From reductionism to hermeneutics

Pat Bracken in an article in World Psychiatry says psychiatry is in trouble and needs to move from reductionism to hermeneutics. He builds on the 'Bracken manfesto' paper (see previous post), as named by Peter Kinderman (eg. see another previous post), that the problem is the technological paradigm which dominates psychiatry. As Pat says, "Hermeneutics is based on the idea that the meaning of any particular experience can only be grasped through an understanding of the context (including the temporal context) in which a person lives and through which that particular experience has significance." Most medicine and surgery is concerned with the natural order, whilst psychiatry is mostly concerned with the human order.

Mario Maj in an editorial argues that the Bracken manifesto has gone too far in rejecting the technical aspects of care. He can't be as sceptical about the value of psychiatric medication or even that non-psychiatric medication could be just as ineffective (see previous post). He raises the spectres of the Italian reforms following the introduction of law 180 and the concept of the 'schizophrenogenic mother' to boost his argument of the dangers of a non-technical approach. However, evaluation of the influence of Franco Basaglia has been controversial. It is also obviously wrong and naive to blame families for causing schizophrenia. However, the problem with the reaction against the 'schizophrenogenic mother' idea is that it has undermined further legitimate family studies of schizophrenia. Maj also sees early intervention to reduce duration of untreated psychosis as a benefit of the technical approach without mentioning the critique of the early intervention approach (eg. see Jo Moncrieff's book The bitterest pills). Nor is it clear, as Maj suggests, that a non-technical understanding of psychiatric diagnosis necessarily leads to the abandonment of any attempt at classification (see previous post).

Still, it's good that there has been some mainstream response to the Bracken manifesto, rather than just ignoring it.

Controversy in psychiatry

A Lancet Psychiatry editorial argues for compromise in debates about mental health issues. I do agree that "the opportunities for global discussion on blogs and social media [shouldn't be] ... squandered". However, it is important, if there is going to be any change in mental health services, that the critical psychiatry position is stated explicitly.

The danger of accommodating all perspectives is that what is being said becomes "intellectually empty" and "ethically blind". This was the verdict, for example, of Andrew Scull on Meyerian psychobiology in his book Madhouse about Henry Cotton, whose programme of radical surgery led to significant mutilation and death by removing parts of the bodies of patients to eliminate what Cotton thought were focal infections believed to be the cause of mental illness. Meyer seemed unable to acknowledge the damage Cotton caused, instead writing a favourable obituary, suggesting he had "an extraordinary record of achievement". When Cotton was alive, Meyer suppressed a report of the poor outcome of Cotton's work in the forlorn hope he could persuade Cotton to accept the reality of his results.

I have indicated several times in this blog that Meyer's theoretical position was not dissimilar from critical psychiatry. However, his compromising position meant that he did not follow through on his challenge to biomedical psychiatry. I quote in my article from a heartfelt note written in the early hours of the morning a few years before he died, where he questions whether he "pussyfoot[ed] too much". He wished he had made himself "clear and in outspoken opposition, instead of a mild semblance of harmony" [his emphasis]. I would actually like mainstream psychiatry to engage more with critical psychiatry, rather than marginalising it.

Reducing numbers of psychiatrists in community mental health teams

Following up previous posts (What place for diagnosis in mental health care? and Responsible clinicians under the Mental Health Act) on Peter Kinderman's new book A prescription for psychiatry, I want to comment on a central theme of the book about replacing psychiatrists with GPs. I'm not necessarily against this suggestion. Too many psychiatrists are too biomedically orientated and may as well be replaced by GPs with a more psychosocial orientation. What GPs want from a mental health service is good assessment and management of their patients with mental health problems. Peter is clear that mental health care should reject the notion that it is (or should be) 'treating illnesses'. He would go along with the view of some mainstream psychiatrists, responding to what they see as the threat to their professional role (eg. see previous post), that psychiatry should focus its efforts on what it sees as the medical aspects of healthcare, specifically biological aspects of mental healthcare. Less psychiatrists may well be needed to do this.

I know what Peter means when he suggests mental health problems are not illnesses. This blog has often enough emphasised the lack of biomarkers for mental illness. Nineteenth century medicine developed because of its anatomoclinical understanding of disease. Just how misguided to expect the same advances in psychiatry is demonstrated by the awarding of the Nobel Prize in Physiology or Medicine to Wagner-Jauregg for malarial treatment of dementia paralytica and Moniz for leucotomy, and the nomination for the same prize of Sakel for insulin coma therapy, von Meduna for shock therapy with metrazol and Cerletti for ECT treatment of schizophrenia and manic-depressive illness. Have these really been the main advances in psychiatry?

I am happy to use the terms 'mental health problems' and 'mental disorder'. And, I am less worried about using the term 'mental illness' than Peter. In fact, I go along with Bill Fulford in Moral theory and medical practice that medicine is primarily an ethical activity. In that sense, psychiatry is the pre-eminent medical speciality. Many people go to their doctor with physical complaints whose origins are psychosocial. Peter doesn't mention this issue in his book. In Germany, for example, psychosomatic medicine has developed as a separate speciality. There may not be that much advantage in me having a medical training for much of my work as a psychiatrist, but at least I do understand psychiatric problems in their medical context. I'm certainly not advocating neuropsychiatry as the solution to the commonly identified crisis in the role of a psychiatrist (eg. see book review). What's needed is a more patient-centred approach to medicine in general. Peter's prescription for psychiatry may provoke this response. But encouraging psychiatrists to be neuropsychiatrists is not the right way to do it. This is a central theme of what Peter calls the 'Bracken manifesto' (see previous post). And clinical psychologists and other mental health professionals do need psychosomatic understanding to be complete practitioners.

Responsible clinicians under the Mental Health Act

As I said in my previous post, I have been reading Peter Kinderman's new book, A prescription for psychiatry. He suggests that, "In time, I believe it should be routine for the 'responsible clinician' [under the Mental Health Act] to be a psychologist or social worker". He makes an interesting reference to discussions on New Ways of Working in which he was involved on behalf of the British Psychological Society. He objected to a phrase, which did not appear in the final report, about the "clinical primacy of the consultant [psychiatrist] in dealing with treatment resistant, acute, severe or dangerous clinical situations". Peter does not agree with the concept of 'clinical primacy'. However, if it does have any meaning, it may arise because generally consultant psychiatrists, not psychologists or social workers, undertake the responsible clinician role.

I've commented before on this issue (see previous post) in relation to an eletter by Sam Thomson and Peter in response to what Peter calls in his book the 'Bracken Manifesto'. Clinical psychologists have been split about whether they should take on the role of responsible clinician. Peter quotes from David Smail, who unfortunately recently died (see tweet), who thought that it was good that "the only power we have [as clinical psychologists] is power of persuasion". Peter thinks what's more important is the "markedly different framework of knowledge and skills" of clinical psychologists, rather than their "historical absence of formal power" under the Mental Health Act.

I would have liked to have seen more discussion of this issue in Peter's book. Would Peter go as far as suggesting that recommendations for detention under the Mental Health Act should not be restricted to doctors? I think the logic of his position suggests he would.

What place for diagnosis in mental health care?

I have been reading Peter Kinderman's (see previous post) new book A prescription for psychiatry. Peter is very clear that "there is no place for medical diagnosis in mental health care". He suggests this is "a challenging assumption" and "may sound revolutionary". He even recognises it "may go against decades of accepted wisdom in psychiatric circles".

I'm not sure how many decades Peter wants to go back! The publication of DSM-III in 1980 marked a return to medical diagnosis in Peter's sense. However, he might have been happier with Karl Menninger's The vital balance published in 1963, which represented a pragmatic consensus, at least in American psychiatry. And going back even further, Adolf Meyer, regarded as the dean of American psychiatry in the first half the 20th century, developed psychobiology which has parallels with Peter's psychobiosocial approach. As Menninger put it, "As a result of his efforts ..., American psychiatrists began to ask, not "What is the name of this affiction?" but rather, "How is this man reacting and to what?"". DSM-III replaced the Meyerian approach to diagnosis, which it saw as too woolly.

Meyer said of the American Medico-Psychological Association's (1918) Statistical manual for the use of institutions for the insane, "I have no use for the essentially 'one person, one disease' view". He went further and suggested that "... statistics published ... are a dead loss ... and an annual ceremony misdirecting the interests of staff". Susan Lamb has described Meyer's psychiatric development from neuropathologist to psychobiologist (see previous post).

For my position on diagnosis, you might want to look at the slides from my presentation 'Some aspects of the moral basis of diagnosis: The challenge of Meyer's psychobiology'. My views are:-
(1) Psychiatry should not abandon diagnosis but recognise it for what it is
(2) Psychiatry should not be panicked by the unreliability of psychiatric diagnosis
(3) Psychiatry should avoid the reification of diagnostic concepts
I think this is a similar but more subtle, maybe, manifesto than Peter's.

Blogging on psychiatry as symbolic representation of the Universe

Tom Stockmann has started his Mandelas blog which looks as though it will be interesting.