This is a book that makes a compelling case for the role of psychoanalytic ideas in raising the IQ of psychiatric practice. Marcus Evans was one of the founding members of the Fitzjohn's unit for patients with severe and enduring mental conditions at the Tavistock and Portman NHS Foundation Trust, as well as associate clinical director of the Fitzjohn's adolescent and adult departments between 2011 and 2015, and latterly a consultant adult psychotherapist in the Trust's Portman Clinic.
Who is the person behind the symptoms and the diagnosis? Can the necessary objectivity of clinical practice cut the psychiatrist off from the pain of contact with a person suffering from mental disturbance? Some psychiatric symptoms do communicate meaning but at the same time may be a dissembled version of ordinary communication designed to discourage understanding. Psychoanalytic thought provides a model for thinking about how patients develop psychic retreats designed to defend themselves from the demands of development and insight on the one hand, and fears of fragmentation on the other. Patients may have to undergo the psychological work of mourning to come to terms with the fact that they have 'lost their minds'.
The psychiatrist may need to work out which part of the patient is talking, and with what aim. Is it the healthy part of the patient, in touch with psychic reality and the need for help, or the 'psychotic' part, which employs denial and rationalisation to justify its arguments? Or is it the perverse part, which wishes to interfere with the establishment of a truthful picture, or an infantile part that wishes to maintain a position of dependence? There are telling chapters entitled 'Tuning into the psychotic wavelength', 'Deliberate self-harm: the murderous voice inside', and 'Pinned against the ropes: psychoanalytic understanding of patients with anti-social personality disorder'.
The book includes a series of clinical illustrations of patients, each with a particular kind of disturbance. I was struck by Evans' analyses of in-patient scenarios. He shows how psychoanalytic approaches do not keep insanity out of view, but tries to offer madness a habitat and human understanding. Naturally this does not exclude other treatments, such as medication. He believes that psychotherapy and psychiatry are dependent on one another in the treatment of patients with severe disorders.
For my part, this book provoked me to remember some of the patients I have dealt with in the past, and how much more I could have made of my work with them. I would highly recommend it.