The following correction was printed in the Guardian's Corrections and clarifications column, Saturday March 3 2007
Darian Leader has asked us to point out that, contrary to the interview below, he does not believe all illnesses are attempts at communication. His new book, Why Do People Get Ill?, argues that believing this to be the case was one of the great problems with early psychosomatic research. He also asks us to make clear that his quoted claim that psychoanalysis would prove effective "20 or 30 years later" is not in fact his or anyone else's view.
One day, a painter went to see her dentist. He diagnosed that she was constantly clamping her jaw at night and recommended treatment. Because he was a dentist and not a therapist, he didn't ask any further questions. This was a shame. It turned out that the painter's symptoms had started when she knew that a painting she had been working on for a long time was going to be sold. The crucial thing that made her symptoms disappear was recognising the link between not wishing to part with something she had produced and her jaw clamping. This, at least, is a story that Darian Leader tells in his new book Why Do People Get Ill?, which has been written as a corrective to the presumed irrelevance of psychological factors to treating illness.
A cynic might regard Leader's book, co-written with David Corfield, a philosopher of science, as a 367-page appeal for work. Leader, after all, is a psychoanalyst. Born in California and educated in Cambridge and France, the 41-year-old (of whom Tatler once asked: "Is this the most intelligent man in Britain?") is the founder of London's Centre for Freudian Analysis and Research. A former beau of Britart doyenne Sarah Lucas and an avid art collector, Leader's current partner is Mary Horlock, a former curator at Tate Britain. And indeed much of the new book is a lament for the fact that art-loving, intelligent psychoanalysts do not get enough opportunity to use their skills with patients whose physical symptoms may have a mental basis.
"What's so sad," says Leader, "is that it didn't use to be like that. Until the 1950s, it was not uncommon for a psychotherapist or a psychiatrist to receive referrals from dentists or ophthalmologists."
For Leader this made a great deal of sense. He argues that psychological factors were proven long ago to bring about changes, for example, in the saliva and gums that might encourage bacterial activity. Medical students have far higher rates of dental erosion and decay after exam time than at other less tense moments, due to the altered composition of their saliva.
Why is so little attention paid to psychological factors these days? "It's a cultural thing. We live in a new dark ages where there's a dangerous lack of consideration of psychological causality," Leader says over tea in his consulting room in central London. Why? "Well, my sociological friends would say we live in market-led economies and in this kind of late-capitalist world if medicine concentrates on psychological issues there is no product to sell. Psychological research won't make people money."
Indeed, Leader points out in the book that in some parts of the US a physician will only get reimbursed for a consultation if it results in a prescription. Could that happen here? "Who knows? Listening is not a big feature of modern medicine here or anywhere in the west." Leader's book claims that, on average, a patient speaks for 23 seconds before being interrupted by their GP. The book concedes that most doctors have such staggering workloads that the average consultation with a GP in London lasts between six and eight minutes (the shortest average in Britain). But this may well make quick-fix diagnoses more likely. For example, the book suggests that the modern, much-talked-of concept of "stress" is a handy tag deployed in GPs' diagnoses, but may ultimately be a way of avoiding detailed analysis of a patient's problems. "It is a modern alibi to avoid listening," says Leader. "The specificity gets lost and so the diagnosis may well miss what is really going on."
If doctors did attend to patients' narratives of illness, Leader argues, they would realise that people often have difficulty dealing with "symbolic" moments in their lives such as births, deaths, children leaving home, promotions at work. Unable to make sense of such events, some fall ill. The body, unbeknown to the patient and, lamentably, most doctors, is trying to speak. Leader argues, for example, that there are such things as anniversary symptoms: we often fall ill on the same date and often with the same illness years after a traumatising symbolic event. Such facts in a patient's narrative should be attended to closely, or so Leader argues, in a process that would take considerable time with no guarantee of a cure.
He talks about the government's preference for cognitive behavioural therapy (CBT) over traditional talking therapies. "The government favours this because it is about correcting surface symptoms and reintegrating people who report psychical problems back into the workplace where they can become useful again."
CBT aims at modifying everyday behaviour. Patients are often encouraged to keep a diary of significant events and associated feelings and thoughts. They are urged to question unhelpful or unrealistic assumptions and to do activities that have been avoided. Its techniques have also been set out in self-help manuals and, more recently, in self-help software.
It sounds potentially helpful for ameliorating just the kind of symptoms Leader's book spends a great deal of time discussing. Only one problem: he despises this form of therapy. "When was CBT used most widely? It was in Mao's China, when people had to be re-educated to see the world in the way that the authorities wanted." Indeed, he regards CBT as akin to drug prescription. "Some forms claim to target specific aspects of illness; they are supposed to be administered like a pill or injection, and this no doubt makes them attractive to health service providers. But I think it is horrible and fatuous."
Leader believes that unless root causes are addressed, they will simply resurface in another form, some months later.
By contrast, Lacanian psychoanalysts such as Leader have never been popular with governments - not in Mao's China, Blair's Britain or even Chirac's France. Lacanian psychoanalysis is based on the work of French Freudian Jacques Lacan, who placed great emphasis on the importance of language. One of the more extraordinary facts about Lacanian practice is that the length of the analytic session is determined by what the patient says rather than the clock, so it can last from five minutes to an hour and a half.
Lacanian analysis has never been very popular on this side of the Channel. And perhaps it is becoming less so in Paris. "Even in France, where psychoanalysis is held in high esteem," says Leader, "there is a growing focus on quick-fix remedies like CBT." But surely one reason analysis is not popular, and particularly not popular with the government, is that psychoanalysis does not claim to produce results, while supporters of CBT claim that it does. "That's true. Having said that, a lot of my colleagues disagree with me and claim that studies show that, over the long term, symptoms will permanently disappear through analysis and that there will be lower rates of consulting GPs." And what is the long term? "They're talking about 20 or 30 years later." No wonder, then, that the government isn't calling on psychoanalysts such as Leader to cure Britain's depressives.
One of my problems with Leader's new book is that while it may be convincing to argue that grinding one's teeth has a psychological cause, can it be true that cancer and heart disease may have psychological factors in what Leader calls the "constellation of causes"?
"Of course! But people are pressured by culture to see illness as caused by something external to them. There's a real difficulty for people thinking about the big picture."
He insists that only in modern, bureaucratic societies would the thought that psychosomatic factors can be relevant to such diseases as cancer be considered incendiary. Nearly two millennia ago, Galen, a Greek doctor practising in the Roman Empire, observed that depressed women were more prone to cancer than cheerful ones. In the 18th and 19th centuries, studies reported that long-term grief and depression are exacerbating factors.
But aren't psychological causes often irrelevant to curing illness? "Absolutely. When you've got the flu, you don't necessarily want an explanation of why you're ill." But he insists that many illnesses are more complicated than flu. And yet Leader and Corfield point out that what they call the infectious model of disease is one that most people subscribe to today, namely: "An external agent comes into contact with an organism, infects it, and the organism falls ill. And from here it's an easy step to the assumption that, given one external agent and one organism, there will also be one cure."
Simple explanations, even if they are inadequate, appeal to common sense - and also make headlines. This is why, they argue, genes are seen as causes of everything from alcoholism to celibacy to sexual orientation: "Genes are portrayed as distinct causal agents - like germs - rather than as part of a dynamic system in which they won't act all the time, but only in response to a complicated range of other factors."
The book begins with a rhetorical question: "If two men of the same age have heart attacks resulting in equal damage to their hearts, why is the man who is single and depressed more likely to die of heart disease within the following year than the man who is married and not depressed?" The question implies, of course, that social isolation and psychological factors can be key factors in whether someone becomes ill. The book ends with the thought that, faced with the rise of alternative therapies that take time to listen to the patient and attend to the specificity of their case, conventional medicine must learn from such trends and rethink its practices.
Leader may be right in his diagnosis. But, just as few attend to the body when it expresses grief or frustration through physical symptoms, so few people are likely to attend to Leader's message. The government does not seem inclined to listen to him, bedazzled as it is by the promises of cognitive behavioural therapy. And, even if some doctors may be persuaded by his book that they should heal themselves and try to listen more, many will be sceptical or ignore his book altogether. He may well be a voice out of time.
·Why do People get Ill by Darian Leader is published by Hamish Hamilton at £16.99
