Psychiatry needs to be more thoughtful

Linda Gask, who I have mentioned before (see eg. previous post), has reviewed Conversations in critical psychiatry (2024) edited by Awais Aftab (see her review and eg. my comment about the book in a previous post). As she says, reading the book reminds her of when she first tried to make sense of psychiatry in her training. Such an experience of trying to make sense of psychiatry in the wake of the so-called anti-psychiatry of the time was common for our generation of psychiatrists (see eg. my MIA radio interview). For example, I've mentioned before (see eg. previous post and my article) Simon Wessely's description of how he went through this process  and was rescued by the book Psychiatry in dissent (1976) by Anthony Clare. As I said in my comment about Awais's edited book, there is a sense in which his book is trying to rescue psychiatry from the more recent critical psychiatry movement, in the same way as Clare did with anti-psychiatry.

As Linda says, she has "never identified with the British version of ‘critical psychiatry’, finding it rather like having to adopt a complete ideology that will only consider hypotheses that are self-confirmatory". I'm not exactly sure what she means by this. If critical psychiatry's ideology is so self-confirmatory, why don't more psychiatrists and people in general go along with it? As I've said several times (eg. see previous post), critical psychiatry has found it very difficult to get its message across. Nonetheless I agree with Linda's conclusion to her review that:-

We need to encourage those training to be psychiatrists to not only be more thoughtful but listen to as many patients’ stories as they can and read widely, even the work of those they are convinced they will disagree with. 

Is psychiatric diagnosis of any value?

I responded (follow my Twitter thread) to Justin Garson’s (mentioned in previous post) tweet . What he said was:-

I can’t fathom how a psychiatric diagnosis would ever be useful to anyone except as a tool to get accommodations or drugs. As far as understanding myself – who I am, why I act and think as I do – it contributes nothing.

I do understand what he means (see eg. previous post). As I said in response, I agree there is no value in the ‘one person, one disease’ view of psychiatric diagnosis. However, I worry that his critique goes too far and can only polarise debate and alienate mainstream psychiatry which does need to change its views about psychiatric diagnosis.

What needs to happen is that psychiatry should recognise psychiatric diagnosis for what it is rather than completely abandon it, as Justin would like. Diagnosis is justified as a means of communication. It is a way of trying to manage clinical complexity. But the boundaries of any diagnosis are fuzzy and there is no point of rarity between different syndromes. These are not absolute terms. Most psychiatric presentations are not natural kinds with an identifiable brain abnormality. 

The problem is that it is too easy to assume a diagnostic concept is an entity of some kind, which then acts as a justification for treatment. In fact a psychiatric diagnosis is an unobservable, hypothetical construct. It is more an idealised description of those aspects of psychiatric presentation that are of interest. Diagnostic concepts are therefore justified by their clinical utility. Diagnosis is not only about identifying disease but also about the reasons for mental health problems.

Where psychiatry went wrong over recent years was in response to the so-called anti-psychiatry critique. In a way, Justin could be said to be resurrecting aspects of that critique. But psychiatry needs to move on from the polarisation between pro-psychiatry and anti-psychiatry. For example, Thomas Szasz became famous for his view that mental illness is a myth. He was correct that psychiatry has misled too many people that their mental health problems are due to their brain. Of course the brain mediates what we think, feel and do, including when we are mentally ill. But that does not mean necessarily that there is an underlying brain abnormality causing the problems. Szasz was right that the supposed brain disease behind functional mental illness is a myth. But Szasz wanted to go further by abandoning psychiatric diagnosis altogether because he did not think psychiatric detention could ever be justified.

Mainstream psychiatry’s response to so-called anti-psychiatry has merely reinforced its belief that functional mental illness is due to brain disease. It tends not to take a hardline position on this issue by saying that functional mental illness is completely caused by brain abnormality. However, it wants to say that there must be brain abnormality as a factor in most psychiatric presentations. This is not necessarily the case. It’s wrong to reduce people to their brains. Personal and social explanations of why we do what we do can improve our understanding of the reasons for our actions but cannot provide a complete causal explanation, certainly not in biological terms.

As I keep saying, too many people are being misled by psychiatry that their mental health problems are due to their brain (see eg. previous post). This includes misleading children who are being given a neurodivergent diagnosis to justify their sense of difference from others. This blog is called “Thinking differently about mental health”. Being different does not necessarily need to be justified by a psychiatric diagnosis. I know the neurodivergence movement does not want to pathologise a neurodivergent diagnosis. But overvaluing the diagnosis, including implying that any personal difference is due to brain differences, is not really helping children, including people in general. Here Justin does have a point. Psychiatry needs to undo the way in which it is itself benefitting  from encouraging a psychiatric label as “the answer” to people’s mental health problems.

Work needs to be undertaken now as part of the process towards complete reform of mental health legislation

I was hoping the new government would revisit the Parliamentary Scrutiny Committee’s report on the last government’s draft Mental Health Bill. This would have also given an opportunity to produce a new Bill taking into account the recent WHO/OHCHR guidance to countries on mental health legislation (see previous post). Instead the new government has produced a Bill not that dissimilar to the draft Mental Health Bill of the last government (see eg. blog post from DHSC Media Centre and version of amended Mental Health Act (MHA) 1983 as if amended by the Bill prepared by Alex Ruck Keane). 

Homicide by psychiatric patients is a political issue which still seems to be preventing proper human rights MHA reform (see eg. previous post about case of Valdo Calocane as an example). Such reform will now almost certainly need to take place over time, maybe in the context of the also necessary reform of the Mental Capacity Act (MCA). In my view, the last government should have been more ambitious looking to replace both the MHA and MCA. There also needs to be a cultural shift of attitude within mental health services to make them more person-centred. As Mind said in its initial reaction to the new Bill:-

[T]here is more to do and questions to ask about whether this [Bill] will go far enough to fix the broken system as we know it. The mental health emergency we are facing will need much more than a reformed Act.

Work needs to be undertaken now as part of the process towards complete reform of mental health legislation. Mere amendment of the 1983 Act as will be enacted by the new Bill is not sufficient. This work (see eg. previous post) should include: reform of the Mental Health Tribunal to make it more rights-based; improving mental health advocacy by creating an integrated service of Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts; and further reducing the commissioning of secure placements, leading to the prevention of all civil detentions to secure facilities, apart from to short-term Intensive Care Units. The latter development needs to be supported by a renewed focus on improving the quality of acute psychiatric inpatient and crisis resolution and home treatment services. Work could also be undertaken on creating a new Mental Health Commissioner for England. The mental health reviewer and Second Opinion Approved Doctor (SOAD) functions of the Care Quality Commission will also have a role in monitoring the implementation of the new S56 treatment provisions for Approved Clinicians to follow a clinical checklist and the introduction of statutory care and treatment plans.

Blaming the brain is out of control in psychiatry

I've said before it's been difficult to get the message of critical/relational psychiatry accepted (see eg. previous post). People are being encouraged to see themselves as their brains. It's almost become heretical to suggest otherwise. Of course the belief that what we think, feel and do are caused by our brains is plausible. This assumption must not be questioned, though.

After all there are brain scans that prove this, aren't there? We've probably all seen pretty coloured scans that show areas of the brain lighting up when they are said to show connections to various human activities. But we’ve forgotten what our forefathers learnt in the late 19th/ early 20th centuries that human activity is not as well localised in the brain as we might have expected or hoped. They appreciated that the brain, indeed the complete human body, generally acts as a whole. People are also alive and cannot be explained in mechanistic terms. 

Elliot Vallenstein's book Blaming the brain was first published in 1998. It described how theories of chemical imbalance in the brain had replaced previous ideas that early experience in the family were the cause of mental disorders. As the publishers website says (see webpage), the book sounded a “clarion call throughout our culture of quick-fix pharmacology and our increasing reliance on drugs as a cure-all for mental illness”. This situation has in fact in many ways only got worse since despite the warning. For example, over recent years, the neurodivergence movement has promoted the idea that our differences from each other are due to our brains. No wonder there is therefore a burgeoning demand for a neurodivergent diagnosis. If it’s believed that the reason why we’ve seen ourselves as different from each other all these years is because of our brain, then the sooner we get a diagnosis the better.

We need a serious rethink about the nature of mental disorder. It may have suited psychiatry to go along with the idea that mental illness is due to the brain. Of course brain abnormalities can cause mental symptoms. But most of the presentations to psychiatrists are not caused by a brain abnormality, however much psychiatrists may have misled people that they are.