Doctors have too much power in the current Mental Health Act

As I’ve been saying (see eg. previous post and my eletter), a new Mental Health Act (MHA) needs to go further than current government proposals for reform. In a chapter in a recent book, George Szmukler & Larry Gostin (2021) provide a helpful history of mental health legislation. 

As they point out, the 1959 MHA was the first time judicial authorisation was not required for compulsory admission. The Act could be said to have promoted a ‘medicalism’ over ‘legalism', in that it introduced primarily medical rather than legal controls over detention and treatment procedures. Such an arrangement requires doctors to manage these responsibilities appropriately. The 1983 MHA, which Larry Gostin himself influenced through his campaigning as legal officer for Mind, provided more safeguards for the rights of detained people; in a way a kind of ‘new legalism’. The containment of 'risk' (see previous post), which motivated the 2007 amendments to the Act, again gave more power to doctors with the introduction of community treatment orders. The changes encouraged doctors to deploy compulsory powers to manage risk: a ‘new medicalism’. 

Doctors in fact have too much power as detention and coercion are not always the most appropriate responses to the management of mental illness, including its risk. As Baroness Wootton pointed out in relation to the 1959 MHA, doctors have been laid open to "the exercise of powers which the public would regard as arbitrary in other connections” (quoted on p.72). There will be inevitable uncertainty about psychiatric diagnosis and treatment, and whether detention is appropriate and enforced treatment necessary. Mental health services’ ability to detain people and treat them against their will needs to be more open to scrutiny and control. The 1959/1983 Acts were reforming Acts in the context of deinstitutionalisation, when traditional asylums were being opened up and the rights of detained mentally ill people promoted, but there is now a focus on increasing security leading to reinstitutionalisation (see previous post). As the independent review chaired by Simon Wessely found, mentally ill people are not always being treated with dignity and respect (see eg. previous post). They need to be supported rather than necessarily have treatment imposed on them (see previous post).

To provide more balance to the authority of doctors, advocacy services need to be developed further, so that patients have a right to an independent opinion of their own choice on medical, nursing and social matters (see previous post). I think this should be a nationally managed service to include Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts (see another previous post). If necessary, any conflict between the Responsible Clinician (RC) and advocacy services, both on detention and treatment matters can be adjudicated by the Mental Health Tribunal, with the Tribunal having the power to require the RC to reconsider a specific treatment decision, as well as order discharge, leave, transfer or community services, either immediately or within a recommended time period.

The other main change that is needed is to prohibit any further admissions of patients detained under civil proceedings (Part II patients) to secure facilities (see previous post), as secure facilities are more suitable for people detained under criminal proceedings (Part III patients) as an alternative to prison. The government recognises that too many people with learning disability and autism are being detained inappropriately in secure facilities (see previous post), but the same also applies to those with serious mental illness. 

Although the government does want to reduce coercion in mental health services, it does need to base this reform on the rights of people with mental health problems. There is evidence that it is actually watering down these principles (see previous post). It isn't just earlier and more frequent access to safeguards against detention and enforced treatment that are needed (see previous post), but a shift, hopefully led by doctors, towards more open and therapeutic treatment. Treatment should not be inhumane and abusive, as it can be currently (see another previous post), and doctors' decisions must be made in the best interests of patients.

A new epistemology for psychiatry

German Berrios and Ivana Marková have a chapter in Kirmayer et al’s (2015) book Re-visioning psychiatry on ‘Towards a new epistemology of psychiatry’. As they point out, biological psychiatry tends to be seen as true, only hindered in its progress by its financial under-resourcing (see previous post). Instead they suggest psychiatry needs better conceptualisations and methodologies to treat and research impaired mental functioning.

They emphasise the hybrid nature of psychiatry, in that not all mental symptoms can be explained as natural kinds but rather are incongruous "admixtures of organic/biological and sociocultural components". The combination of biological and semantic elements in the hybrid object means that the functional specificities of the brain signal are lost. In other words, "a simple and direct (cause-effect) relationship between the brain signal and the symptom" is precluded. The meaningful nature of mental symptoms cannot be located in the brain (see previous post). 

German and Ivana distinguish between mental symptoms that have either primary or secondary brain inscriptions. In those with a primary inscription there is a relatively direct relationship between brain inscription and symptom; whereas in those with secondary inscription the meaningful nature of the symptom must be represented in the brain but no "alteration of brain activity is necessary or sufficient for this type of mental symptom formation because it can only occur in an intersubjective space". 

As I have pointed out before (see eg. previous post), DSM-IV wrongly abolished the distinction between organic and functional mental illness. In a way, dividing mental symptoms into those with primary/secondary brain inscriptions reintroduces this distinction, although German and Ivana seem to want to suggest that the differentiation they are making is not the same. For example, they complain that the organic/nonorganic distinction is too rigid. However, functional does not mean non-organic (see previous post). Similarly, they seem to imply that psychotic depression, for example, has primary brain inscriptions, whereas it's not clear to me that it is an organic rather than functional disorder.

I totally agree that psychiatry needs a new epistemology and think that relational psychiatry provides just that. For example, Thomas Fuchs’ ecology of the brain (eg. see previous post), Sanneke de Haan’s enactive psychiatry (eg. see another previous post) and Laurence Kirmayer’s ecosocial psychiatry (see yet another previous post) all have the same epistemology. The history of psychiatry shows that psychiatry has been caught in an opposition between psychogenesis and organogenesis (see eg. previous post). The distinction between mental symptoms with primary or secondary brain inscriptions is fundamental and may actually not be that much different from the distinction made by Étienne-Jean Georget in the origins of modern psychiatry in the early eighteenth century between symptomatic diseases with organic causes and idiopathic disorders resulting from purely functional disruptions (see previous post). The problem is that the success of the anatomoclinical method in medicine has led to belittling its different implications for psychiatry. We need to give up trying to establish biological causes of mental illness as such (see eg. last post). 

Limits to knowledge about mental illness

As I've said before (eg. see previous post), biomedical psychiatry makes unsubstantiated claims about the nature of primary mental illness by suggesting it can be understood, let alone explained, as a brain abnormality. It's natural to go beyond the evidence on topics to which we can't possibly know the answer. Even though it's absurd to make such an attempt to understand primary mental illness in biological terms, nonetheless it seems to make sense to us that we should be able to provide such understanding and explanation. We, therefore, embark on wish-fulfilling fantasies about biological causes, even believing they have been established when they have not. Neuroscientists know that biological causes of primary mental illness have not been found, but nonetheless speculate about the latest research findings which unexpectedly never turn out to be proven, as there are so many inconsistencies and confounders in the data.

The fundamental problem is that we cannot know in mechanical terms how life arises (see previous post). Organisms don't follow the same rules as physical objects and seem purposive. We can, therefore, only talk about the reasons for primary mental illness, not its empirical causes. It cannot be reduced to brain disease in principle (see previous post). Although mental illness is of course enabled by the brain, mental states have meaning, which the brain as an object lacks. However much we may hope that we can explain primary mental illness in physical terms, we can't. We need to learn to accept the limits of our knowledge and how this applies to mental illness.

Reducing coercion in hospital for people with learning disability and autism

My letter to Lancet Psychiatry in response to Hassiotis et al (2021) has been rejected as it is said not to add sufficient new information. I don’t agree and it concerns me that there does not seem to be sufficient discussion in the academic literature about the shortfalls in the government’s White Paper on reform of the Mental Health Act (MHA). As I have said before (eg. see previous post), the proposals should be supported but they do not go far enough in reducing coercion in mental health services, including learning disability services.

Not many people have argued as I have (see previous post) that new admissions under civil detention arrangements (Part II MHA) of people with autism or learning disability (and serious mental illness) should be prohibited to a secure hospital. I do not think the criteria for detention of people with learning disability, which already require associated abnormally aggressive or seriously irresponsible conduct, should be altered. The White paper proposes that autism and learning disability are no longer to be considered mental disorders warranting treatment under section 3. Such patients can be admitted under section 2 for assessment of factors driving any abnormally aggressive or seriously irresponsible conduct and section 3 continued if a mental health condition is the driver. My concern about this proposal is that it will result in too technical, not always very meaningful, arguments about whether there is a mental health condition in addition to learning disability. It is almost as though the White paper is encouraging the reintroduction of the term ‘psychopathic disorder’, which was abolished by the 2007 amendments, so that someone with a learning disability can then be detained if they have a psychopathic disorder as well as learning disability. I am not convinced this is the best way forward.

The White paper also talks about the warehousing of patients with learning disability and autism. Transfer to secure provision leads to unnecessarily long admissions. I’m not denying the need for more community rehabilitation, but the issues are not just about difficulty in placement and lack of appropriate community resources. It is also about developing the skills to manage learning disability patients with challenging behaviour in a more open way in Assessment and Treatment Units (ATUs). Prohibiting any further admissions of Part II patients to secure facilities by legislation will help to create the right environment for the treatment of such challenging behaviour.

Reversing re-institutionalisation

I’ve always tended to prefer the term de-hospitalisation to de-institutionalisation, because although the traditional asylums have closed, institutional practices still exist in the network of community, including smaller residential, facilities that have replaced them. In fact, since 1990 there has been a re-institutionalisation of mental health services, particularly with increasing numbers of secure psychiatric beds both in the NHS and private sector. For example, Rutherford & Duggan (2008) reported that the "forensic services population rose by 45% in the 10 years between 1996 and 2006". This resort to re-institutionalisation, as Turner (2004) said, partly “reflects a culture of risk management, [and] an overriding concern for public safety ... “ (see previous post). 

Despite the move to community care and the reduction in both mental illness and learning disability in-patient beds overall, the number of detentions under the Mental Health Act (MHA) 1983 continues to rise (Keown et al, 2018). This is one of the major reasons why the MHA is currently being reformed. Alongside the increase in detentions, the proportion of involuntary admissions to private hospitals increased from 3% in 1984 to 15% in 2015/6. This shift was more pronounced for forensic (Part III) patients, although also occurred for civil (Part II) cases.

Of course, part of the motivation for the rundown of the traditional asylum was the institutionalisation of patients. The new MHA needs to bring a halt to their re-institutionalisation and do more to improve the process of de-institutionalisation started by the 1959 and 1983 Acts. The White paper has talked about the warehousing of patients, primarily for learning disability patients, although this also occurs for those with serious mental illness. To complete the quote from Turner (2004) above, the other reason for re-institutionalisation is “the burdens and pressures upon services trying to manage ‘revolving-door’ psychotic patients”. These patients are seen as difficult to manage and place and have been shipped out of the NHS to private care and to low and even medium security, when they should be managed in a more open door-environment. As I have said (eg. see previous post), civil detentions of people with learning disability and serious mental illness should be prohibited to secure provision. This will allow secure services to develop their proper function of providing a therapeutic alternative to prison. The 2007 amendments to the Act, which were motivated by an inappropriate over-concern with risk, need to be reversed by repealing community treatment orders (see another previous post).

Simplifying depression

Flow Neuroscience has “truly global ... ambitions” to “make depression treatment simple and accessible”. As an article in the Financial Times, which mentions this Swedish company, says, “Technology to treat the brain has come a long way from the hundreds of volts used in brute-force electric shock therapy in the psychiatric clinics of the 1930s”. Neurostimulation (see previous post) now includes transcranial magnetic stimulation (rTMS) (see previous post), transcranial direct current stimulation (tDCS) and deep brain stimulation (DBS) (see previous post). Flow Neuroscience has introduced the first medically approved tDCS electricity-emitting headset for home use, which it says boosts an app-based behaviour therapy treatment programme. The blobs in their YouTube advertisment seem happier than the sad blob in the original Zoloft advertisement (see previous post).

Not sure how randomised controlled trials can be double-blind when comparing rTMS with sham treatment, as it causes a tingling sensation, which will break the blind. Also not sure how accessible the treatment will be (let alone value for money) as the headset costs £399 (although there’s also a renting option). Still the app is free to download. As I said previously (see post), I just wish that psychiatry could focus its efforts on providing more hope and effective treatment than neurostimulation, which is really exploiting people.

(with thanks to Alex Macauley)

In favour of the person

I’ve mentioned before (eg. my article) that Martin Roth saw anti-psychiatry as “anti-medical, anti-therapeutic, anti-institutional and anti-scientific”. He made it sound very negative being against all those things. 

Actually, relational psychiatry is anti-positivist, anti-reductionist, anti-institutionalisation and anti-racist. It’s against all those things because the fundamental problem of psychiatry is the objectification of people.  It also recognises the limitations of treatment and that there are differences between psychiatry and the rest of medicine. 

So, what it’s positive about is people and their relations in social context. The extent to which psychiatry has a tendency to be positivist, reductionist, institutionalised and racist undermines its proper, personal task of supporting people with mental health problems.

Making mental health services more humane and efficient

An open letter to the media about mental health services is available to sign. It highlights the following:-

1. lack of confidentiality in services eg. on mental health helplines 
2. more information needed for patients eg. about psychiatric treatment 
3. differences between psychiatry and the rest of medicine should not be minimised 
4. patients' mental capacity, their will and preferences need to be taken more into account
5. the dangerousness of people with mental health problems is exaggerated

Psychiatric practice should no longer be based on the notion that primary mental illness will be found to have a physical cause, but move on to a more personal, relational practice.

Risk and blame in mental health services

I've mentioned before (see previous post) that the over-preoccupation with risk in mental health services in the last 20 years or so has been counterproductive. This is relevant to the current review of the Mental Health Act (MHA) (see another previous post). The new MHA needs to reduce coercion in mental health services and risk is not always best handled by increasing coercion.

As I wrote in my book chapter, one of the reasons for the rundown of the traditional asylum was the mistreatment of patients in a number of institutional scandals. These traditional services needed to be opened up and patients moved more to the community. I've argued that the recent scandals of Winterbourne View and Whorlton Hall should similarly lead to the prohibition of any further civil psychiatric detentions to secure facilities (see previous post), so that these people if they need inpatient treatment should be managed in open door wards. A secure environment is unsuitable for most people with learning disability or serious mental illness. The new Mental Health Act must deal with abuse and over-restrictive practices within services.

As I also wrote in my eletter, many psychiatrists were opposed to the rundown of the asylum and the development of community care because of their, at least perceived, loss of power in the traditional hospital. There is no longer an active debate about whether the asylums should have been closed, because the process has been completed. But at the time, because of the relatively high level of mental illness amongst the homeless population, it was argued that patients were being discharged irresponsibly from the traditional asylums ‘onto the street’. However, follow-up studies of discharged patients (such as TAPS eg. see my book review) showed that the rundown of the psychiatric hospital, at least in the UK, was not the main factor contributing to the numbers of homeless mentally ill. The tack of campaigning organisations, such as SANE, therefore, changed to blaming dehospitalisation for homicide by psychiatric patients, leading to a focus on public safety. High profile media cases, such as the death of Jonathan Zito, who was pushed under a train by Christopher Clunis, led to the formation of the Zito Trust. The new Labour government concluded that community care had failed. Any homicide by a psychiatric patient had to be investigated, despite the fact that homicides by psychiatric patients had not in fact increased. There is no standardised approach to such inquiries, however, (see Ng et al, 2020) and many of them have been destructive (see my unpublished paper).

The current reform of the Mental Health Act has to be understood in the context of the last attempt to reform it, which led to the 2007 amendments. The introduction of community treatment orders (CTOs) then was hailed as saving lives, with fantasy estimates of how many suicides and homicides would be prevented. Of course there is no evidence that CTOs have reduced deaths (see eg. previous post) and they should be repealed (see another previous post).

The forensic theory of risk comes from Mary Douglas (1992). Talk about risk is a political process. Debate about accountability is a contest to muster support for one action rather than another. People pressurise each other in society and a conformity is created. The charge of causing risk is a stick to beat opponents. Ulrich Beck (1992) advocated in his book Risk Society that science needs to stop pretending it is neutral. It needs to become more conscious of its political nature. As I said in my talk:-

There is a debate about the balance between risk taking and risk aversion. If anything, what the Risk Society seems to mean is a shift towards the risk aversion end of this relationship. The word risk has been pre-empted to mean bad risks. The promise of a good political outcome is couched in other terms. Yet any society which did not take risks would not be making the most of its opportunities for growth. Over-cautious risk-averse behaviour can be crippling.

The new Mental Health Act again needs to open up debate about the balance between risk taking and risk avoidance. The 2007 amendments were an aberation in progress towards freeing up mental health services started by the 1959 and 1983 Acts. Risk aversion is leading to too many people being detained for too long and inappropriately and forced to have treatment when it is not benefitting them. This situation needs to change and the White paper does not go far enough to correct it.

Second opinion for enforced psychiatric treatment

I've mentioned before (see eg. previous post) that patients detained under the Mental Health Act (MHA) should have a right to a second opinion of their choice for medical, nursing and social matters. Currently, detained patients who are not consenting to medication must have their treatment certified after three months by a Second Opinion Approved Doctor (SOAD) from the Care Quality Commission (CQC). The government's White paper to reform the MHA (see another previous post) proposes that patients refusing medication treatment must have it certified by the SOAD at day 14, and by 2 months if they do not have relevant capacity, rather than 3 months. I don't think it's fair that patients with capacity should have stronger protection in this respect merely because they have capacity. Protection should be the same for detained patients with and without capacity, although at least civil detention should actually be difficult to justify for people with mental capacity.

As I've also mentioned (see previous post), SOADs, certainly these days, merely tend to 'rubber-stamp' Responsible Clinicans’ (RCs') treatment plans. For example, I think it's reasonable for a SOAD to consult the nearest relative about the treatment of an incapacitous patient, but I don't think I've ever seen it happen. SOADs need to take account of the will and preferences of the patient (see another previous post), including any advanced statement or Advanced Choice Document but I'm not convinced they do.

As I've again also mentioned before (see eg. previous post), I think a better safeguard would be to abolish SOADs and have their function taken over by the Mental Health Tribunal (MHT). The MHT should be able to require the RC to reconsider a specific treatment decision in a Tribunal hearing, if necessary, as proposed by the White paper, following a preliminary ‘permission to appeal’ stage. Personally I've no objection to this decision being made by a single judge sitting alone, particularly if it makes the Tribunal more responsive in these circumstances, as it's simpler to organise a single rather than three person panel. If necessary, the judge should be able to seek advice from a panel of medical members. The judge will be able to consider and make a judgement about any conflict between the RC and second opinion doctor of the patient's choice and made by the second opinion doctor in their best interests.

Finally, in my previous post, I've talked about independent clinical opinions being available routinely for patients and nearest relatives as part of an improved advocacy service. As I keep saying, the White paper proposals do not go far enough. They need to be put under proper scrutiny on the basis of these alternative proposals that I am making.

Principles of the Mental Health Act

I've indicated before (see previous post) that I think the White paper on reform of the Mental Health Act (MHA) actually dilutes the principles in the current Code of Practice. I'm not exactly sure where the four principles come from that were produced by the Wessely review and went into the White paper: choice and autonomy; least restriction; therapeutic benefit; and the person as an individual.

The current Code of Practice in chapter 1 has five overarching principles: least restrictive option and maximising independence; empowerment and involvement; respect and dignity; purpose and effectiveness; and efficiency and equity. I do not think these principles should be replaced without clear reason, which the White paper does not seem to provide. These principles were strengthened when the Code of Practice was revised in 2015 from the Code first published in 2008. Certainly they seem stronger and more comprehensive than the White paper principles.

For example, having maximising independence as part of least restriction seems more positive. Similarly, empowerment and involvement as a principle seems better than mere choice and autonomy. The continual complaint of patients found by the independent review was the lack of respect and dignity they experienced in treatment, so it is helpful surely to have these as principles, whereas they are not included in the White paper. Adding person-centred care as a principle, which is presumably what the review meant by person as an individual, is helpful, as people should not be treated as objects. I think this was meant to be covered by purpose in the current Code of Practice. Effectiveness is not the same as efficiency and this distinction may be lost in the more generic term of therapeutic benefit. And anyway, isn’t the whole point of the Act for treatment (and assessment)?, so I’m not sure what’s added by including therapeutic benefit as a principle.

Considering the mistreatment of patients uncovered by the investigations into Winterbourne View and Whorlton Hall (see last post), I think there needs to be explicit reference to the principle of avoiding  inhuman and degrading treatment. Part of the motivation for the Wessely review was because of racial disparities in the application of the Act (see eg. previous post), so I think anti-discrimination, including anti-racism, should also be included as a principle.

It is surprising to me that so many people seem prepared to accept that any change in the MHA is better than none, when there is good evidence that the principles proposed in the White paper are insufficient. There needs to be proper scrutiny of the White paper proposals.

Civil psychiatric detentions should be prohibited to secure facilities

I've mentioned before the scandals of Winterbourne View (see BBC report) and Whorlton Hall (see BBC report) exposed by Panorama (see previous post). The White paper on reform of the Mental Health Act (MHA) talks about needing to prevent the warehousing of patients in psychiatric hospitals. As I've said before (eg. see previous post), the White paper does not go far enough in its reforms. Specifically in this regard, it does not go far enough in preventing further mistreatment of detained patients as happened at Winterbourne View and Whorlton Hall.

The mistreatment is not just of people with learning disability and autism, but also serious mental illness. What happened with the rundown of the traditional asylums, including those for learning disability (mental handicap as it was then called), is that difficult to manage or place patients have been shunted to secure provision, often out of the NHS in private facilities. I called this situation a scandal in 2007 (see my eletter). It has continued and needs to stop. What I'm suggesting is that any new admissions of civil detentions (part II of the MHA) should be prohibited to secure facilities.

It's as though psychiatry has forgotten its history of opening the doors of the asylum (see my 2015 talk on making the mental hospital therapeutic). By 1963, 80% of English psychiatric patients were in open wards. The advantages were said to be striking: tension reduced, violence declined, ‘escapes’ were no longer a problem and staff were able to give their attention more to therapy rather than custody. When I first started in psychiatry, we used to pride ourselves that acute wards were open. These days most of them are locked, if only behind key fobs, which patients and families do not have. This level of security may continue for those that may be difficult to manage because of their level of disturbance or aggression, as they may be moved to low, even occasionally medium, security, really designed more for forensic (Part III) patients who have committed a crime. This transfer to secure provision may follow unnecessarily long admissions to psychiatric intensive care units (PICUs), which were originally designed merely for very short-term treatment. And people can continue to spend unnecessarily long in secure facilities, rather than their disturbance being managed properly in a more open way. 

Part of the problem, as the White paper recognises, is about patients who are difficult to place. There is a need for more community rehabilitation, which the White paper recommends for learning disability. It should also have recommended it for serious mental illness. But the issues are not just about difficulty in placement and lack of appropriate community resources. It is also about developing the skills to manage people with disturbed mental states and challenging behaviour in a more open way in acute treatment to prevent further aggression and disturbance. I worried about the development of PICUs when this first happened because I thought it would mean, and I think has happened, that acute wards would lose the skills to manage disturbance and aggression. 

The White paper misses this point about Winterbourne View and Whorlton Hall. It makes a distinction between the criteria used for detention under Part II and III. But the criteria for these admissions should remain the same, except that, as now, Part III cases may have a restriction order, as the real issue is about the environment in which Part II admissions take place. Any further admissions under Part II should be prohibited to secure facilities.

The future of psychiatry

I recently came across an obituary for Lyn Pilowski (who I have mentioned in parenthesis in a previous post). Unfortunately she died aged 46 in 2007 of a brain tumour.

What interested me is that Anthony Clare (who I have also mentioned before eg. see previous post) thought she "embodied the future of psychiatry in the years to come". I think this just shows that Clare, despite his emphasis on an eclectic approach to psychiatry, really was a biomedical psychiatrist (see previous post), even if at the softer end of that spectrum. 

The hope of brain scanning for elucidating the biological basis of schizophrenia, which Pilowsky could be said to have embodied, has failed (see eg. another previous post). Psychiatry needs to be helped to become more relational in its practice.

Improving mental health advocacy

I've said before that the government's proposals to reduce coercion in mental health services do not go far enough (see previous post). This applies as far as advocacy services are concerned, as I think they need to be developed even further than the White paper proposals.

Advocacy promotes the human rights of people. The response to the consultation from the British Institute of Human Rights (BIHR) highlights problems currently with a number of human rights issues in mental health services, including "long periods of detention that are not of therapeutic benefit, concerns around people accessing mental health services and their loved ones having little say over their care, treatment and recovery". 

Patients and their families need to be helped to make informed decisions about mental health treatment. They need support to have their voices heard about poor service delivery, inaccessible care and unnecessary enforced treatment. As I’ve said before, detained patients should have a right to a second opinion of their choice both about detention and treatment (see previous post), and this should be available for medical, nursing and social matters. Reports produced by these independent experts should, if necessary, be much more routinely presented by solicitors to Mental Health Tribunals (MHTs). 

The White paper has made welcome proposals to improve the role of the Independent Mental Health Advocate (IMHA), including that the IMHA can appeal to the MHT on the patient’s behalf and can make a challenge to the MHT for the Responsible Clinician to reconsider a specific treatment decision. I think a pilot programme of culturally sensitive advocates to respond appropriately to the diverse needs of individuals from BAME backgrounds is already underway, and surely needs implementation in legislation.

I think there should actually be a national advocacy service, which is culturally appropriate, composed of IMHAs, mental health lawyers and independent experts. This new service would replace local contracts which provide a very variable IMHA service across the country. Such a new service should reduce coercion as patients and their families will be far better represented. 

Relational psychiatry should not be seen as extreme

Robin Murray, who I've mentioned before (eg. see previous post) has an invited editorial in Psychological Medicine, which he co-edits with Kenneth Kendler, on 'Listening to our critics; the care of people with psychosis'. In the article he mentions the Critical Psychiatry Network (CPN). What I want to pick up is how he says that CPN is not only critical of psychiatry, but extremely critical. 

Robin Murray himself accepts that there is a "great deal wrong with psychiatry as it is practiced". He recognises that some critics want to abolish psychiatry. I've said before that critical psychiatry may partly have itself to blame for being seen as 'too critical' (see previous post).

Nonetheless, if the main intention of CPN is to make psychiatric practice more relational, then it should not be marginalised. Instead, the person-centred nature of psychiatry should be fundamental. It is actually an indictment of psychiatry that such a position could be seen as extreme. Psychiatry does need to face up to its tendency to objectify people.

A new Mental Health Act in England and Wales

I said in a previous post that I was pleasantly surprised by the White paper proposals for reforming the Mental Health Act 1983. Consultation (see my summary of the proposals) will end in a week’s time.

The government’s reforms to reduce coercion in mental health services should be supported, but they do not go far enough. For example, there is no consultation about community treatment orders (CTOs), which are proposed to be continued for at least another 5 years. The impact of the new Act on reducing their use and racial disparities in their application will be monitored during this period. This is despite there being research evidence that Section 17 leave arrangements under the Act and informal community arrangements have just as good outcomes (see previous post). The ‘long-leash’ arrangements of CTOs cannot be justified in my view.

The principles of the Act proposed in the White paper also need to be improved. For example, it is commonly stated that the Wessely review that preceded the White paper (see eg. previous post) was to respond to the need for respect, dignity and anti-racism in mental health services, but these principles are not even proposed in the White Paper. Other improvements of the White paper would include extending its proposals even further for an increased role for the Mental Health Tribunal and the development of advocacy services.

There needs to be further debate about these and other issues to create a new Mental Health Act.

Relational psychiatry has a reformist agenda

I said in a previous post that critical psychiatry, in my view, is reformist. I’ve also emphasised in the past (eg. see previous post) that the critical psychiatry movement is a broad church of reformers and revolutionaries. There are significant differences within the movement (see another previous post). In a way, I’ve always made a distinction between my view of critical psychiatry and the critical psychiatry movement as a whole.

I have now moved on to using the term relational psychiatry (see eg. previous post) at least partly because I think the broader radical approach of critical psychiatry has outlived its usefulness. I want to be clear that relational psychiatry does not take an exclusionist view that mental illness does not exist (eg. see previous post). Perhaps in a similar way to which mainstream psychiatry marginalised ‘anti-psychiatry’, there is a danger that ‘the criticals’ are also being marginalised, as, for example, illustrated in Twitter debates. I never have been ‘a critical’ in that sense. 

Nonetheless, relational psychiatry does not see primary mental illness as brain disease. Instead, it provides a framework which focuses on the person and has ethical, therapeutic and political implications for clinical practice.

Philosophy has discovered that the mentally ill are people - seriously!

The paper entitled 'I Am Schizophrenic, Believe It or Not!: A Dialogue about the Importance of Recognition' by Gilardi & Stanghellini (2021a) must be a major publication if it warrants 6 commentaries (from Brencio (2021), Fulford (2021), Banicki (2021), Bergqvist (2021), Flanagan (2021) and Myers (2021)). Understandably, Gilardi & Stanghellini (2021b) were given a chance to reply.

However, I can't quite see what the value of the paper is. Obviously, mentally ill people may want recognition. However, most people who have experienced a schizophrenic illness don't see themselves as mentally ill, at least at the time of the episode. I'm not saying there's no value in thinking psychodynamically about psychosis (eg. see my book review), but quite a few 'schizophrenics' are not interested in psychotherapy. And I’m not undermining the value of psychotherapy for those that want it (eg. see my talk).

Of course dialetical recognition is needed in therapy. But is this as far as the philosophy of psychiatry and psychology has got after all these years? Or am I missing something?

Dualism and psychiatry

Christopher Chen-Wei Ng defends Cartesian dualism in psychiatry in an article in BJPsych Advances. It is a bold position to take as biomedical psychiatry often denigrates any challenge to its position as dualism (see eg. previous post). Chen Ng deals well enough with that claim, whereas I don’t think he deals so well with his other suggested reason for rejecting dualism, which he identifies as “an unhelpful attitude to patients and their illnesses”.

The original challenge to Cartesianism was vitalism. Georg Stahl took a integrated approach to mind and body rather than splitting them like Descartes. Stahl instead separated life from inanimate objects. For him, mind and body are not distinct, but integrated in the living organism. His explanation of why life was different from inorganic matter was more speculative, suggesting that the soul provided movement to matter in the body. Vitalism is as much derided now as Cartesianism, because it is seen as postulating a vital principle distinct from purely chemical or physical forces.

The reality, of course, is that living beings, including human beings, do have a purposiveness which cannot be derived from mere physico-chemical processes (see eg. previous post). Chen Ng is right to focus on the person in psychiatry. He doesn’t, however, need to return to dualism as such to do that.

The nonsense of reductionism in psychiatry

Konstantinos Fountoulakis (who I've mentioned before, see eg. previous post) argues in an Acta Psychiatrica Scandinavica editorial that anti-reductionism in psychiatry is unscientific. He thinks the unavoidable consequence of the argument against reductionism is the affirmation of a "supernatural (divine or paranormal) source of additional properties". The line of reasoning of anti-reductionism from his point of view leads to a "creator with an intelligent plan". 

Even though this view is nonsense, I'm sure many psychiatrists are sympathetic to it. This situation shows how much psychiatry is still trapped in the history of conflict between Cartesianism and vitalism (see eg. previous post). Rather than go along with the stark binary opposition of Fountoulakis between reductionism and believing in a "creator with an intelligent plan", I think it makes more sense to concede that the relation between mind and matter is an enigma that can never be solved (see eg. previous post). Intentionality and directedness is part of the nature of life, not something external to life. Neuronal processes are not meaning making and lack intentionality, so can only mediate intentional acts as part of an overall life process (see eg. previous post). It is absurd to expect to be able to explain life in terms of merely mechanical principles of nature (see eg. another previous post). This situation doesn't justify belief in a supernatural external force. Even Stahl's vitalism did not posit a transcendent soul. Stahl’s anima was an immaterial ordering principle of movement within physiology. Of course I'm not defending vitalism; merely indicating the bizarre way in which Fountoulakis polarises the debate about reductionism. Anti-reductionism can still be a valid explanation without ontological implications (see another previous post). Fontoulakis should accept that our relationship to ourselves is irreducibly ambiguous (see eg. previous post).

Fountoulakis reinforces his argument for minimising the role of the environment in mental disorders by pointing to "the universality of mental disorder manifestations, with only a few culturally bound syndromes of questionable validity". Actually, it is important to recognise the extent to which psychiatric diagnosis is a cultural judgement (see previous post). Fountoulakis questions the WHO cross-national research which is commonly seen as having found a better outcome for schizophrenia in developing countries in comparison with developed ones. Nonetheless, it is important not to minimise the considerable differences in the presentation of psychosis in different countries. 

Fountoulakis says without reference: "Beyond doubt, there is a minority of patients which under strict double-blind placebo-controlled conditions respond absolutely perfectly to medication treatment". He goes on to conclude, "For these patients, there is no doubt that their mental illness can be completely reduced to neurobiological dysfunction." I'm presuming his degree of certainty comes from his own experience, but we do need to see some evidence. I think the lack of references for these claims is telling. Fountoulakis makes clear that if a position like this is not generalisable that his fear is again that it introduces "some kind of supernatural process" into the origins of mental disorder. He actually thinks psychiatrists are "too much psychosocially rather than biomedically inclined". He blames what he calls “'violent' deinstitutionalization since the 1960s" for the current deterioration in the condition of mental health patients who are being deprived of their rights to biomedical treatment. His defence of the biomedical model seems rather desperate. 

Of course, there are organic brain effects, but, despite what Fountoulakis implies, there are also functional mental disorders without biological abnormality (see eg. previous post). He does not seem to accept what he calls a “modified bio-psychosocial model” that sees mental illness as having a “basic neurobiological etiopathogenesis ... shaped by psychological, social, and cultural factors”. I too have difficulties with such an eclectic approach (see last post) but Fountoulakis seems to prefer a radical reductionistic point of view. The brain of course mediates mental illness, but although people may find it difficult to accept the lack of any neurobiological determination of functional mental disorder, such a view is not as “off the wall” as Fountoulakis makes out.

Understanding the biopsychosocial model

Rebecca Roache (who I’ve mentioned before eg. see previous post) in her two chapters of her co-edited book Psychiatry reborn: Biopsychosocial psychiatry in modern medicine considers the implication of viewing Engel’s biopsychosocial model as a Kuhnian paradigm (see previous post referencing Kuhn’s The structure of scientific revolutions). As she points out, there is a dichtomy between understanding (Verstehen) and explanation (Erklären). I tend to prefer the terms used by Thomas Fuchs: personalistic vs naturalistic (see previous post) as two ways of looking at the body. Basically, first and second person narratives provide understanding, and third person narratives attempt explanation in terms of brain processes. 

As Rebecca Roache points out, we need to apply psychosocial concepts to understand mental illness, which is contingent on the person having certain sorts of subjective experience. In this way it differs from physical illness. Psychiatric disorders do not stand or fall with the presence or absence of biological pathology, whereas physical diseases do. Psychological or behavioural considerations in fact cannot be eliminated in characterising mental disorders. Rebecca Roache suggests we should therefore be “cautious in hoping for biological characterizations of mental illness”. I would go further in suggesting it is a mistake to do so (see eg. previous post). At least Rebecca Roache agrees that “it is unrealistic to hope that a purely biological account of mental disorder is possible”. 

As far as the biopsychosocial model is concerned, Rebecca Roache concludes, “Psychological and social explanations are not eliminable in favour of (that is, reducible to) biological ones, largely because of the way that mental illnesses are conceived and diagnosed.” I think this is the message that Engel was trying to convey in promoting his biopsychosocial model. The problem is that this meaning has been lost in eclectic accounts of what ‘biopsychosocial’ means (see eg. previous post).

As Rebecca Roache says in her other chapter in the book, this eclecticism “often involves little more than an acknowledgement that biological, psychological, and social factors are all relevant to understanding mental illness”. As she goes on, in one sense this is “so obvious as to be trivial”. The implication is that psychiatrists often say that the causes of mental illness are multifactorial. Rebecca Roache picks up Kenneth Kendler’s use of the term ‘dappled’ in this respect, although Kendler in fact does not see his empirically based pluralism as being the same as Engel’s biopsychosocial approach (see previous post). 

As Rebecca Roache indicates, it is far from clear that Engel is taking an eclectic position. In fact, I do not think he does (see eg. previous post). I agree with her that his account can be improved, particularly when it has been so often misunderstood as eclectic (see another previous post). I have mentioned that Sanneke de Haan has criticised the biopsychosocial model for being vague about how the biological, psychological and social interact (see eg. previous post). I think her description of enactive psychiatry, seeing mental illness as abnormal sense-making (see another previous post), can help to flesh out the biopsychosocial model. I also think Thomas Fuchs ecological approach to understanding the brain (see eg. previous post) can do the same. Engel himself noted that his biopsychosocial approach links to Adolf Meyer’s Psychobiology (see eg. previous post and my article). I’m sure Engel’s biopsychosocial model can be enriched by accounts such as these. But we first need to understand it as a non-eclectic model, a mistake which I think came about because of psychiatry’s response to so-called anti-psychiatry (see eg. previous post).

Objectives of Mental Health Act reform

The impact assessment of the white paper on Reforming the Mental Health Act lists the policy objectives for the proposed legislation. I have been pleasantly surprised by the changes proposed and think that the consultation can be worked with to improve mental health legislation. I think it does provide a potential framework for new legislation to make mental health services more supportive of people without mental capacity, the loss of which in the case of mental illness may just be temporary. 

As I have said before (eg. see previous post), though, I think this aim of supporting people, rather than focusing on compulsion, could be made more explicit. As far as the policy objectives are concerned, improving patient choice, experience and participation are important, but it isn’t just earlier and more frequent access to safeguards against detention and enforced treatment that are needed. Instead, the focus of intervention needs to be on informal rather than formal measures. This is not to deny that such formal measures may be needed but, for example, the right to refuse treatment should not merely be taken away by detention. Treatment should be seen as being of the highest quality if it avoids compulsion whenever possible. Such high quality services also need to be anti-racist, which again could be made more explicit in the objectives. 

Consultation on changes to Mental Health Act begins

With considerable press publicity, the government has announced it will set out its proposals for reform of the Mental Health Act in a White paper (see eg. previous post). Despite all the apparent good intentions (see press release), we do need to see the detail in the White paper. 

For example, a statutory advance choice document may seem like a good idea but it's not clear why the will and preferences of people are not taken into account whether or not they have signed an official document. Nor am I clear how the appointment of a nominated person will work or how the role of advocacy will be expanded, including culturally appropriate advocates. I doubt whether learning disability and autism are being excluded from the Act, and it's not clear how these provisions will differ from those for mental illness. Nor am I sure how legislative changes may impact on improving access to community services. 

There do not seem to be any proposals for reform of the Mental Health Tribunal, so that people have a right to an independent report of their choice to be presented before the Tribunal. It is also unclear whether community treatment orders will be changed. Consideration needs to be given to whether they should be abolished. Nor is there any mention in the press release of improving the role of the CQC, and whether Second Opinion Approved Doctors (SOADs) still provide a safeguard. This function could be taken over by an improved unbiased Tribunal (a single judge, without medical and lay input) which fully considers the evidence presented to it from the person's point of view and makes decisions both about detention and treatment. In general, there seems to be insufficient acknowledgement that the criteria under which coercive treatment can be given are too wide (see eg. previous post), which leads to far too much unacceptable, and even abusive, treatment. The evidence collected by the Wessely Review in this respect does not seem to have been fully taken into account (see eg. another previous post).

Supporting people through mental health and capacity legislation

I’ve said before (see eg. previous post) that I’m concerned that the government’s White Paper on reform of the Mental Health Act will not go far enough. This is because it is likely to be based on the review chaired by Simon Wessely. He says in the foreword to the review that “the Mental Health Act takes away your liberty and imposes treatment that you don’t want ... and ... can help restore health, and even be life-saving”. As he also says, this tension is nothing new, but I think the opportunity to have a fundamental rethink about the role of legislation for treatment of mental health problems may have been lost.

Surely the essential aim of mental health and capacity legislation should be to support people with their incapacity/disability, which may well be temporary in the case of mental illness. I actually don't think legislation should primarily be about the removal of liberty and the imposition of treatment. Informal admission should again be seen as the dominant mode of inpatient treatment if this is needed. If detention is necessary, the person's dignity and respect need to be preserved and any decisions made need to take account of their will and preferences. Part of the problem is that we have become trapped in a historic tension between restraint and freedom. We do not immediately need to be jumping to substitute decision making or coercion to support people when they lose or do not have mental capacity. I have always accepted that these measures may be needed, but the legislative framework needs to change so that such interventions are not necessarily seen as a priority. Coercion may be more to do with a failure of treatment than treatment itself.

Oversimplistic psychiatric treatment

Analysis of prescription data in England in 2017/8 found that 16.6% of the population received a prescription for an antidepressant, 3.1% for a benzodiazepine such as diazepam and 2.3% for a z-drug night sedative, such as zopiclone (see Public Health England review). For talking therapies, there were 1.69 million referrals in 2019/20 to Improving Access to Psychological Therapies (IAPT) (see annual report). Psychiatric treatment, both medication and talking therapies, is therefore frequent. 

Consistent with this high level of treatment, around one in six adults surveyed in 2014 met the criteria for a common mental disorder (see Adult Psychiatric Morbidity Survey). IAPT is seen as a treatment for common mental health problems. I have argued (see previous post) that the distinction between common and severe mental health problems in the NHS can become confusing when people are referred on from IAPT to secondary care services. IAPT is essentially a non-medication service. Psychological therapy is also provided in secondary services but very few patients treated in secondary services do not also take medication. People seen in IAPT may well be taking medication, but the expectation usually is that this aspect of their treatment will be managed by the general practitioner (see previous post about role of primary care in mental health treatment).

Concern has been expressed about people becoming over-reliant on medication in psychiatric treatment (eg. see @JDaviesPhD’s tweet). I suppose we shouldn’t be too surprised when medication is sold as an easy answer to mental health problems that people may want to take it. The rhetoric for IAPT has also encouraged seeing psychological therapy as a panacea for mental health problems (eg. see previous post). 

Don’t get me wrong; I’m not being nihilistic about outcome for mental health problems. Plenty of problems can get better spontaneously and over time. But I think services would benefit from becoming more realistic about the nature of mental health problems and what can be done about them. It’s not always as simple as taking a tablet or going for a few sessions of therapy, not that these might not be helpful as long as we realise their limitations. As I said when discussing the response to mental health issues created by the coronavirus pandemic (see previous post), I don’t want to discourage people from coming forward for help if they need it. I just think services need to stop exaggerating the benefits of treatment. Mental health treatment can be helpful, but it may not necessarily have all the answers.

Towards a definition of relational psychiatry

Having renamed this blog 'relational psychiatry' (see previous post), I probably should make more of an attempt to define relational psychiatry. As Richard Gipps says (see last post), the term "doesn't yet have an established use".

Relational psychiatry takes an anti-mechanistic approach to life, including human life. Despite its attractions from Descartes onwards (see eg. previous post), a mechanistic conception of nature fails to provide a complete characterisation of living systems (see eg. another previous post). Medical psychology therefore needs to take a pragmatic anthropological approach as a mechanistic psychology is impossible to realise in practice. It needs to focus on the person-environment interaction.

The implications are that there is nothing else apart from the therapeutic relationship, both individual and group, in psychiatric treatment (although I agree with Richard that this position forms part of the definition of relational psychiatry, as it doesn't' necessarily follow from what I am saying about mechanistic psychology). I also agree with Richard that actual clinical practice is not necessarily the same as theoretical practice. Relational psychiatry does need to actually make psychiatry more relational. This means that practice needs to be truly person-centred (see eg. previous post). As Richard points out, the current Royal College of Psychiatrists' curriculum doesn't even make this clear. 

What’s a relational psychiatry?

I've mentioned some of the reasons before (eg. see previous post) why I've changed the name of this blog from critical psychiatry to relational psychiatry. I'm grateful to Richard Gipps for this guest blog to develop the notion of relational psychiatry.

What is it for a psychiatric theory or practice to be 'relational'?

Whilst (thanks to Harry Stack Sullivan and Stephen Mitchell) the phrases 'interpersonal psychiatry' and 'relational psychoanalysis' already exist, the term 'relational psychiatry' doesn't yet have an established use. Our question then becomes not 'what does 'relational  psychiatry 'mean?' but instead 'what's it reasonable and useful to use these words for?' In what follows I distinguish three different uses. My point in doing this is primarily to urge that they not just be folded up together. There's nothing incoherent about the idea of being relational in all 3 senses. But we become mired in disreputable conceptual confusion as soon as we mistake the reasons for believing in one form of relationality as reasons for believing in another.

1) Relationality as articulating the locus of psychopathology and apt treatment 

Consider the difference between these two sets of treatments:

i) Drug treatments, ECT, DBS, neurosurgery, hypnosis, cathartic psychotherapy. Whilst questionable in practice (think e.g. of compliance and expectancy effects), an intelligible assumption is that these treatments work, when they do, in a way we might describe as 'from the inside out'. In play here is the idea of something like a localised underlying fault. The aim is to treat this, release the patient from their 'inner' disturbance, so they'll be able to freely flourish in the world again. What is appealing about this idea of psychopathology and intervention is the way that it promises a simplification of complex clinical pictures and treatments. A whole wealth of symptoms can now be explained in terms of a single underlying cause, and it's by treating the single underlying cause that the whole wealth of symptoms can be quieted. Medications could of course be prescribed not to treat singular underlying biological causes of psychopathology, but to intervene in a psychopathological process of whatever sort. Even so we can readily understand the rationale of using medication to treat a condition by treating its putative underlying neurological cause. 

ii) Occupational therapy, family therapy, behaviour therapy, therapeutic communities, open dialogue approaches. An intelligible assumption about these treatments is that they work 'from the outside in'. That is, they aim to re-set the patient's relationships with the physical and personal world by intervening in the context of these relationships. The idea is that practice, or repeated exposure, here will lead to the laying down of healthier dispositions and forms of self-regulation.

In relation to these two visions, a 'relational psychiatry' might be understood as being in the business of reminding us just how autopoietic we are. That is to say, it may remind us that we really do enact - i.e. ongoingly constitute - ourselves in our relationships with our worlds and with others. These enactions may be of both healthy and mentally disturbed casts of mind. Now, talk of causality which presupposes that all causes are of the 'underlying' form, and which thereby ignores the systemic aspect of state formation and maintenance, is rife in such psychiatry as is bioreductionist. And because we habitually think in terms of linear causality, we can miss this circular self-creating aspect of human life. And so we can plump for treatments of type i) when treatments of type ii) - which aim to alter our enactions rather than alter their only putative underlying, inner, causes - may be more effective and less damaging.

Here I want to point out that simply acknowledging that many aspects of human life are permeated with what we could call 'relational causality' doesn't mean that all aspects will be so permeated. For example, certain genetic disorders could inevitably come on line at a certain point in someone's development, inexorably unfolding into a clinical picture. You can't philosophise your way to the irrelevance of linear and 'inside out' causality in human life. All you can do is point out the fallacy of assuming that 'underlying' causes are the only relevant causes in the psychiatric domain. I'd also like to point out that other rationales than the treatment of underlying neurological causes can be offered for why we might use, say, a pharmacological treatment. For example we might think that depression, say, is caused and maintained by a patient's interactions with their environments, and use a medication to help lever them out of one self-maintaining mode of interaction into another, happier, self-maintaining state.

2) Relationality as an anti-monadic philosophy of human existence

Consider next the following two visions of human mindedness:

a) On the first view, to have a mind is to enjoy thoughts and intentions and beliefs and perceptions - and these are all inner entities or inner processes. We infer to them in others by examining others' outer behaviour. We look inwards at our own inner states to find out what they are. These inner states actually cause our outer behaviours and expressions. As well as being hidden away behind our behaviour, and so being inner in that sense, they may also be inner in the literal sense - consisting in states and processes of the brain that's inside our skull. To the extent that the outer world and other people are involved in our inner mental states, this is merely by way of providing these states with content through their causal relations to the inner ('functionalism' and 'identity theory' in the philosophy of mind are examples of this vision).

b) On the second view, to have a mind is to enjoy cognitive (thought-involving) and conative (will-involving) capacities. These are not helpfully thought of as intrinsically 'inner' or 'outer', although we can sometimes hide them (so in that sense alone they can sometimes be called 'inner'). To believe or intend or perceive or think is not to have inner states or processes in play, but to enjoy particular intentional relations to our life worlds. ('Intentional': not 'intended', but rather: 'replete with intentionality or directedness'. When I think of you, you are the 'intentional' object of my thought.) Not being entities, beliefs etc. don't have constitutions and so aren't helpfully thought of as 'identical with' brain states. Instead they're more like sets of dispositions to engage in certain verbal and non-verbal actions. We don't need to look inwards to find out what we ourselves think or intend; in fact we're not usually in the predicament of needing to find that out: instead we can just avow or express, rather than report on or express judgements about, our thoughts and intentions. To have a mind, we can also say, is to essentially be in relation to others. We aren't monads who merely contingently happen to have relations to an 'external' world. Rather, and to borrow the terminology of the existential phenomenologists, our existence is characterised by being-in-the-world and by being-with-others - where the hyphens are designed to show how we're (to now use another one) 'always-already' in relation to a world and to others.  

So, might we say that a 'relational psychiatry' is one that is committed to the image of humankind we find in b), and that a non-relational psychiatry has got stuck with a)? Well, we can say whatever we like - but it might not be useful. Daseinsanalysis in the hands of Medard Boss, for example, pitted Heidegger's relational conception of human mindedness against the sometimes rather non-relational vision served up by Freud. But the clinical boons of this reconceptualisation were not vast; reading his work we're treated to long animadversions on Freudian concepts but little by way of novel psychopathological or psychotherapeutic insight. Furthermore, whilst psychoanalytic concepts (transference, defence mechanism, projection, primary process, etc.) often have a non-relational (and objectifying) 'inner mechanism' twang about them, this tells us nothing about the use to which they're put in clinical practice. And it's in that use, rather than in their twang, that their meaning and value lie. (I've critiqued elsewhere John Heaton's far more recent critical evaluation of psychoanalytic theory along similar lines.) In sum, because the idea of a 'non-relational' psychology or psychiatry is, on this understanding of 'relational', basically just a nonsensical muddle about human existence, it's not really clear that talk of a 'relational psychiatry' amounts to anything much either. And those who hope to reap rewards for clinical practice by cutting down the confusions that clinicians can get into in reflective moments, whilst ignoring how the clinicians are actually practicing, are after an easier win than is truly available.

3) Relationality as characterising the treatment medium

Consider finally a third sense of 'relational':

This is the one contained in Stephen Mitchell's notion of 'relational psychoanalysis'. Paramount here is the idea of the clinical relationship as itself (part of) the medium, and not merely the vehicle, of change. Sometimes one finds a clinician defending, say, cognitive therapists against the charge that such therapy ignores the importance of the therapeutic relationship. As Judith Beck writes, for example, cognitive therapy ‘requires a good therapeutic relationship. Therapists do many things to build a strong alliance. For example, they work collaboratively with clients . . . ask for feedback . . . and conduct themselves as genuine, warm, empathic, interested, caring human beings.’ However, as psychoanalytical psychotherapist Jonathan Shedler (caustically yet aptly) responds, ‘This is the kind of relationship I would expect from my hair stylist or real estate broker. From a psychotherapist, I expect something else. [Beck appears] to have no concept that the therapy relationship provides a special window into the patient’s inner world, or a relationship laboratory and sanctuary in which lifelong patterns can be recognized and understood, and new ones created.’ Shedler’s optimism regarding his hair stylist and estate agent perhaps warrants some 'cognitive restructuring', but his point about the therapeutic relationship stands. What a relational psychoanalysis does is use the therapeutic relationship itself as the medium of change - rather than merely form a good relationship which facilitates an independently intelligible therapeutic process. Part of this involves developing such an alliance with the patient as can itself be internalised into a healthier self-relation. Into a self-relation, that is, which intrinsically undoes and wards off such psychopathology as stems from a harsh, unforgiving, lonely-making, self-relation (i.e. stems from the 'superego', 'toxic introjects', 'ego-destructive internal objects', etc). But in the psychoanalytic context one will be expected also to carefully attend to the transference dynamic manifest in that relationship. The closeness of the therapeutic relationship also potentiates the transference in both its negative and positive aspect. Relationships which keep in the polite and friendly zone are not going to allow the patient's underlying fearful expectations to be truly experienced and challenged. When the transference relationship does become the medium of therapeutic change, however, the idealising feelings toward the analyst which guard against unconscious expectations of being hurt or let down or judged can also be made clear. This all makes for a genuine experience - not only of a trust and loving acceptance that can be internalised into a sense of self-worth, but also of profoundly difficult latent expectations of that sort which drive mental illness and which can finally be deconstructed.

As regards a relational psychiatry, I note that although in the UK all trainee psychiatrists are required by the GMC to be able to develop therapeutic alliances, and to have some familiarity with psychoanalytic concepts, they aren't required to have expertise in psychotherapy, let alone in working with or in the transference. Unless we're promoting a radical change in psychiatric practice - in the direction of contemporary psychoanalytic psychotherapy - it won't do to borrow Mitchell's meaning for 'relational' to explicate 'relational psychiatry'.

Conclusions

At this point I should perhaps own that I'm rather 'relationally' minded in all 3 of the above senses of 'relational'. What I want to stress here, however, is the absence of any necessary connections between the 3 above-described forms of relationality. I want to stress this because I think that a clear danger of talk of 'relational psychiatry' could be that the term becomes woolly, and unwarranted support for one of the relational notions above gets drawn from one of the others. Such illegitimate arguments would quickly invalidate the approach.

To spell it out, we may (rightly or wrongly) think that serious psychopathology is sometimes sustained by certain largely unconscious dismal beliefs about self-in-relation-to-other. (Perhaps I have a largely unconscious habit, for example, of expecting others to be dismissive about my concerns - so I tend not to let either myself or the other know about them.) And these beliefs may be considered to be sustained just by default rather than through any activity on the subject's part - in the same way that the reason the colour of the living room curtains remains self-same day to day isn't because anything is actively maintaining it, but rather just because nothing comes along to change it. In this sense, then, we don't here have a relational conception of psychopathology in the sense outlined in 1): the depression isn't here considered as autopoietically or systemically maintained. Perhaps you'd have to really dig out such underlying beliefs with psychoanalysis. Yet this psychoanalytic therapy might well be relational in sense 3): it might require a canny working in the transference before this patient's depression is going to shift. And perhaps if this therapist has got interested in philosophy, his underlying vision of what it is to have beliefs is relational in sense 2). Nothing, however, dictates that this shall be the case: he may work in the transference whilst maintaining a psychopathological theory which deprecates the idea of an ordinary ongoing interpersonal enaction of psychopathology - seeing it instead simply as something which manifests in his patient's life, bodying forth relentlessly from 'underlying' disturbances in self-image - and he may moonlight as a Cartesian philosopher who eschews a conception of human beings as constituted by their relations to the world and to others. Constitution is not necessarily causation: We may maintain the significance of causal relations between self and world whilst deprecating the idea that we are constituted by our world-engagements. Or we may have a fully relational (in sense 2) conception of our existence - i.e. see what we are as constituted by our relationships, rather than as monads whose minds consist in a pure interiority - whilst maintaining the value of a pharmacological treatment which aims to causally alter our mood state. Perhaps, as suggested above, the drug treatment could tip us into a different level of self-sustaining equilibrium (i.e. affect our relational nature in sense 1), and this new manner of world-relation be understood (in sense 2) to genuinely constitute a new form of mindedness.

To end: is there nothing which binds together these different senses of relationality? Well, consider that you're attracted to a monadic (non-relational in sense 2) conception of human existence. You're also not a dualist, let's say, but - despite not thinking that mind consists in immaterial spirit - you're nevertheless attracted to the idea that mind must at least consist in something. Understanding as we all do that the brain is rather important for mental functioning, and not being persuaded by the 'extended mind' theorists (who take mind to consist not only in internal but also in environmental states and in the interactions between these), you tend to think your mental states consist in your brain states. And, unlike most materialists, you're also not a functionalist (i.e. you don't think these states are individuated by their worldly causes and bodily effects), and so you're  moved to think them individuable without reference to anything outside your head. With that conception of the mind in play, what might you now think about mental illness? Are you likely to think it non-relational in sense 1) as well? I think many people are intuitively inclined to answer 'yes' to this - but, speaking for myself, and following the logic of the argument, I just don't see it. For surely you could either think that depressed or delusional mental states, which allegedly 'just are' brain states, are self-maintaining underlying causes of the depressed or delusional actions they inspire. Or you could think take these inner brain states to arise and be causally maintained by the interactions in which the person engages. And so even whilst cleaving to the most fully 'materialist' and 'internalist' conception of mind we can imagine, there's nothing here which ought to make you generalise from your non-relationality (in sense 2) about persons to a non-relationality (in sense 1) about psychopathology and treatment. You might well do this, because like many of us you get muddled about what's entailed by what. The relational psychiatrist, however, is not required to follow you in that muddle.

Richard Gipps offers broadly psychoanalytic psychotherapy and is an associate of the Faculty of Philosophy, University of Oxford. He is the web secretary of the International Network for Philosophy and Psychiatry and blogs at Philosophical perspectives on clinical psychology and the pain that breaks.