Conceptual competence in psychiatry

Awais Aftab and Scott Waterman have an interesting article on conceptual competence in psychiatry. As they say:-

The considerable challenges facing our discipline [psychiatry] will not be met without rethinking our approach to educating and training the next generation of psychiatrists, specifically attending to the implicit—and thus rarely confronted, examined, and questioned—conceptual foundations of the field.

The four elements of conceptual competence are: assumptions and questions; tools;  discourse; and humility. Training can improve conceptual competence.

I asked Awais Aftab in a tweet what the implications for practice are and he gave an interesting and important initial response (see conversation). I don’t think all practitioners need to be philosophers of psychiatry but they do need to understand there is a mind/body problem. I also think it may be worthwhile emphasising how cultural competence overlaps with conceptual competence.

The concept of mental illness

I want to follow up my previous post about the nature of mental illness. The article I've always thought that does the best conceptual analysis of 'mental illness’ is by BA Farrell (see article).

Farrell makes clear that ‘mental illness’ is a statement about psychological functioning. It’s not primarily a statement about statistical abnormality. It standardly implies social maladjustment, but social misfitting is not just due to mental illness. Nor does mental illness necessarily imply bodily dysfunction. As Farrell says, the regulative principles of physical medicine are extended in the concept of mental illness to the psychological reactivity of human organisms. In other words, the psychological functions of the person do not operate within their standard limits when someone is diagnosed as mentally ill. This concept of mental illness fits more clearly with psychotic than neurotic conditions in general, and may well be problematic for personality disorders. What counts as a psychologically morbid process can be open to debate. Applying the concept of mental illness is both descriptive and evaluative in the sense of implying an undesirable and unwelcome state. There are real problems with defining mental illness as behavioural disorder. As Farrell says “all concepts have their difficulties”. We need to work through what we mean by the term ‘mental illness’, rather than merely dismissing it as invalid.

This definition of mental illness is reinforced in an article by Aubrey Lewis. The concept of illness can be ambiguous. It designates a change from a pre-morbid state. As Lewis says, maladaptive behaviour is only pathological if it is accompanied by a disturbance of psychological functioning. Social criteria play no part as such in the diagnosis of illness.  To quote from Lewis: “The concept of disease ... has physiological and psychological components, but no essential social ones”. Doctors may well deal with more than illness. And psychoanalysis generally defines mental illness quite loosely. The recognition of illness may well not be very reliable or valid, and this is even more likely to be the case for mental than physical illness. But Lewis is clear that “it is not possible to set up essentially different criteria for physical health and mental health”.

Psychopathology is, therefore, a morbid process like physical illness. To be diagnosed as mentally ill, a person's psychological processes are dysfunctional. A tweet pulled me up for suggesting that psychosis is maladaptive, as using the word ‘adaptation’, perhaps particularly in the evolutionary sense, may actually explain why people do become psychotic. Psychosis may well increase survival eg. by preventing someone dying by suicide (see my twitter response). I agree that whether mental illness is maladaptive is not the essential relevant criterion to consider. From the individual perspective becoming psychotic may be a necessary reaction. However logical the private sense may seem to the person, it is the loss of common sense viewed by most people that is characteristic of madness. The correctness of our judgments and the soundness of our understanding are subjective but our understanding is also restrained by the understanding of others. As Jaspers said, there may be an 'un-understandability' about psychosis. This applies, however, to others' perspective, as from the individual's point of view a psychotic reaction may make sense (at the time at least).

As both Farrell and Lewis emphasise, our modern idea of illness as physical lesion only really starts from the nineteenth century. The concept of ‘illness’ itself is much more long-standing. Modern critics of the concept of mental illness need to have this longer historical perspective rather than juxtaposing it too much with physical illness and thereby invalidating the concept.

Facing up to the difficulty of treating depression

Following a Guardian article by Ed Bullmore, I tweeted today asking why psychiatry allows and encourages speculation about depression being an inflammatory disorder. As I've said before (eg. see previous post), it’s non-sensical to believe that depression is a form of inflammation. Yet, as in the article by Bullmore, such speculation is promoted as a “new frontier” which could lead to “breakthroughs” in the treatment of depression, with the “potential to transform our thinking about illness more broadly”. Exciting stuff apparently! But why the hype?

Of course part of the reason is to encourage participants to express an interest in the NIMA ATP trial. More fundamentally, the real problem is that depression is not always easy to treat (see previous post). We always need hope that there might be simpler and more effective treatments (see eg. previous post). I don't want to appear pessimistic about the treatment of depression. There can be spontaneous improvement over time. People have considerable personal resources and resilience to be able to overcome and adapt to their difficulties. 

Of course psychiatry is merely responding to our idealistic wish for a simple, quick, cheap, painless and complete cure for depression. It does this for psychological therapy as well as medication (eg. see previous post). But promoting myths that depression is due to inflammation does not justify deflecting from the hard work required to help people recover from their depression. 

Does psychiatry need a diagnostic system?

As I said in a previous post, when commenting on Lucy Johnstone’s article on whether mental illness exists, I was left with the issue about the nature of illness. I’m even more focused on this question, as I am reading Peter Kinderman’s book A manifesto for mental health. Like Lucy, Peter does not want to see emotional problems as illness. He, therefore, doesn’t want to see ‘psychological health issues’, as he calls them, as pathological. He wants to ‘drop the language of disorder’.

I think I do understand what Peter means when he says, “Madness and sanity are not qualitatively different states of mind”. There may not be an absolute distinction (see previous post). I agree with him that psychiatric diagnoses are not ‘things’. We need to focus more on “how and why we feel or act the way we do” rather than naming mental health problems. I even agree that psychiatry could still be practised without a psychiatric classification system (see previous post). Such a situation may well have benefits, as it would encourage psychiatry to focus on formulation, rather than biomedical diagnosis.

But I do worry that the ‘drop the disorder’ mantra is open to misinterpretation. Peter does recognise that, “Giving a name to our distress serves a function”. But he wants to suggest that naming a mental health problem shouldn’t be identifying it as illness. He does nonetheless recognise that people may want the apparent benefits of identifying it as illness.

Talcott Parsons described the two rights afforded to people in the social role of being sick:-

1. The sick person is temporarily exempt from performing ‘normal’ social roles (such as going to work or housekeeping). The more severe the sickness, the greater the exemption. 

2. A genuine illness is seen as beyond the control of the sick person and not curable by simple willpower and motivation. Therefore, the sick person should not be blamed for their illness and they should be taken care of by others until they can resume their normal social role.

These rights are conditional on the patient following two obligations:-

1. The sick person is expected to see being sick as undesirable and so are under the obligation to try and get well as quickly as possible.

2. After a certain period of time, the sick person must seek technically competent help (usually a doctor) and cooperate with the advice of the doctor in order to get better.

Peter thinks simply listing people’s actual experiences and problems is sufficient rather than seeing them as ill. He doesn’t object to people taking time off work “if we’re depressed, or anxious or hearing voices”. And he acknowledges for some that “personal circumstances mean that we can no longer work on a permanent basis”. I agree with Peter that provision of services may only be connected loosely with psychiatric diagnosis. But I worry that by focusing so much on psychological aspects he has ignored the social implications of these experiences and problems. Health care may well be provided for people who are not ill as such, but that doesn’t necessarily invalidate the notion of illness.

People who are disabled also may not necessarily be ill. There is a need for judgement about whether people are ascribed the sick role. If people are in need, the reason for it may be illness. Not all need may be due to pathology, but some of it might be. I just worry that Peter’s insistence on avoiding pathologising is more technical than practical. His laudable aim to encourage understanding of the reasons for mental health problems may undermine the pragmatic sense in which mental illness can be like physical illness. Of course the concepts are not identical. Certainly functional mental illness should not imply physical lesions (see eg. previous post). But there is sufficient overlap for the concept of mental illness still to be useful and valid.

Resistance to critical psychiatry

Giovanni Fava (who I've mentioned previously eg. see post) quotes from Thomas Kuhn’s The Structure of Scientific Revolutions in an article about the importance of pluralism and the challenge to current paradigms in medicine: "Novelty emerges only with difficulty, manifested by resistance, against a background provided by expectation". Critical psychiatry seeks to help psychiatry move on from its current biomedical dominance (see previous post).

Fava describes obstacles to change, including: (1) barriers to publishing, such as the commercial nature of open-access journals, requiring contributors to pay for publishing, as truly innovative research is unlikely to be funded (2) special interest groups, including so-called key opinion leaders, using their power to suppress conflicting information and bias interpretation of the evidence (3) the pseudo-objectivity of evidenced-based medicine failing to recognise its limitations, and (4) the general lack of familiarity of researchers with clinical practice meaning that research lacks clinical relevance.

I've argued that social media can help maintain freedom in an academic system motivated by commercial interests (see post on my personal blog). I have used this blog and tweeting (@DBDouble) to promote critical psychiatry. But we do need academic journals, as Fava says, to "host dissent, debates, and heresy, as long as they are supported by methodological soundness" (see previous post). Academic psychiatry needs to be rebuilt by the recognition of the limits of biologic research (see previous post). Medicine in general needs to be rethought (see another post on personal blog).

Developing global mental health services

I've discussed before (eg. see previous post) how we tend to have an understanding of illness as implying physical abnormality. An article by Suman Fernando highlights how much this perspective is a 'Western' understanding. Even within Western cultures this interpretation of illness is only really since the nineteenth century (eg. see previous post). 

Suman highlights the plurality of mental health systems in place in the global south: "Western systems, traditional indigenous systems, new, innovative systems, and those that attempt to adapt Western systems to make them ‘culturally sensitive’ to local norms". I  don't think we should underestimate the plurality of health care systems in the West with much uptake of 'alternative' and complementary health care besides standard health care.

This blog has been critical of biomedical approaches in psychiatry. I therefore agree with Suman than mental health development should not be colonised by biomedical psychiatry (eg. see previous post). Nor should we medicalise difficult social problems, like poverty and lack of social support, that require political and economic solutions (see previous post). As Suman concludes:- 

the aim of all agencies seeking to develop mental health services must be to enable local people to develop services that are ethical, that is for the benefit of the people concerned as subjects rather than objects of development, and sustainable without dependence on rich countries in the West. 

Integrating critical approaches into the training of psychiatrists

I've mentioned in a previous post that I had an application turned down for last year's International Congress of the Royal College of Psychiatrists (RCPsych) on 'Integrating critical approaches into the training of psychiatrists'. I'm not sure if RCPsych is really interested in an initiative of this sort.

I've said before (see previous post) that there is an orthodoxy in psychiatry. Trainees do need help to manage this indoctrination. Current training could be said to be biased towards neuroscience (see eg. another previous post). It is insufficiently global in its perspective (see previous post) and trainees need help to deal with psychiatry's institutional racism (see another previous post) and institutional corruption in general (see previous post). Trainees need to become more patient-centred (see another previous post) in their practice.

Psychiatry shouldn't see this agenda as a threat. As I've kept emphasising in this blog (eg. see previous post), critical psychiatry is a legitimate part of current psychiatry. It is not anti-psychiatry or a "warped political ideology" (see recent previous post).

Reducing suicide in young people

Jacob Hess comments in an MIA blog post on a NYT Op-Ed essay entitled Why are young Americans killing themselves? In the UK, despite having a low number of deaths overall, rates among the under 25s have generally increased in recent years (Office for National Statistics, 2019). 

Despite some yearly increases (including 2018, the first increase since 2013), suicide rates for all persons have generally decreased since 1981 (see figure). Over this time frame, it is particularly in the over 60s for men and the over 45s for women where this is apparent. Suicide reduction has primarily happened for older people. I'm not saying the recent increase for young people is not of concern but it does need to be set in context. Many factors contribute to trends in suicide rates which can be very difficult to disentangle.

I agree with Jacob Hess that the solution to suicide in young people is not as simple as the Op-Ed piece makes out. It asks, "How is it possible that so many of our young people are … killing themselves when we know perfectly well how to treat this illness?" It then goes on to state that "We know that various psychotherapies and medication are highly effective in treating depression."

Public mental health strategies should not be driven by exaggerated claims for the effectiveness of psychiatric treatment. For antidepressants, for example, there are substantial non-response and recurrence rates (see previous post) and the difference between active and placebo treatment in clinical trials is much smaller than most people realise (see eg. another previous post).

The readiness to use antidepressants in children has increased over recent years (see my BMJ letter) as the concept of childhood depression has been socially constructed (see previous post). Concerns about lack of efficacy and increased suicidality created a hiatus in 2004 in the relentless continuing increase in antidepressant prescribing for children. I suspect that children and young people object more than adults to the medicalising of their mental health problems. We do need to look wider than psychiatric treatment to helping suicidal young people.

Is critical psychiatry a "warped political ideology"?

Paul Morrison @PaulMor64695904 tweets praise for a blog post about antidepressants by George Dawson (who I have mentioned previously eg. see post). He suggests the blog counters the "warped political ideology of anti-psychiatry extremists". I'm not sure what is meant by his claim. I've said before (eg. see previous post) that psychiatrists often label views with which they do not agree as 'anti-psychiatry'.

Dawson regards what he calls the "war on antidepressants" as "really a war on psychiatry".  He doesn't seem to be able to appreciate the institutional corruption of modern psychiatry (see eg. previous post) and even seems to suggest that psychiatrists' conflicts of interest with pharmaceutical companies do not matter (see eg. another previous post). I'm not sure who he's blaming for the widespread belief in the chemical imbalance theory of depression (see previous post). He doesn't seem to be able to accept that the evidence for the effectiveness of antidepressants is still open to question (see previous post); nor that the placebo amplification hypothesis could be valid (see another previous post). In fact he seems to think that the placebo amplification hypothesis is that antidepressants work by side effects, which is a misunderstanding of the theory. He needs to gain more understanding of the position of critical psychiatry (see previous post).

I agree antidepressants are not "tools of the devil" but let's stick to the scientific arguments rather than  stigmatise so-called warped ideology.