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.