Review: Suzanne O'Sullivan, It's All in Your Head

This is another book picked up by chance in Waterstone's and a most unusual one too. It's quite easy to find books which narrate the case histories of patients seen by private psychotherapists (Stephen Grosz's The Examined Life is a recent example, reviewed on this site 3 February 2014) or, in the case of Adam Phillips, by a former NHS child psychologist. But this book is by a consultant neurologist with a special interest in epilepsy who in the course of her work (both NHS and, I assume, private) encounters patients whose symptoms have no identifiable organic base and are thus, sooner or later, classified as psychological in origin.

The symptoms are major and disabling - seizures, convulsions, paralysis, blindness. They are symptoms which have led to ambulances being called, A and E working flat out, consultants being telephoned, provisional diagnoses and medication being prescribed - and to no avail. 

For the most part, they are symptoms which if not organically caused, would once have been assigned to the category of hysteria. Dr O'Sullivan devotes some pages to the history of hysteria within modern clinical medicine, starting with Charcot and Janet and continuing to Breuer and Freud. But - perhaps on editorial advice - she gives no bibliographic references at all, not even a Further Reading list. This is a pity since part of the interest of this book lies in the fact that it is written from the perspective of a neurologist with an orthodox medical training and wide experience of conventional clinical practice in Ireland and the UK. It thus gives an unusual insight into what hospital neurologists nowadays know and think about psychosomatic or psychogenic disorders.

But the book uses case histories rather than theoretical argument or research review to guide our understanding. One of the first things to strike me about these case histories was the prominent position of the patient's parents, partners and other carers. Of course, if you are confined to a wheelchair you are going to have carers. But the carers are often present in the kinds of unhelpful way which R D Laing and A Esterson flagged up many years ago now in Sanity, Madness and the Family: the carers present themselves as authoritative in regard to the medical history and current feelings of the patient. They also have strong views on what will count as an acceptable diagnosis. O'Sullivan does not really engage with the facts she extensively reports and the patient is always referred as an individual to a psychiatrist and never everyone involved to family or marital therapy.

She frequently makes the point that the psychogenic illnesses she encounters are found in people who often have no conscious awareness of being anxious, depressed or stressed and who indeed often enough proclaim themselves happy and worry-free. You could say, this is why they have ended up in A and E rather than in the armchair of a private psychotherapist. At one point she remarks, "Perhaps those who deny stress do so because they do not feel stress, having converted it to something else" (p 243) - that "something else" being a somatic symptom. But this is not an incidental "Perhaps" feature. It seems to be the heart of the matter - the patients she is seeing suffer from conversion disorders in which the body expresses (in a terrifying manner) what the conscious mind, the tongue cannot.

This is a very interesting, quite brave book. It is consistently humane, even towards the occasional malingerer who makes it all the way to the neurologist's telemetry suite - in the final chapter, there is a charming, warm portrait of just such a person. We know a lot about the world of those who can be articulate on the analyst's couch, much less about those whose body takes the brunt of their illness.

Essay: Writers, Intellectuals, Professors

One of the first things by Roland Barthes that I read was, "Ecrivains, Intellectuels, Professeurs" which appeared in Tel Quel (Issue 47, 1971) just as I turned up to enroll as Barthes' student at l'Ecole Pratique des Hautes Etudes. It came to mind as I was reading Adam Phillips's On Balance (2010) - a book I can't review here because I didn't read it Cover to Cover: I skipped some of the book reviews.

Barthes (at least as I recall) carves up a space which can be occupied by different kinds of individuals (the ones he names in the title) and different kinds of writing (which, as it were, go with the job). Over time, the organisation of the space changes: roles and styles get (partially) interchanged; orders of dominance shift.

Nowadays, the professors and the academic style very much have the upper hand. The fundamental reason is economic.

Imagine. A Prof earns let's say 36 000 a year (dollars, euros, pounds- it doesn't matter) for a working commitment of 240 days (probably a bit less but it makes the arithmetic simple). So it's around 150 a day, before tax. Modest, but it pays the bills. In the United Kingdom, it would not be unusual for a third of those 240 days to be charged as "research". For a Prof in the arts and humanities, this is when he or she can read and write and get paid for it. Eighty days (plus whatever voluntary overtime you put in). And no one says (yet) into how many published words that must convert, though if no words are published then eventually the Prof will lose those 80 days back to teaching and "admin".

In contrast, the writer and the intellectual have to live off Royalties - which depend on number of books sold - and Fees - which usually depend on number of words commissioned. At the beginning of a career when you have no back list of publications generating continuing income, there is absolutely no way to make a living out of being a "writer" or "intellectual". Even many years later, only a few do. That is why you find novelists taking jobs teaching Creative Writing and critics taking jobs as Visiting Professors.

Adam Phillips is a figure to be honoured. Starting out as a working child psychotherapist (in the National Health Service), he has gone on to carve out a space for himself as a writer and (public) intellectual. He showed in his Fontana Modern Master Winnicott that he could do the kind of job only a very good academic could do; he has also done the kind of editorial work academics reckon is their job. But he has now worked for a couple of decades, without footnotes, exploring how we live our lives (or have them lived for us) in a way which is both creative and open-ended but also disciplined by an enduring commitment to a psychoanalytic paradigm - a paradigm which universities, at least in the UK, have never really endowed with salaries.

The pressure must sometimes feel immense.

Academics feel (peer - ) pressured to publish and end up finding outlets in unreadable (and unread) journals for work which is - what? - ninety percent of the time banal or simply repetitive of what they published in another journal last year. Unless they belong to a fraternity or sorority whose members swear to cite each other, the only person who will ever cite these publications is the author, in his or her CV.

Writers and Intellectuals look at their bank balances. The temptation to publish every last jot and tittle, if you can, must be considerable. The temptation to take on too much, ditto. Even in Adam Phillips there are times when I feel he multiplies his trade mark Questions because they provide the words on the page that he needs without consuming the hours it would take to craft considered Answers.

Roland Barthes had more elevated concerns in his essay than my Benjamin Franklin preoccupations, but he wrote as someone who himself made the transition from intellectual (writing newspaper columns even) to (rather uncomfortable) Prof.

In the year I studied with him, he was assigned a real theatre for his popular lectures. He sat modestly enough on the stage behind a small table, with a sign from the current production ("Le Petit Cirque" ) hanging in the background. But he abandoned the theatre for a seminar room the week after someone stood up in the Balcony and denounced his reactionary adherence to theories of Binary Opposition. Someone there was making a Category Mistake.