Hokum is not fine by me

Max Pemberton, in  this week's Dr Max the Mind Doctor column in the Daily Mail (see section entitled Hokum is fine by me if it works) mentions a recent decision by a judge to reject a patient’s challenge to the Lothian Health Board’s decision to stop funding homeopathy services on the NHS (see BMJ news article). Dr Max admits homeopathy is merely placebo but says he doesn't care as long as it makes the patient feel better. He seems happy enough, I guess like a lot of doctors, to deceive his patients (see my BMJ letter, on bottom of the page from this link).

I do understand that the patient may have a different view. She apparently had found homeopathy helpful for her arthritis and anxiety. I'm not convinced the Health Board has considered the potential harm (nocebo) effect of removing a placebo, for which I guess it could be held accountable, as presumably it was originally funding the homeopathy. What I'm objecting to is Dr Max supporting the use of homeopathy, which he regards as "utter hokum".

Reconsidering psychiatry

Hugh Middleton (who I have mentioned in a previous post) has recently published Psychiatry reconsidered: From medical treatment to supportive understanding. As he is the current co-chair of the Critical Psychiatry Network, of which I am a founding member, you may well think I would agree with a lot of what he says, and I do. However, I have some concerns about how he expresses the critical psychiatry position. These concerns are similar to those I have expressed about Peter Kinderman's book A prescription for psychiatry (see previous blog and links to other posts on his book from that blog).

Where Hugh and I agree is that mental health difficulties are not brain diseases. The implication is that psychiatric diagnosis is not about identifying brain abnormalities and treatment is not about correcting such abnormalities, such as biochemical imbalances in the brain. Rather, referrals to psychiatric services are made for psychosocial reasons because of people's distress and/or the disruption they cause to others. Mental health problems are primarily functional and not organic (eg. see previous post).

It follows that there are differences between psychiatry and the rest of medicine. However, Hugh makes too much of these differences from my perspective. He points to "the unsuitability of locating provision for people with 'mental health difficulties' alongside other aspects of medical practice" (p. 8). He also suggests "psychiatry is not proper medicine" [his italics] (p. 9-10) and that psychiatry is "not about treating illnesses" (p. 9). My own view is that this position, at least potentially, is misleading.

Our difference arises from our understanding of 'mental illness'. I think that abnormalities of mental function can be understood as 'illnesses' in the same way as bodily dysfunctions. On the other hand, Hugh restricts 'illness' to physical pathology. He is, therefore, inclined to follow Thomas Szasz, who was very clear that the concept of mental illness is a category error, because he defines 'illness' as bodily pathology (eg. see previous post). The trouble is, from my point of view, that this distinction is not so absolute. People commonly complain of physical symptoms which have a psychogenic origin - what medicine these days calls 'medically unexplained symptoms', or previously may have called psychosomatic illness. These presentations are so common, in some ways, that they are central to medical practice. In other words, psychiatry is proper medicine. Medical practice should take a patient-centred perspective (see previous post), which inevitably requires engagement with mental health problems. I don't want to polarise the difference between patient-centred and disease-centred medicine, and diagnosis and treatment in medicine need to be patient-centred even when treating physical disease.

I'm also not entirely happy with Hugh leaving the issue of coercion to the last chapter, entitled Afterword. As he says, historically psychiatry "was commonly brutal" (p. 204). In fact, institutional practice can still be abusive. Human rights are a central issue for psychiatry. Because of its social role, psychiatry inevitably manages madness on behalf of society (eg. see my book chapter). This was why modern psychiatry originated in the 19th century, however much psychotherapy and other informal, voluntary services now dominate practice. But, these more modern developments haven't made the 'sharp end' of psychiatry irrelevant. They have led to the closure of the traditional asylum, but people are still detained under the Mental Health Act in hospital and, for some, this makes them eligible for the imposition of conditions under a Community Treatment Order (CTO). True, Hugh does recognise this situation, and here he differs from Szasz, although he uses it as a dubious justification for electroconvulsive therapy (ECT) in limited circumstances. And, it was the reform of the Mental Health Act, that produced the 2007 amendments, that led to the formation of the Critical Psychiatry Network in 1999. I think these issues should have warranted more than an afterword when reconsidering psychiatry.

Adolf Meyer's legacy

I have mentioned Susan Lamb's Pathologist of the mind in a previous post. The book has been reviewed by Andrew Scull in the TLS (see WSJ version). Andrew argues that "comprehensive reassessment of Meyer’s life, career and influence is long overdue" (is Andrew writing this thesis?) but suggests Susan's book isn't that work because it scarcely considers his later career. I think this judgement may be a bit harsh as Susan primarily seeks to defend Meyer's theoretical position, which was called "psychobiology", which I think was consistent through Meyer's life once he had switched from neuropathology. Andrew isn't convinced that Susan's been successful in her aim.

I've commented on Meyer favourably in previous posts (eg. see The psychogenic legacy of Adolf Meyer). I've argued that critical psychiatry is a neo-Meyerian perspective. This doesn't mean, like Andrew, that I'm suggesting a straightforward following of Meyer or 'resurrecting his ghost' (eg. see previous post). But Andrew says Meyer's programme was "largely devoid of substance" and that he was an emperor with no clothes. I agree Meyer's obsessional "quest for data" could become futile, but at least it ensured that the psychosocial reasons for patients' presentations were considered, which can't be said for much of modern psychiatric assessment. The problem is that the reality of psychiatry may be that it is "essentially empty" in Andrew's sense. It probably doesn't boil down to much more than relationships between people. If Andrew's hoping for more from psychiatry, I suspect he'll be disillusioned.

The biomedical model has an intrinsic advantage over psychobiology in that it provides an apparent clarity. But modern psychiatry seems more willing to hide behind absolute definitions rather than face the uncertainty of human action. Psychobiology is not an aetiological psychiatry, in the sense of providing psychoanalytical mechanisms or Kraepelinian disease entities. True, Meyer's tendency to fudge and compromise may not have always provided the best of ethical foundations for psychiatry. But I don't think Andrew should be quite so dismissive of Meyer's theoretical position, or Susan's attempt to explain it.