Thursday, September 17, 2020

Towards a more relational psychiatry

I have mentioned 'relational psychiatry' before (see previous post). Even though I come from a critical psychiatry position, which has never hidden that it grew out of what mainstream psychiatry called 'anti-psychiatry', there are more recent developments from anti-cognitivist phenomenological and enactive accounts of psychopathology that come to the same conclusion about the biomedical model of mental illness. For example, I have mentioned books like Sanneke de Haan's Enactive psychiatry (see eg. previous post) and Thomas Fuch's Ecology of the brain (see another previous post). 

Laurence Kirmayer summarises his perspective on what he calls ‘ecosocial psychiatry’ in an article in World Social Psychiatry. As he says, "Cognitive science supports the view that mental processes are intrinsically social, embodied, and enacted through metaphor, narrative, and discursive practices". As I've argued throughout this blog (eg. see previous post), there needs to be a shift in perspective from a narrow biomedical perspective towards a more truly biopsychosocial approach. As Laurence puts it, what's required is "a shift in perspective from a psychiatry centered on brain circuitry and disorders toward one that recognizes social predicaments as the central focus of clinical concern and social systems or networks as a crucial site for explanation and intervention". In this quote and the article in general, Laurence also helpfully illustrates the importance of social psychiatry, as focusing on the person inevitably means including the interpersonal dimension. This leads, as Laurence says, to an emphasis on "the powerful effects of structural violence and social inequality as key determinants of health".

Reductionism leads to the loss of meaning of human action and a mechanistic psychology cannot be realised in practice (see eg. previous post). This critique of reductionism and positivism in psychiatry, including mechanistic psychological approaches, creates a framework that focuses on the person and has ethical, therapeutic and political implications for clinical practice. It also has consequences for psychiatric research, which has become far too focused on speculative neurobiological notions. 

Descriptive psychopathology is not studied organically at the level of neurobiology. History and mental state examination instead produce a formulation of people’s problems in terms of differential diagnosis and aetiology. Examining the brain in a scanner, for example, does not tell us anything about the cause of thoughts, emotions and behaviour. An integrated understanding of mental dysfunction in the context of the whole person, including emotional needs and life issues, forms the basis for patient-centred and relational psychiatry. The physical disease model of mental illness is outdated and needs to be replaced by a relational psychiatry.

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