Dr David Bell is a well-known Sydney neuropsychiatrist, who has run a psychiatric research unit, developed a therapeutic community, pioneered addiction rehabilitation, been a driving force in forensic studies, and for a long while worked as a leading forensic assessor. He has had a particular professional interest in epilepsy, drug addiction and the assessment of head injury.
Bell’s autobiography, Welcome to the Loony Bin describes his 55 years of work as a psychiatrist. Bell is not a shy man intellectually; for decades he has taken iconoclastic and often unfashionable positions in relation to what he has regarded as fads and unscientific fashions of the day within psychiatry and the law. He has many admirers and many detractors.
The polarisation about Dr Bell and his views will not diminish with the publication of his autobiography. However, a number of observations need to be made about it. Firstly, it is exceptionally well and engagingly written. Bell has a memorably entertaining and eloquent turn of phrase. Welcome to the Loony Bin is a pleasure to read. Second, there are aspects of its historical content which are fascinating and valuable as a record of landmark events, places and people in the history of Australian psychiatry. Thirdly, Dr Bell engages in debates, taking firm stances, which have been extremely important for the evolution of psychiatry and for the contribution of psychiatry to the law over the past half century. His is a voice that one may disagree with, but it is a voice that deserves to be heard and needs to be engaged with.
Dr Bell’s career in psychiatry commenced in the mid-1950s at a time when pharmacological options for treatment of people with mental illnesses were only commencing – in particular chlorpromazine. It was a time of hope and innovation within psychiatry. He studied at the University’ of Sydney in the period immediately after the conclusion of the Second World War and his first job was at Callan Park Mental Hospital, a 19th century lunatic asylum, that had been the subject of a notorious Royal Commission in 1923. When Dr Bell started work, it was with the now infamous Dr Harry Bailey, with whom, to his credit, he promptly had a falling out. Young Dr Bell’s role was to work his way through the back wards, identify those with epilepsy and treat them. Soon the next Royal Commission into Callan Park followed and thereby an early introduction for Dr Bell to the world of the law. The 1961 report by Justice McClemens was important; it resulted in concerted efforts to improve the psychiatric services of New South Wales.
One of its side-effects was to propel Dr Bailey into private practice, in due course at Chelmsford and his provision of deep-sleep therapy. Bell’s description of the Chelmsford experiments and the subsequent Royal Commission is an important perspective on tumultuous events. Dr Bell describes the practice of electroconvulsive therapy at Callan Park and the suspicion that he developed that its administration to persons with schizophrenia was causing post-traumatic epilepsy. He relates too the practice of insulin-induced coma treatment, commenting: ‘Under this regime, disturbed and uncooperative patients became docile, warm and sane. Those who held to their doubts reasoned that attention alone could explain the benefit. … Opponents argued that humane care could achieve the same results without the danger and expense of adding the coma’ (p. 51).
Bell describes being inspired by a group therapy centre at Newcastle-On-Tyne which he visited – where the body and mind doctors met on an equal footing for constructive interchange. He details various of the therapeutic strategies that he came to employ, giving case examples, including the use of a prokaletic intervention with a ‘cutter’ – as he describes it, ‘a forceful challenge to a deeply ingrained crippling drive of the psychoneurotic.’
In 1969 Dr Bell was appointed to plan a drug addiction service for New South Wales. Later he commenced the editorship of the Australian Journal of Alcohol and Drug Dependence. In relation to marijuana, probably conscious of the current calls to legalise medicinal cannabis, he comments: ‘Heavy users lose drive and initiative, developing an indolent chronic apathy known as the “amotivational syndrome.” At a high enough level it produces hallucinations. On the other hand, marijuana impairs learning and memory only slightly and IQ not at all. It has some therapeutic potential. … As with all other drugs, it attracts the maladjusted. Schizophrenics seem particularly attracted’ (p. 89). Bell has strong views about drugs. His argument is that legalisation cannot solve the unalterable dilemma posed by human nature: ‘Experience indicates that the most vital plank of policy restricts the availability of drugs, for some the extreme of making them illegal. Every move to abandon drug control has resulted in catastrophe. The converse reveals equally dramatic successes, albeit only for a limited period. Control cannot change human nature. It can only keep up the struggle’ (p. 97).
Dr Bell joined the Australian Academy of Forensic Sciences in 1970 in which he was to play a very significant role for decades. At the same time he commenced to undertake medico-legal work, at first entering the courts ‘with the awe and respect for the law that the good training of my parents and teachers inculcated’ (p.98). That did not last. In time he came to rank the law and psychiatry as sharing ‘a key sin, the use of reason to justify current belief, no matter how invalid. Both provide a great boon. They err so often that we cannot but help learn from their mistakes’ (p.99). He denounces juristic reliance on demeanour, observing that it has deservedly earned trenchant criticism: ‘Woe betide the ugly, deformed or deficient, the person of different ethnic origin or with eyes too close together’ (p.101).
Dr Bell is well known for his views about malingering, post-traumatic stress disorder (PTSD) and repetition strain injury (RSI). He presents a series of cases in which neuropsychiatry has figured in litigation, lamenting that ‘Malingering continues because in most cases it succeeds … Only singular chance or the fortunate use of investigations exposes them’ (p. 146). This is a challenge which Bell has embraced. His use of case examples is persuasive, the patients he describes memorable and his arguments about their conduct powerful. He describes an array of ‘faking’ of symptomatology of many kinds, expressing the lugubrious, albeit somewhat nihilistic, conclusion that: ‘Those who claim an ability to detect malingering fail to do better than chance when put to the test. The judge would do better to toss a coin’ (pp. 157-158). Dr Bell’s review of Munchausen’s syndrome makes particularly entertaining reading. In respect of RSI, Dr Bell comments that its epidemics around the world ‘reveal the impotence of informed individuals in the face of false belief. For more than half a century, country after country fell for the myth,disguised by repeated changes of name. The experts aware of what had happened elsewhere issued their warnings futilely’ (p. 181).
Bell takes aim at many targets, only some of which are referred to in this review. He criticizes the definition of pain utilised by the International Association for the Study of Pain and lambasts conditions such as multiple chemical sensitivity and dissociative identity disorder, commenting: ‘I remain amazed at the phlegmatic acceptance by the community of widespread illness behaviour. The uncritical award of compensation greatly increases complaint, pushing insurance premiums to burdensome levels’ (p. 201). He devotes particular attention to the DSM conceptualisation of PTSD, instancing the Melbourne-Voyager litigation (in which he figured prominently) as an example of the cynical manipulation of the diagnostic construct: ‘From an impressive witness in the box touting a fashionable notion, gobbledygook can sound convincing and become impregnable dogma’ (p. 239). He describes colourfully a ‘confection of false recovered memories’ amongst litigants in the Voyager litigation. Bell’s view is that RSI, PTSD and latter-day depression are pseudo-illnesses, that they are largely iatrogenic. His denunciation of pandering to them by forensic assessors and by the law is characteristically forthright: ‘Although they make profitable enterprises for the Psychology Industry and lawyers, in the final analysis the professions arrive at their illusions not through mastering ideas, but by bungling. … In mass hysteria an idea masters the group’ (p. 321). He argues for abandonment of pseudo-invalidism and more critically rigorous analysis.
Bell assails the law as well as psychiatry, but comes away ‘from my experience of it with more optimism for the future’, regarding the approach of the United States Supreme Court in Daubert v Merrell Dow Pharmaceuticals, 509 US 579 (1993) with its emphasis on scientific standards of reliability as introducing an important check and balance on the potential for miscarriages. Ultimately, it is the opportunity to learn from error that Bell champions. His voice calls for rationality and the need to separate ourselves from the latest fashion, anxiety or panacea.
Welcome to the Loony Bin is not a paean to the successes and progress in psychiatry since the Second World War. It catalogues failures and abrogations of rigour in reasoning by psychiatry as well as the law. Such accounts will be unwelcome to many. They do not make us feel good. They are not reassuring and they do not encourage the myth that with the development of knowledge we are becoming wiser and making fewer mistakes. Bell has always been an iconoclastic figure and to expect his autobiography to have been otherwise would have been naive.
Welcome to the Loony Bin will offend, antagonise, confront, and entertain. Its challenge to greater intellectual rigour is an important scholarly contribution. It is a reflective account of a genuinely independent thinker, of a professional life oppositionally lived, of a psychiatrist who has battled the fashions of the day and who moves toward retirement as feisty as he was, perhaps more so, when he first entered Callan Park Hospital in the mid-1950s. Dr Bell’s autobiography is an engaging and important work. It provides articulate and historically valuable insights into the development of psychiatry over the past 55 years. This alone makes it worthwhile. But, most particularly, it contains a powerful critique of uncritical thinking into which it is too easy for psychiatrists and lawyers alike to lapse. It should be mandatory reading for medical and legal practitioners. In agreeing or disagreeing with the views expressed by Dr Bell, we are the better for having been challenged.