Still against the grain to be against biomedical psychiatry

I've managed to find a Psychiatric Times article by David Kaiser (1996) 'Against biologic psychiatry' which I thought had been lost in the ether. Unfortunately I can't find his associated articles that featured in the MHi 'Against the Grain' series. My critical psychiatry webguide, which originally was published on the Royal College of Psychiatrists' website in 2001 featured these articles. Some of the other links on the webguide are also now dead.

Kaiser's articles were also some of the first I posted on my list of articles critical of psychiatry, which I collected over many years on my Critical Psychiatry website. Again, many of the links in the list and on the Critical Psychiatry website in general are now dead.

As I indicated in the webguide, an advantage of the internet in the early days was that it provided a forum for critiquing biomedical psychiatry. In the modern days of social media, we have become used to everyone being able to express their views online about many things, besides psychiatry. Still, two of my first posted comments in the list of articles (see first and second), critiquing 1999 psychiatric journal articles about the biological basis of schizophrenia stand as much now as they did then. I didn’t bother submitting them to the journals as letters because they wouldn’t have been published! But I could self-publish on the internet. Kaiser's expression of his "dismay and outrage [at] the rise and triumph of the hegemony known as biologic psychiatry" doesn't seem to have had as much impact as it should have done from within psychiatry.

On psychiatric diagnosis

A diagnosis is a name for an illness or a disease. Technically, illness is the experience of symptoms and suffering and disease is the underlying biological pathology. People can be ill without have a disease and primary mental illness is an example where there is no underlying brain abnormality.

So, having a psychiatric diagnosis does not necessarily mean there is something wrong with your brain. And anyway, people are not their brains or bodies.

Psychiatry needs to abandon its biomedical framework

Campolonghi & Orrù (2023) argue that psychiatry needs to abandon its biomedical framework (see Mad in America research news). As they say, treating functional mental illness as brain disease "constitutes an illegitimate epistemological leap” which “leads to pseudoscientific (and unethical) practices”. 

As they go on, “biological processes and the brain are [of course] involved in enabling and mediating cognitive, emotional, and behavioral functions and responses”. However, "the consistent and systematic search for biological and neurological causes of distress and problematic behaviors conducted over more than a century" has not provided "any evidence or support for the existence of 'mental disorders' as natural kinds”.

The problem is that “psychiatry is not built upon physical sciences (as medicine is) and yet adheres to a (neo)positive-empiricist tradition”. Psychiatry will not find it easy to abandon its biomedical framework but it needs to do so in the interests of patients.

Improving compassion in mental health services

Elisa Liberati et al (2023) tackle the issue of the lack of compassion in acute mental health services, exposed, for example, by undercover reporting of abuse in psychiatric inpatient services (see eg. previous post). As they say, the preconditions for compassion in mental healthcare have been severely eroded.

The reasons for this are complex. There has always been a tendency for staff to dissociate themselves from the pain and distress experienced by services users. As Liberati et al say:-

Rising demand, resource shortages, and weak organisational support are causing staff burnout and disillusionment, compromising their ability to act compassionately. … These problems are especially acute in inpatient settings, where staff are often exposed to intense negative emotions and may experience vicarious trauma.

But this lack of compassion seems to have become worse over recent years with the rise of risk management. The challenge for staff is to maintain therapeutic relationships with patients in the context of an organisational bureaucracy which has become primarily concerned about its accountability and responsibility rather than concentrating on its main task of patient care. In this context, staff may practice defensively for fear of making mistakes and being blamed by the organisation. Such tension can lead to practice becoming too risk averse, prioritising service requirements over patient needs.

Risk management in mental health is not always applied sensibly (see eg. previous post). Emotional safety can actually be reduced by too much of a focus on physical safety and organisational risk. Rigorous adherence to procedures designed more to protect the organisation rather than patients may not really reduce risk but instead infantilise people, taking away their personal responsibility and thereby emotional safety. Relationships between staff and patients need to be prioritised in practice and developed to provide therapeutic services.

Biomedical understandings of mental illness can also objectify people by reducing their psychosocial problems to brain disease. Nonetheless, even biomedical services should act humanely. If staff cannot provide good quality care, their sense of professional integrity may feel violated. It may nonetheless be difficult to challenge ways of working which conflict with their values leading to the normalising of poor practice.

The lack of compassion in mental health services needs to be taken seriously and staff supported by service organisations in their supervision and training to provide good quality care. The rights of people with mental health problems must be promoted to improve the standards of modern mental health care (see eg. previous post).