conscience. At the very least, policy makers and ethicists need to give due attention to medical and psychotherapeutic research on psychedelics and the role they have in facilitating direct spiritual experiences. This includes acknowledging the transformative effect that experience may have on the self, as well as the right of all people to freedom of religion, thought and conscience.
Any book that rates these substances highly as a connection between the individual, society and the human race as a whole will find its detractors. That being said, The Psychedelic Policy Quagmire presents a strong case for the notion that psychedelics have transcended seemingly outdated legal, academic, cultural and spiritual paradigms. Althoughby the editors' own admission -this volume is by no means definitive, it will undoubtedly prove to be a lightning rod in the academic community. With its focus on research and policy that maximise the benefits of the use of psychedelics, reduce the potential dangers of misuse and remove impediments to achieving these ends, it is inevitable that this book will be a catalyst for lively and robust debate. Recommended to academics and researchers in various fields, including psychology, psychiatry, anthropology and the arts, this work should challenge many long-held assumptions about these fascinating substances. Telling stories is probably as old as human culture. Our ancestors used storytelling to entertain, instruct and make sense of their experience. A psychiatric history, when well taken, should be more than a fact-finding mission to provide a diagnosis and treatment plan. To be effective in providing treatment, helping with healing and promoting recovery, we need to know what matters to our patients. This includes the realm of belief and practice encompassed by the broad term spirituality. A book then that explores both spirituality and narrative is welcome.
Spirituality and Narrative in Psychiatric Practice, like the term spirituality, is broad in its scope. On the one hand, we have agnostic atheist Jeremy Holmes describing in his chapter ''Meaning without 'believing' '' the spiritual nature of mentalising. As he puts it, 'an intensely practical and loving pathway to spiritual aliveness'. On the other hand, there are writers from a theistic background, such as mental health chaplain Beaumont Stevenson, who considers how God or a higher power may manifest in the everyday stories of patients, providing a greater frame of reference than the story of self that often limits a human's potential. The early chapters give a range of perspectives on narrative. With characteristic clarity Andrew Sims indicates how through careful psychopathological appraisal from attending to the patient's story, it is possible to distinguish between spiritual experiences and psychiatric symptoms. Later chapters explore narrative and spirituality in a wide variety of themes such as affective disorders, offending behaviour, psychosis and the end of life.
The subtitle of the book is Stories of Mind and Soul and it is the stories that really shine. To preserve anonymity some are composite -made up from several people's histories or typical examples -and therefore feel somewhat artificial; nevertheless, they engage the reader and serve didactic purposes well. Others are the words of individuals who have been willing to share their stories, and these have a greater ring of authenticity. In particular, the chapter by Jo Barber stands out as an honest and moving account of someone who has struggled with mental health problems and for whom spirituality has been important -at times problematic but often a resource that has supported her ongoing journey of recovery.
As the editors note in their concluding chapter, pressures on service delivery may get in the way of the time and space to listen well to patients' narratives. However, for good psychiatric practice, not taking a good history is a short-cut we can ill afford. This work is a timely reminder of the importance of the fundamental tool of psychiatry and a welcome enjoinder to attend to what is significant to our patients.