I said in a
previous post that mainstream psychiatry ignores critical psychiatry and I seem to have been wasting my time trying to get my message across in this blog. I have subsequently changed the name of this blog from critical psychiatry to relational psychiatry (see another
previous post), partly in case the term 'critical', which tends to have negative connotations, is what puts people off. But it does seem to be the content of the message that people do not want to hear, rather than necessarily the way it's expressed. I'm not convinced psychiatry is really interested in relational psychiatry either. Why is that?
People not wanting to hear the message of critical/relational psychiatry may seem surprising to some, because isn't psychiatry primarily about relationships with people, as the term ‘relational psychiatry’ implies? Surely it's about trying to support them with their difficulties in their personal situation and relationships with others through an independent professional relationship. Is psychiatry then not really about helping people?
Well, yes and no seems to be the answer! Psychiatry does think it is helping people but not apparently necessarily through relationships with them. The focus tends to be on treating their brain problem. Psychiatry believes people's psychosocial difficulties may well be correctable by some physical intervention, such as prescribing medication, or by a simple, brief psychological course of therapy. The person will then be alright, or at least better with that treatment. Is there any more to it?
That’s the positive component to psychiatry's answer, is it? But what about the negative? What's wrong with just accepting this mainstream psychiatric view? However much of a caricature of psychiatry I'm presenting, it does seem to describe the essence of what people think psychiatry is expecting them to believe. No need to wrap it up in an academic critique of psychiatry called critical/relational psychiatry. Just express it in plain terms. That's not to deny that mainstream psychiatry certainly seems to suit some people. If that's all that's needed, all well and good. Keep things simple. That's fine for them at least, maybe!
But is that generally what people want from mental health services? Most people know their problems are more complex. They might hope they can be made simple and corrected easily. But generally, when they think about it, they may well be prepared to admit to themselves that might be wishful thinking. It might well take time and effort to recover from personal difficulties. And anyway, by reducing people's complex emotional difficulties and personal situation to a brain problem, hasn't the essence been lost of trying to understand why they are thinking, feeling and behaving in the unhealthy way they are? Ok, there might be a brain problem behind it. But for the vast majority of presentations to mental health health services, that is not the case.
So, what’s the point of encouraging people to believe that there is a brain problem? There are several reasons for this. As I’ve already said, it’s simpler to reduce the complexity of mental illness to brain disease. Understanding the relationship between mind and brain is difficult. For example, do we think and feel and do things because of our brains? We certainly need a brain to be alive. When we’re dead, it’s definitely not working! But then neither are our other bodily organs. We need a body to be alive. The brain is certainly an important part of that body to create the people we are. To some extent our human functioning is localised in specific parts of the brain, but actually not as well localised as people often think. The brain functions very much as a whole, despite all the attempts in research over the years to localise mental illness within it. Certainly mental illness shows through the brain but not necessarily in particular places within it. Nonetheless it’s attractive to think that mental illness may be localisable within the brain. We then don’t need to bother about what it means to be alive and can avoid having to deal with difficult abstract concepts like the nature of mental illness. Troublesome ethical debates about what psychiatry needs to do to manage such problems can then be short-circuited.
Another advantage of reducing mental illness to brain disease is that it makes mental illness more like physical illness. We can then follow the same kind of physical approach as the rest of medicine, which seems to have been remarkably successful in finding treatments for our various illnesses. Although, in practice, we may often overestimate how successful medical treatments are, it’s seductive to think that psychological medicine may be able to utilise the same scientific principles as the rest of medicine. Any differences between mental illness and other illnesses can, therefore, be minimised, if not obliterated. All well and good! As well as simplifying the conceptual issues, we now have a technological solution to mental illness following the same methods in psychiatry as the rest of medicine. However much people may be fearful of mental illness, and want to exclude disturbed people from society, psychiatry has provided a way to give itself professional respectability in its dealings with them by making it more like the rest of medicine.
By adopting the same principles as the rest of medicine, psychiatry then creates another apparent advantage. It now needs a massive research industry, with considerable funding behind it, to find the so-called 'answer' to mental illness. It doesn’t matter that people are being reduced to their brains by seeing their mental health problems as being in the brain. It’s anyway more commonsensical, surely after all, to think that people are driven by their brains. There must be a need for neurobiological research to understand what’s gone wrong when people become mentally ill. Psychiatry's now avoided complex conceptual issues, found that it can follow medical methods and technologies, and just needs to invest more in research to make progress. Psychiatry has created a firm edifice and foundation to provide care for mentally ill people, or has it? The problem is that it may suit us to think solutions are just round the corner but meanwhile there are still a significant number of people with mental health problems that need help, and we’re being distracted from dealing with what matters by seeking unattainable solutions in the future.
Biomedical psychiatry has, therefore, created a remarkably successful economic model. No wonder people don’t want to give it up and feel threatened when it is challenged. The problem is that taking this approach to psychiatry means that it has become more like a faith than a science. It has certain tenets which need to be believed. As we have outlined, these are: firstly, that mental illness will be shown to be due to brain disease and that there’s subsequently no need to get bogged down in complicated conceptual issues about the relationship between mind and brain; secondly, as mental illness has a material basis as do physical illnesses in general, it follows that psychiatry is not that different from the rest of medicine, so psychiatry can follow the same methods and technologies as the rest of medicine; and thirdly, that the scientific ambition of psychiatry and its associated research programme is to uncover the neuroscientific causes of mental illness and great progress has already been made in this aim. These fundamental tenets must not be questioned, otherwise the edifice of modern psychiatry may come tumbling down.
That's fine, maybe, but psychiatry has considerable legal powers, such as being able to detain mentally disordered people in hospital, subject to certain criteria within the Mental Health Act. It may well think it needs a firm foundation to be able to exercise that authority. It can’t really have people undermining its conceptual foundations, when it has such important social responsibilities. However, it is perhaps particularly because of the power that psychiatry has over people with mental health problems, that it's important to be honest about the state of its practice. Psychiatry may not want to to listen to any candid criticisms, but it should. We're now back to where we started this post. If psychiatry is primarily about relationships with people, then it does need to accept this reality. However successful psychiatry may be in marginalising any critique, people do feel obliged to speak openly and fearlessly about how psychiatry needs to change. Otherwise, it may just continue to be designed more for its own interests than the people it purports to serve.
