Overstating the impact of psychiatric research

Medium has a new mental health publication - 'Inspire the Mind' - produced by the Stress, Psychiatry and Immunology (SPI) Lab at the Institute of Psychiatry, Psychology and Neuroscience at King’ College London led by Professor Carmine Pariante, who I have mentioned previously (eg. see previous post). It has reprinted 'Facts You Should Know About Psychiatry and Why It Is Helping the Person Next to You' from a HuffPost article, although it's dropped the reference to 29 facts we should know, I think because the booklet from the Royal College of Psychiatrists to which the original article refers no longer exists (if it was ever published). Maybe the College had second thoughts about making such 'scientific' claims (eg. see previous post).

It is important to encourage debate about the potential harm of recreational drugs and whether substitute prescribing of methadone leads to harm reduction, but Pariante seems to think it is clear that cannabis causes schizophrenia, which is not the case (see eg. previous post). Like him, I also agree the development of psychological therapies should be evidenced-based, but he doesn't describe the realities of the Improving Access to Psychological Therapies (IAPT) programme (see previous post), nor mention the evidence bias towards specific therapies, such as CBT, or even the problem of the adequacy of controls in evaluating psychological therapy (eg. see previous post). Nor am I sure where his apparently inflated figure of 80% recover for psychological therapy of panic disorder and social anxiety comes from. I doubt research is really needed to show that reducing the maximum pack size of over-the-counter sales of paracetamol, and limiting sale to one pack, reduces paracetamol overdoses (although has such research actually been done?). But Pariante needs to be more careful about making claims for the value of the National Confidential Inquiry into Suicide and Homicide in improving patient safety (eg. see previous post).

I do understand why Pariante wants to answer criticisms of psychiatry. He admits himself that the article is a "little bit of PR". But his attempt to create a positive view of psychiatry shouldn't lead to him unscientifically overstating his case.

The realities of working in IAPT

Despite me saying (eg. see previous post) that people must be more realistic about the effectiveness of Improving Access to Psychological Therapies (IAPT) and stop saying that it is a "marvellous treatment", a recent self-congratulatory event (see programme) celebrating 10 years of IAPT led to a further bout of overhype for the programme (apparently to obtain further funding - note that the Chief Executive of the NHS and the Secretary of State for Health and Social Care were both speaking). For example, Claire Murdoch, NHS England's National Mental Health Director, in a tweet to me said that she was sad that I was dismissing the "brilliant IAPT work".

I'm actually not undermining the work of IAPT. I just want IAPT therapists more recognised for the difficult work they do. Helping people is not always as straightforward as following an IAPT protocol. Luckily the natural history and spontaneous improvement of anxiety and depression over the short-term is about 50% or above, which is what the IAPT programme calls its recovery rate (see previous post). But, particularly over the long-term, it's not always easy to help people deal with their suffering, dependency and vulnerability (see another previous post). IAPT is perverting care, as Rosemary Rizq said (see her article). It shouldn't be seen as a simple programme that people just need to follow and everything will be alright, which is how Claire Murdoch's comment could be interpreted. Politicians seem prepared to invest in IAPT further, maybe to meet the so-called 'parity of esteem' target required to treat mental health services at least as well as they do physical care, even though we don't hear much now about the original reason for the programme being agreed, which was because politicians were persuaded it would take people off benefits.

David Clark (who I have mentioned before, see eg. previous post) in his blog on IAPT at 10, seems to see the only challenge for the IAPT programme as being the need for further expansion. As I said in my talk, David Clark has said that his initial research interest was in psychotropic medication not psychotherapy. He has merely succeeded in encouraging the exploitation of the placebo effect with psychological therapy in the same way as for medication. Although people on average may well prefer talking therapy to medication, let's try and be more realistic about how we develop mental health services.

Progress in mental health research

The Wellcome Trust has said it believes "a radical new approach is needed [in mental health] to drive science forward and improve people’s lives" (see its webpage). I couldn't agree more. As it says, "some underlying problems need to be addressed before the field can make significant progress ... We want to bring ... [a] sense of common purpose to mental health, with different disciplines working together to collaborate in a new super-discipline of mental health science.“

As I have said throughout this blog, the underlying problems that need to be addressed are more conceptual than empirical. There's no point (eg. see previous post) pursuing the reductionist agenda that has come to a halt (eg. see previous post). We need an organismic rather than mechanistic perspective. Psychiatric research has become too focused on speculative neurobiological notions which produce studies plagued by inconsistencies and confounders (see my BJPsych editorial). Would Wellcome be interested in funding the Institute of Critical Psychiatry?

Critical psychiatry is not Cartesian (nor vitalist)

I want to pick up on the way people who take a reductionist view on psychiatry, such as Ed Bullmore (see previous post), accuse their critics, such as myself, of being Cartesian. René Descartes (1596-1650) was the first to apply a natural scientific mechanistic approach to life (see previous post). Animate and inanimate matter were understood by the same mechanistic principles. Animals are therefore machines; and human physiology is also mechanistic. Descartes stopped short, though, of including the human mind in this mechanistic framework. The soul was denied any influence in physiology. Descartes, thereby, avoided the materialistic implication that man himself is a machine. The split he created between mind and brain is what is referred to as Cartesianism.

One of the first to challenge this perspective was Georg Ernst Stahl (1659-1734). Living beings, including humans, have a purposiveness which cannot be derived from mere physical-chemical processes. For Stahl, the anima or soul provides what he regarded as the key element of movement to matter within the living body (motus tonicus vitalis). However limited this concept may have been by the understanding of mechanics and physiology at the time, Stahl’s dualistic notion was different from Descartes, in that he differentiated organic life from the inorganic, not the soul from the body. Unlike Descartes, the soul and body were not separate but integrated in the organism. Stahl originated an organismic perspective in the life and human sciences. I have several times (eg. see previous post) emphasised how critical psychiatry integrates mind and brain. It is not Cartesian. This perspective formed the basis for Stahl having an emphasis on psychosomatic medicine, and a focus on clinical medicine rather than the physical sciences. 

Yet, Stahl took a mistakenly conceived vitalist position that reductionists deride as much as Cartesianism. Vitalism is the claim that living things possess something else - a vital entity - that is neither physical or chemical in nature. In fact, Stahl's anima was a force within the body, an explanatory agent within physiology, rather than a religious transcendent soul. But, still, Stahl conceptualised the soul as an immaterial ordering principle of movement. Despite this erroneous element in Stahl's thinking, we do need to build on his organismic perspective. 

Those that suggest that life cannot be explained in mechanical terms, as Stahl did and I do (eg. see previous post), may seem to be open to the charge of vitalism. But I'm not anti-physicalist. Biological wholes do not literally cause their parts. Nor am I suggesting that living matter has a level of organisation above the physicochemical level that makes it different ontologically. Biological processes do not have causes (such as a vital entity) outside of physicochemical terms.

Neither am I saying that living processes cannot be studied mechanically. The mechanistic conception of nature, however, fails to provide a complete characterisation of living systems (see previous post). Understanding the meaning of human action is a different kind of explanation from mechanical explanation. We explain the parts of biological wholes in functional not structural terms. Non-organic mental illness, for example, is a functional disorder and cannot be explained structurally as brain pathology (eg. see previous post)

Reductionists of course do appreciate there is a mind-body philosophical problem (eg. see previous post). They think, though, that this problem will eventually be solved (see previous post). I take the same view as Kant that the irreducibility of biology to physics is permanent. Our knowledge is limited. We conceptualise organic matter in a different way to inorganic matter. Our understanding is discursive and how living wholes cause their parts is unknowable to us. In fact, it's the discursive nature of our understanding that creates the possibility of mental illness (eg. see previous post). Summarising Kant's Critique of Judgement, we can never have theoretical knowledge that anything in nature is teleological, but such judgment is nonetheless necessary and beneficial for us. We have to accept this enigma to practise psychiatry (eg. see previous post).

More research required on withdrawal from antidepressants

Fava & Balaise (2018) in a Psychotherapy and Psychosomatics editorial comment on a failed trial (see letter) of CBT to prevent relapse after withdrawal of antidepressants in remitted anxiety disorder. Despite guidance, only 36% of patients succeeded in discontinuing antidepressants over 16 months and only 28% did not have a recurrence and there were no differences between the CBT group and controls.

As Fava & Balaise say, the trial wasn't futile as it has confirmed that:-

Withdrawal symptoms and syndromes may occur during and despite slow tapering, do not magically vanish after a couple of weeks from discontinuation and may persist for a long time, leading to postwithdrawal syndromes.

As they also say:-

.. discontinuation that is performed without medical consultation and adequate psychotherapeutic support entails substantial risks for the patient and is often bound to fail

Fava and Balaise tend to emphasise their model of oppositional tolerance, which I have said before does not convince me (see previous post). Personally I have tended to argue for the importance of psychological dependence (eg. see previous post). This does get me into trouble with the 'prescribed harm' patient community, but despite what they may think, I am not minimising their problems, which mainstream psychiatry does (eg. see previous post). As Fava & Balaise conclude:-

The time has come to initiate research on withdrawal phenomena related to AD [antidepressants], and to redefine the use and indications of these medications

Repeal Mental Health and Mental Capacity Acts

The Independent Review of the Mental Health Act 1983 (see previous post) has produced its final report ‘Modernising the Mental Health Act: Increasing choice, reducing compulsion’. It is disappointing, as Suman Fernando says in his blog, although not surprisingly so. It gets the government ‘off the hook’ of having to do anything about the observations from the Committee on the Rights of People with Disabilities about the UK government’s response to the United Nations Convention on the Rights of Persons with Disabilities (CRPD). The proposals made for change are minimal and will do little to prevent the unacceptable, including racist and abusive, treatment of detained patients (eg. see another previous post). CRPD is being ignored by suggesting that it prevents involuntary detention, which I don’t think is the case and in fact the Independent Review concedes this. Instead current legislation should be repealed and replaced by new legislation to preserve the dignity and respect of detained patients.

Progress in psychiatry

Peter Tyrer (who I have mentioned before, eg. see previous post) has recognised the value of critical psychiatry, however grudgingly, in his commentary on a BJPsych Advances article by Hugh Middleton & Joanna Moncrieff (also previously mentioned eg. see post). However, Tyrer thinks critical psychiatry is Luddite by hindering progress in psychiatry. Psychiatry has always had the forlorn hope that it will discover the biological basis of mental illness, and I don’t think that Tyrer has given up this wishful thinking. The examples he gives of progress in psychiatry include lithium for bipolar disorder and methylphenidate for ADHD, and these must be suspect, and even CBT for traumatic stress disorders is questionable.

I actually agree with him that critical psychiatry should be constructive. I also agree critical psychiatry’s views on psychiatric diagnosis can appear confused, but this is because there are actually different views within the critical psychiatry movement about whether psychiatric diagnosis is valid and whether mental disorder should be seen as illness (eg. see point 3 in previous post). Critical psychologists within the critical psychiatry movement, such as David Pilgrim, who Tyrer quotes, tend to be against psychiatric diagnosis. Michel Foucault, who again Tyrer mentions, actually probably wasn’t against diagnosis as such. What he was against was the positivist reduction of mental illness to brain disease (see last post). Despite what Tyrer says, incorporating positivism into psychiatry has actually made it less scientific not more (see another previous post).

Psychiatry, as well as human and life sciences in general (see previous post), need to take Kant’s explanatory anti-reductionism seriously. Kant was clear that it is absurd to expect to understand goal-directed mental disorder in physical terms. Epistemologically it’s just not possible. Consciousness is a puzzle we’d like to be able to solve but we can’t (see previous post). That doesn’t mean that we can’t study part-functions such as the brain, but we need an organismic psychiatry to treat the whole person. Such a view was present in the origins of psychiatry, such as Ernst von Feuchtersleben’s Principles of Medical Psychology (see eg. point (1) on previous post). Psychiatry needs to go back to its roots to make progress. Critical psychiatry is arguing for a positive way forward by promoting an organismic psychiatry. Psychiatry has never really been able to achieve this because of its dominant biomedical positivism.

Was Foucault an anti-psychiatrist?

John Iliopoulos in his book History of reason in the age of madness, which I have mentioned in a previous post, has a chapter entitled ‘Is Foucault an anti-psychiatrist?’. As I said in my book chapter on ‘Historical perspectives on anti-psychiatry’, Foucault’s Madness and civilisation is included in anti-psychiatry because Foucault is said to have viewed the Enlightenment as oppressive.” Actually, I think Iliopoulos’ position is correct that Foucault was neither for or against the Enlightenment.

As Iliopoulos says, Foucault stresses he was ignorant of anti-psychiatry at the time of writing History of madness. Iliopoulos corrects the position of post-psychiatry (see previous post) that “Foucault is engaged in an anti-psychiatric endeavour using counter-Enlightenment discourse” (p.101). Instead, Foucault accepted the validity of the anthropological project of the late eighteenth century with its phenomenological diagnostic approach to madness. Where psychiatry went wrong was its positivist reduction of mental illness to brain disease in mid-nineteenth century. In Iliopoulos’ words:-

[T]he subjugated, disempowered status of current psychiatry authority and the value-laden and pseudo-scientific definition of mental illness are not the result of the infantile epistemological level of psychiatry, its axiological nature or its inherently coercive role, but the product of a new, all-encompassing rationality denying and suppressing the anthropological kernel of psychiatric discourse. (p.98)

Reading Foucault’s History of Madness

Jean Khalfa, in his Introduction to his edited edition of Michel Foucault’s History of Madness, says that the book “has yet to be read”. Certainly I haven’t made an attempt to read it until of late. I have been too influenced by the “cursory caricature of Foucault’s work”, to which, as Colin Gordon suggested, even Roy Porter was prone (see Gordon’s review of History of Madness). Andrew Scull’s TLS review has been particularly misleading about the value of Foucault’s work (see, again, Gordon’s response to Scull). Even R.D. Laing’s enthusiastic reader’s report (see image above) for publication of the abridged version, Madness and Civilisation, may have given the wrong impression. Gordon wonders whether Scull has really read the book and Laing’s brief report (I presume this was all he submitted), again, makes me wonder whether he even read the abridged version.

Laing was right, nonetheless, that this is “an exceptional book of very high calibre”. As Gordon says, the book “is the work of a young genius, a work of masterful accomplishment and prodigious and prodigal energy, grasp and daring”.  More needs to be made of it (see previous post).

Holding onto delusional thinking

I went to a talk yesterday by Lisa Bortolotti in the Cambridge University Psychiatry department (see tweet). This was based on her chapter in a recent book. Delusions are not necessarily un-understandable, nor always "bad for us", nor even particularly an exceptional way of thinking.

Picking up this last point from a previous post, we believe all sorts of things, partly often because there isn't clear evidence one way or another for some of the things we believe, eg. belief in God. We also live in societies where power relations can determine what we believe. In fact, following Foucault (see previous post), psychiatry had its origins in the Enlightenment with a focus on human rights, the questioning of dogmatic beliefs and the development of science, particularly social science. Reason itself now questioned the rational foundations of what is accepted as reason. Alongside reflection on the state of the human mind, alienists identified unreason and madness as an un-understandably, different state. The madman’s delusional thinking is central to this fundamental distinction between reason and unreason. Lisa Bortolotti usefully reminds us that this distinction is not really so absolute. 

All this happened before the development of our modern understanding of disease (eg. see previous post). Although there has been progress since the middle of the nineteenth century in our understanding of physical disease, the functional rather than structural nature of mental illness has been difficult to appreciate in this context. The assumption that mental illness is due to brain disease, like delusional thinking, isn’t actually based on logic, but on faith, desire and wish fulfilment (see previous post). It seems to challenge our viability as psychiatrists to believe otherwise (see another previous post). This belief seems to be held onto almost with the same intensity as delusions.

Drugs culture

The Times had a leading article last week that took up from its news article the day before. It stated that "David Baldwin, a government adviser on the use of antidepressants, has resigned after a vituperative social media campaign against him". The leading article does mention the Public Health England (PHE) review set up by the Parliamentary Under Secretary of State for Public Health and Primary Care to review the evidence for dependence on, and withdrawal from, prescribed medicines, but doesn't make clear that Baldwin has resigned from this review. He's still Chair of the Royal College of Psychiatrists' Psychopharmacology Committee.

The Times says that scientists should not attack advocates of antidepressants because antidepressants are a "gain to human wellbeing". I'm not quite sure what it means by this, because there is an ongoing debate in the academic literature about the efficacy of antidepressants (see previous post). Instead The Times has already concluded that the "evidence base is impressive".

The leading article also makes much of the difference between clinical depression and everyday moments of low mood and sadness, although this distinction is of course relative and not absolute.  Medication has in fact always been used in the history of psychiatry but what happened in the 1950s was that tricyclic antidepressants were marketed as a specific treatment (eg. see previous post). These drugs were closely related to the chemical structure of chlorpromazine, the first marketed specific neuroleptic treatment for schizophrenia. Before then drugs tended to be used in non-specific ways.

The Times does recognise the value of talking therapy as well as medication. Helping people understand their problems and deal with them psychosocially has actually always been the mainstay of psychiatric treatment. And, of course, a multitude of different psychological therapies have developed after psychoanalysis - The Times mentions principally cognitive behavioural therapy and interpersonal therapy.

The Times quotes the statement made by David Baldwin (and Wendy Burn, President of the Royal College of Psychiatrists), which led to the complaint which I signed about antidepressant discontinuation problems being minimised (see eg. previous post). But it doesn't say that the complaint was signed by 30 people, not just psychiatrists and psychologists, but also people who have experienced antidepressant discontinuation problems. Instead it misleadingly says that 10 psychiatrists and a psychologist from the PHE panel complained. I'm one of the 10 psychiatrists that the leading article is referring to, but I'm not on the PHE panel!

I also signed a subsequent letter, as I was concerned that Baldwin's conflicts of interests could compromise his work on the PHE review group. The letter suggested he should be replaced with someone who had no such conflicts of interest (see Mad in the UK post). I'm not sure whether PHE had any concern about his declaration of interests. Certainly the Royal College of Psychiatrists had no such concerns (see press release). However, there are problems with institutional corruption within the Royal College of Psychiatrists (see previous post). Our complaint was not a personal attack on Baldwin but to ensure that the issues within the PHE group are discussed in as unbiased a way as possible. I'm sorry if David Baldwin felt distressed by the concern expressed about his role on the issue of antidepressant discontinuation but he is in a responsible position in the College.

What happened was that @Truthman30 became aware of Baldwin after the joint statement with Wendy Burns. He has produced a blog since 2007 on what he calls the Seroxat Scandal. This issue is much wider than just antidepressant discontinuation problems. This includes the role of paroxetine (original trade name Seroxat) in producing suicide and violence. Personally I'm more sceptical about these claims (see eg. my review of Peter Breggin's book) but @Truthman30 regards Seroxat as perhaps one of the most dangerous drugs ever made. He knows this from his personal experience and 10 years of research for his blog.

So @Truthman30's research into David Baldwin led to posts on his blog, which he described as being about David Baldwin's "long, incestuous, and financially lucrative relationship with the Pharmaceutical industry". This is where the term "pharma-whore" mentioned by The Times was used and @Truthman30 sought to defend its use. The "worse than Hitler" label comes from a comment on the blog by kiwi (not actually anonymous as The Times news article said, although the google profile has not been completed). @Truthman30 is unhappy that Baldwin described Seroxat in 1998 (the year @Truthman30 was first prescribed it) as "one of the safest drugs ever made" because of course this is not his personal experience, nor has it been backed up by the results of his research for his blog.

As The Times says, "Inflammatory and calumnious invective is unfortunately part of online discussion on many issues." I agree that scientific research should be based on evidence and I look forward to the report that will come out of the PHE review. I would like to see more discussion in the academic literature about antidepressant efficacy and discontinuation problems (see previous post). I would also like to see more academic discussion about the issues of safety raised by @Truthman30 (even though I tend not to agree with all he says). It's important to stick to the issues. It's also a privilege to be able to discuss these issues publicly on social media and this privilege should not be compromised. I'm glad to be able to do so on my blog.

Analysing the evidence about antidepressants and other psychiatric medication

Editorial in The Lancet Psychiatry helpfully calls for a “dispassionate analysis of the evidence” about psychiatric medication. It seems to be particularly concerned about what it calls “Hooked on happy pills” headlines that have appeared in British newspapers over recent years (see one example). 

By criticising these articles without dealing with the issues, the editorial could be taken as another example of minimising the significance of antidepressant discontinuation problems (see previous post). This issue does need to be taken seriously. 

Why doesn’t The Lancet Psychiatry commission a review of the evidence? Or more generally, why doesn’t it commission an analysis of the placebo amplification hypothesis of antidepressant efficacy (see previous post). Rather than platitudes in an editorial, it should be doing its job of analysing the evidence. There are too many issues about psychiatric medication that are being fought out in the press rather than psychiatric journals dealing with these matters scientifically.

The wish for a biological basis for mental illness will never go away

James Davies in his book Cracked (see my review), was surprised when Robert Spitzer, chair of the DSM-III task force, said no biological markers had been identified for functional mental illness (see recent @ClinpsychLucy tweet). Spitzer understood that organic mental illness is different from functional mental illness. It was DSM-IV, led by Allen Frances, that abolished the distinction. This was a mistake (eg. see previous post).

I have mentioned in a previous post how Sami Timimi couldn’t understand why he was indoctrinated in his psychiatric training. Similarly, I remember the discussions I had with Alec Jenner, my professor of psychiatry in Sheffield (see previous post), about why people believed what they did about psychiatry. The problem is that the belief in the biological basis of functional mental illness will never go away (see my tweet in response to @ClinpsychLucy). I’m not one who hopes for a radical, new psychiatry that will replace biomedical psychiatry. But we do need to break the dominance of the biomedical model and recreate a more pluralistic psychiatry. This situation is not helped by dissolving the distinction between functional and organic mental illness, which needs to be reinstated.

Running amok in American society

The New England Journal of Medicine (NEJM) has an article about how to stop mass shootings (see article). I've written before on this situation in the USA (see Psychiatry shooting itself in the foot and The omnipotence of the mental health system).

It isn't just in the USA where people have run amok (see medical definition of amok from Merriam-Webster). The NEJM article says that such US tragedies are "entirely preventable" by the implementation of policies requiring that firearm sales involve background checks on purchasers and also allowing courts to have firearms removed temporarily from people who pose an imminent hazard to others or themselves but are not members of a prohibited class. These policies may well reduce such incidents, but the article doesn't provide any evidence to suggest that their implementation will prevent mass shootings entirely. And there must be questions about whether they really go far enough.

Amok episodes normally end with the attacker being killed or committing suicide. Murders which are followed by suicide are most likely to be committed in anger by aggrieved people blaming others as well as themselves. Although amok was traditionally seen as a syndrome bound to cultures such as Malaysia and Indonesia, all societies, including American society, can subtly sanction such mass shootings (and perhaps also not so subtly sanction them - eg. How does NEJM publish an article like this that doesn’t properly consider removing guns from civilian possession). The American government and people need to understand the ways in which they themselves are doing this. Amok isn't just happening in other parts of the world.

Institutional corruption within the Royal College of Psychiatrists

I’ve commented before on institutional corruption within psychiatry (eg. see previous post). I’ve also pointed out how the Royal College of Psychiatrists can’t be relied on for its information about psychiatry (eg. see another previous post).

The College does need to do more to deal with institutional corruption within its own ranks. The American Psychiatric Association may be more blatantly corrupt (eg. see previous post), in that there doesn’t seem to be much attempt to hide commercial influence. However, this doesn’t mean there aren’t problems within the Royal College as well.

The College does prevent pharmaceutical company influence within College meetings. But many of the speakers have a conflict of interest. Declaring conflict of interests, even if it does make matters more transparent and honest, is insufficient to deal with the issue of conflict of interests (see previous post). If one thinks about it, declaring conflict of interests doesn’t purify the content of College meetings. In fact it does the reverse.

Peter Gordon’s campaign to make disclosing of payments from drug companies mandatory may help (see BMJ news item), but ultimately it’s up to the Royal College of Psychiatrists to deal with institutional corruption within its own organisation. The problem is that I don’t think the College agrees that conflict of interests compromises the work of its representatives.

We are all mad here

Peter Kinderman is giving a lecture at Salomons Centre in Tunbridge Wells this week entitled 'Our turbulent minds: why we’re all crazy, but none of us is ill'. I've mentioned Peter several times in this blog previously. For example, I’ve said he can express the essence of critical psychiatry better than me (see previous post), as he points out that explaining mental disorder in terms of the brain is no different from explaining all other behaviour and emotions in terms of the brain.

Despite all my agreement with Peter, I have been critical of some aspects of his book A prescription for psychiatry (eg. see previous post with links from that post). Obviously I don’t know exactly what Peter’s going to say in his Salomon’s talk. He might start with a quote from Lewis Carrol in Alice in Wonderland (see tweet):-

“But I don’t want to go among mad people," Alice remarked.  

"Oh, you can’t help that," said the Cat: "we’re all mad here. I’m mad. You’re mad." 

"How do you know I’m mad?" said Alice. 

"You must be," said the Cat, "or you wouldn’t have come here.”

Of course we’re all crazy in this sense. We believe all sorts of things which it might be very difficult to justify. Our very existence relies on having a worldview that protects our viability as human beings. It’s particularly difficult to give up these kind of beliefs. For example, it was quite traumatic when in my late teens I gave up my belief in God. Similarly psychiatrists find it very difficult to give up the biomedical model. They may feel that their very existence as psychiatrists may fall apart if they do.

Yet I worry that Peter may mislead by going on to say that no one is ill. I do understand what he means. Illness since the nineteenth century (although not really before) has been understood as having a bodily tissue pathological basis. I agree with Peter that functional mental disorder does not have a physical basis in this sense. For example, no physical pathology has been established for psychotic disorders, such as schizophrenia or bipolar disorder. True, with the amount of psychiatric research that is done, many people assume that a physical basis has been established for these conditions, but this is wrong.

However, this does not mean that psychosis does not exist. It’s not surprising Alice may not have wanted to go amongst psychotic people who are out of their minds. We all have the potential to lose touch with reality and this is different from believing our normal everyday crazy ideas which sustain our worldview. Of course, the psychotic person’s delusions and hallucinations are sustaining their worldview in this way, but it’s idiosyncratic and the rest of us find it very difficult to understand why they’re out of their mind.

Personally I’m happy to see mental disorders as ‘illness’, as the 19th century anatomoclinical understanding of disease in terms of physical pathology has never incorporated functional mental illness. We’ve been misled by defining illness so narrowly. That definition allowed Thomas Szasz to say that mental illness is a myth.

But we need more historical undestanding of the origin of psychiatry. Of course mentally ill people were looked after by the state in poor law arrangements. And it was once the state started to intervene in this way that it identified there was a group of people that were mentally ill. They weren’t necessarily responsible for their poverty, as they were mentally ill and needed treatment. Psychiatry developed the role of identifying this group. What psychiatrists now call phenomenology is the process of identifying psychological abnormalities. Peter’s right that there may well be disagreement about what counts as an abnormality. But the fact that people were prepared to question the beliefs that they had led to psychiatry having the role of identifying insanity. They were alienists, identifying mental alienation.

This proto-psychiatry existed before the introduction of anatomoclinical thinking in medicine. Much of the thinking about the origins of mental illness was in fact very physically based. For example, there were ideas about the brain being oppressed by blood and several early psychiatrists were phrenologists. Yet incorporating the anatomoclinical way of understanding disease into psychiatry has eclipsed a more psychological understanding. This is why we need a critical psychiatry to point out that psychiatry can be practiced without believing that mental illness is due to brain disease.

Realising the right to mental health

The European Psychiatric Association (EPA) has expressed "great concern and disappointment" in a position paper about what it sees as "the misleading and false portrayal of psychiatry ... as well as the lack of any evidence or statistics supporting this opinion" in a report from the UN Special Rapporteur, Dainius Pūras, who I mentioned in my last post. I actually thought the report was very good (see previous post).

EPA is particularly concerned by what it sees as the ignoring of evidence for the effectiveness of psychotropic medication, which it says "risks harming people" by encouraging avoidance of treatment. It defends the biomedical approach and does not see it as "a source of neglect, abuse and coercion" or as "the key factor explaining the current unsatisfactory status of mental healthcare". Rather, it sees inadequate government funding as the primary obstacle to mental health.

The EPA position paper is helpful in clarifying points of disagreement. I've always emphasised the need to avoid polarisation in the debate about psychiatry. However much I think the biomedical view is wrong, I am aware that it will never go away.

Recognising the bias in the evidence for psychotropic medication is not unscientific. In fact, I've always said psychiatry needs to be more scientific in its interpretation of the evidence (eg. see previous post). It is true that biomedical theories are used to encourage people to take their medication (eg. see previous post) but I've always found that patients are able to understand that a physical basis for mental illness has not been established.

I do see the dominance of the biomedical approach as an obstacle to the realisation of the right to mental health. We need a more balanced perspective. The tendency to reduce people to objects, which the biomedical approach can encourage, hinders understanding of peoples' problems and may prevent helping them deal with their problems. Of course some patients take a biomedical perspective but imposing such a view on people is a misuse of psychiatric power. The EPA should encourage further debate on these issues.

Institutional corruption in psychiatry

I've commented before on corruption within psychiatry (eg. see previous post). Dainius Pūras, the United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, who I have mentioned before (eg. see previous post), produced a report last year on corruption and the right to health, with a special focus on mental health. The World Psychiatric Association (WPA) objected strongly to the report (see letter sent to Dainius Pūras) and seems to be particularly complaining about the specific focus on psychiatry.

Robert Whitaker and Lisa Cosgrove in their book Psychiatry under the influence highlighted the institutional corruption due to over-marketing of stimulants for ADHD, the expansion of the notion of depression, the extension of SSRI antidepressants for other neurotic conditions besides depression and for children, and the promotion of mood stabilisers (see previous post). Perhaps WPA need to read this book to find the evidence for the statements in the Special Rapporteur's report.

There is no doubt that psychiatric power is misused for private gain. It seems reasonable that the Special Rapporteur should have a focus on corruption in mental health in this report, taking into account the context of his previous report, which raised the issue of the global burden of obstacles that persists in mental health care systems globally and how this hinders the realisation of the right to mental health. These obstacles include (1) the dominance of the biomedical model and the overuse of biomedical interventions, in particular psychotropic medications (2) power asymmetries and (3) the use of biased evidence.

Institutional corruption develops when systemic practices, which are legal, accepted and normative, nonetheless undermine the integrity of the institution. Disclosure is insufficient to control conflicts of interest (see previous post). In fact, there is little attempt to hide the commercialisation of psychiatry. Ironically being open about commercial interests does not purify psychiatric science but rather exposes its self-interest (see another previous post). The WPA does need to recognise and correct its own institutional corruption. The corrupting self-interests of psychiatry demand change in psychiatric practice.

Anatomoclinical understanding in psychiatry

In the introduction to The birth of the clinic, Michel Foucault contrasts the views of Pomme from the middle of the eighteenth century and Bayle less than a hundred years later. Pomme believed that baths for ten or twelve hours a day for 10 whole months desiccated the nervous system and its sustaining heat, and observed in a patient after this treatment that:-

‘membranous tissues like pieces of damp parchment… peel away with some slight discomfort, and these were passed daily with the urine; the right ureter also peeled away and came out whole in the same way’. The same thing occurred with the intestines, which at another stage, ‘peeled off their internal tunics, which we saw emerge from the rectum. The oesophagus, the arterial trachea, and the tongue also peeled in due course; and the patient had rejected different pieces either by vomiting or by expectoration’. 

Such “language of fantasy” was not used by Bayle when he described the encephalitic lesions of general paralysis. Foucault describes such new pathological understanding as a “mutation in discourse”.

Such anatomoclinical understanding, relating symptoms to their underlying physical pathology, was a major advance for medicine in the first half of the nineteenth century and still underlies our modern understanding of disease. But the enthusiastic search for anatomical localisation in psychiatry still led to fanciful notions later in the nineteenth century. For example, Theodor Meynert (1833-1892) delineated various ‘fibre-systems’ in the brain and deduced functions for these ‘pathways’. Despite his skills in brain dissection, his theories were not based on empirical findings. They were eventually attacked and labeled as ‘brain mythology’, particularly after his death. To quote from Auguste Forel, who studied with him:

He [Meynert] was certainly brilliant and full of ideas, but his imagination made leaps that were ten times as bold as mine. The longer I remained, the more I lost faith in his encephalogical schemata, and the fibrous connections which he perceived in the brain. … I could not always see what Meynert saw.

Modern neuroimaging studies also have the tendency to be interpreted as facts despite the inconsistencies and confounders in the data (eg. see previous post). Meynert’s research may have appeared so successful because it seemed to give a material explanation of the basis of mental illness, in the same way as brain scanning does for us now. Its empirical truth is a lesser concern in whether the results are believed or not.

Equality in the Mental Health Act

Race on the Agenda (ROTA) and Race Equality Foundation (REF) have made their submission to the Mental Health Act (MHA) Review 2018. I have shown support by signing up on the ROTA website and hope others will as well.

I have blogged before on the MHA review (eg. see previous post). I have questioned how open this review is (see previous post). I hope it doesn’t boil down merely to ‘watering down’ community treatment orders (CTOs), because I think that will be a missed opportunity to create a more rights-based focus for mental health work in England and Wales.

Anti-discriminatory principles and the acknowledgement of institutional racism do need to be made explicit in any new Mental Health Act. I understand historically why mental illness was not defined in the 1983 Mental Health Act, but I think this difficult issue needs to be grappled with in this review. For example, even alcohol intoxication seems to have been misunderstood as a disorder that is liable to detention (see twitter conversation). However much this may be against the spirit of the MHA, there is clearly confusion and a clearer definition of mental disorder that is liable to detention is required. More stringent criteria are required to avoid cultural misunderstandings and racial bias. It should be explicit that diagnosis must take account of the person’s social and cultural background. In practice, detention may only be justified for psychosis, with loss of mental capacity, and for personality disorder which is treatable. And there need to be rigorous standards to avoid misdiagnosis of psychosis because of cultural and racial bias. And if people are going to be detained for personality disorder or psychosis, the degree of risk should not be exaggerated because the person is "big and black". Mental health professionals should have the skill to appreciate cultural diversity in diagnosis and treatment and this needs to be legislated for by stipulating that Approved Mental Health Practitioners (AMHPs) and Responsible Clinicians (RCs) can only be approved (and their approval renewed) when they do have these skills. A similar process needs to apply to independent mental health advocates (IMHAs).

The interim review does say it will look at improving the Mental Health Tribunal (MHT) (see extract). The MHT should be able to deal with specific appeals against failure to take account of the person’s social and cultural background, with expertise from Black and Minority Ethnic (BAME) interests on the panel and the ability to call evidence from outside sources. MHTs need to be able to seek additional information on cultural background of the detained person. Their decisions need specifically to take account of cultural diversity and institutional racism. People appointed to MHTs need to have experience of race and anti-discrimatory practice. Personally I think the MHT has become too legalistic and has lost sight of its role as a safeguard in detention. I think there is a case for wholesale reform of the MHT. I would actually change its name to the Mental Heath Rights Tribunal. This is putting the R back into the acronym of MHRT, but inserting the word 'rights' rather than 'review', as it used to be.

As I said in my previous post, I was surprised that the interim report did not mention the statutory responsibility of the Care Quality Commission (CQC) (after taking over the role of the Mental Health Act Commission (MHAC)) to interview detained patients and investigate their unsatisfactorily dealt with complaints, as well as deal with any other complaints in relation to detained patients. This was a significant safeguard introduced by the 1983 Act and its significance seems to have been lost with MHAC's assimilation into CQC. The CQC should be reducing the use of detention and racial inequalities in practice. It needs to reinforce its inspection of cultural competence of mental health professionals and address racial bias. It also needs to be fulfilling its role to prevent ill treatment under the Optional Protocol to the UN Convention (OPCAT) (see duties under National Preventative Mechanism). Personally I think the Mental Health Act functions of CQC need to be taken out of CQC and taken over by a new body. Maybe this could be a new single Mental Health Rights body, which also incorporates the MHT functions. Second Opinion Appointed Doctor (SOAD) functions also need to be strengthened so that they are not merely a rubber-stamping exercise.

As a member of the Critical Psychiatry Network (CPN), I was against the introduction of CTOs. CPN was an original member of the Mental Health Alliance that campaigned against the reforms that eventually led to the 2008 amendments to the Mental Health Act. CPN was the first group of psychiatrists that was part of the Mental Health Alliance, which was subsequently joined by the Royal College of Psychiatrists. CPN resigned from the Alliance when it looked as though the Alliance was going to compromise on the introduction of CTOs, which in fact proved to be the case. I am not opposed to CTOs because I don't realise there has always been provision within the MHA for enforced community treatment, in the form of guardianship orders. I think at the time of the 2008 amendments there was a supervised community treatment provision, which was never used as much as community treatment orders. I'm not proposing returning to supervised discharge arrangements. Too many CTOs are currently technically unworkable because of non-compliance and even those that seem to be workable the person consents to the treatment, so there may be a question about why the CTO is needed. Quite commonly people are recalled just for breaching conditions, which is actually an insufficient reason for recall within current legislation but there is no safeguard. I'm pleased to see that the interim report of the MHA review has said that CTOs will be reformed or replaced. My personal option would be to go for replacement, perhaps building on the current provision within guardianship.

I'm also not one that necessarily thinks it would be a good idea to replace the MHA with Mental Capacity legislation. The trouble is that mental health professionals tend to define people who do not make very rational decisions as lacking in capacity. Mental capacity legislation makes clear this is incorrect but ensuring its implementation may in fact be more difficult than reforming the MHA, as RCs and AMHPs have got used to interpreting the spirit of the Act. That spirit of the Act needs to be reinforced in reformed legislation to make it even more rights-based.

Global critical psychiatry

The Mad in Asia website has recently been launched. It’s part of a global network (see links). I’ve posted before on global mental health: eg. Mental health as a global health priority, Global human rights violation in mental health, Human rights and mental health worldwide, Think about investing in intercultural mental health and How to get money for global mental health research.

I have always encouraged critical psychiatry to be a broad church (eg. see previous post). However, I do worry that this may dilute the essential message of critical psychiatry that mental illness should not be reduced to brain disease. Critical psychiatry needs to be a genuine global movement. And, it needs to be concerned about its systemic whiteness.

The true situation about antidepressant discontinuation problems

I’ve mentioned before (see previous post) that I signed a complaint to the Royal College of Psychiatrists about a statement made by Wendy Burns, the President, and David Baldwin, the Chair of the Psychopharmacology Committee, that discontinuation problems on stopping antidepressants resolve within two weeks for the vast majority of patients. I do not think this statement is evidenced-based. The complaint has been dismissed by the College as unfounded (listen to MIA Radio podcast)

Minimising the significance of antidepressant discontinuation problems doesn’t seem to matter to the College. I’m not convinced the College membership fully agrees with this unwillingness to engage with the evidence and I am ashamed as a member of the College about this apparent lack of concern. As I said in my previous post, there is a history of antidepressant discontinuation problems being minimised, even denied, and this situation just seems to be being perpetuated by the College.

On the other hand, I guess we shouldn't be too surprised that the College is unconcerned about the truth of a matter of this sort. It finds it difficult to acknowledge the political and ethical implications of psychiatric practice. However neutral and objective the College may like to think it is, it exists, actually, as an institutional structure to justify psychiatric treatment, such as antidepressant medication. So, it would want to minimise problems caused by medication, wouldn't it? More generally, the validity of what it promotes as science does need to be challenged (eg. see previous post). We should not assume that the College has full and absolute legitimacy in truth over psychiatric matters and this has been demonstrated by the way this complaint has been handled.

Let's hope Wendy Burns and David Baldwin are prepared to discuss these matters further now that the complaints procedure is over.

The origin of critical psychiatry

The origin of the term 'critical psychiatry' was probably in an edited book Critical psychiatry: The politics of mental health by David Ingleby (1980). My own edited book Critical psychiatry: The limits of madness (2006) deliberately echoed David's use of the term, and, of course, the name was adopted by the Critical Psychiatry Network (see previous post). David also contributed a chapter to my book.

In the preface to the second impression of his book (2004), David commented that "the notion of mental illness as a brain disease has become even more widely accepted than ever before" (p. 5). The essential position of critical psychiatry can be said to be the critique of this notion. Mental illness should not be reduced to brain disease (eg. see previous post). Even Thomas Szasz contributed to critical psychiatry in this respect, as he regarded the biological basis of mental illness as a myth (eg. see another previous post).

There are, of course, implications of taking this conceptual position. How critical psychiatry's essential understanding is taken forward does lead to differences within critical psychiatry (see previous post). In his introduction to the book, David suggested that, "One premise shared by all contributors to this book is that mental illness is, in fact, a political issue" [his emphasis] (p. 8). In fact, Franco Basaglia (eg. see previous post), one of the contributors to his book, tended to be less concerned about whether mental illness had an organic aetiology. His primary motivation was to abolish the asylum as, as far as he was concerned, its main purpose was to segregate the under-privileged (see extract from my book chapter).

David made it clear that "mental illnesses ... do exist" (p. 18). He, thereby, moved critical psychiatry on from Szasz's theme of 'the myth of mental illness', in the sense that Szsasz did not believe that the concept of mental illness is valid (see previous post). David also notes how some critical psychologists and others have questioned whether mental health problems "really have much to do with medicine in the first place" (p.8). However, he also quotes Peter Sedgwick, who argued that "mental illness was, after all, a medical problem" [his emphasis] (p. 9).

David juxtaposed 'positivist psychiatry', defining positivism as "the paradigm of studying human beings as if they were things' (p. 13), with 'interpretative' approaches, by which he meant "[u]nderstanding people's 'symptoms' in terms of their social situation" (p.52). Mental illnesses are "meaningful responses to difficult situations ... [but] in many conditions a 'residue' remains refractory to commonsense understanding" (p.13). Here he turned to psychoanalysis to interpret the 'residue' in terms of unconscious meanings.

David concludes his chapter by saying that “until the political component of our disagreements is brought out into the open, we will never go beyond the phoney synthesis of psychiatric ‘eclecticism’” (p.71). His book was written at the end of the period of conflict know as 'anti-psychiatry'. He does mention (on p.7) Anthony Clare's book Psychiatry in dissent, which, as I have said previously, many have seen as the compromise outcome of the anti-psychiatry debate. Clare reinforced an eclecticism in psychiatry by avoiding any clear conceptual basis for psychiatry (eg. see my Psychiatric Bulletin letter). Manschrek & Kleinman called this kind of position in psychiatry 'semi-critical' (see previous post). In many ways, psychiatry is still in this situation (see eg. previous post). The critique of psychiatry does need to go further. Critical psychiatry, in very much the sense originally used by David Ingleby, does need to be seen as a valid solution to the anti-psychiatry debate.

Mind-body relation

Further to my previous post in which I mentioned Charles Myers, I came across a lecture he gave in 1932 entitled ‘The absurdity of any mind-body relation’. (1) What he meant by this was that life has direction and is more than blind mechanism. And, “[c]onscious mind is essentially a specialization, a distillation of that directive activity” (p.8). So mental activity and living bodily activity are identical and it doesn’t make sense to talk about a mind-body relation.

Physical concepts of mechanism are incomplete for a total description of nature (see previous post). The primary distinction is between life and inanimate matter, not life and consciousness (see previous post). To quote from Myers’ lecture, “In no form of life is directive activity wholly absent.” (p.21) As Kant said in the Critique of Judgement,

there will never be a Newton of the blade of grass, because human science will never be able to explain how a living being can originate from inanimate matter

Directive activity is still inherent in plants, even though, as Meyers said, “locomotion and plasticity are minimal” (p.25). This doesn’t mean that there can be no causal explanations for an account of the physical nature of organic matter. But, mechanistic explanations are insufficient for an account of the totality of human and living nature. As Myers concludes, “There is no separable mental or vital force: and the mental must be regarded as identical with the vital.” (p.26) Psychiatry needs to recognise its mistake in reducing mental illness to inanimate brain disease.

(1) Hobhouse memorial lectures 1930-1940 OUP: London

The roots of medical psychology

I’ve mentioned before (eg. see previous post) that I am doing a PhD in psychology at Cambridge University. It’s probably just as well that I’m in the psychology department rather than psychiatry, considering how critical I’ve been of some of the emphasis within the psychiatry department (eg. see previous post).

What may be of interest is that it was actually the psychology department that first started psychiatric training at Cambridge University with the setting up of a Diploma in Psychological Medicine (DPM) course in 1912. It only lasted until 1927 (although no students had enrolled on the course for two years before it was abolished). But the intention had been to make Cambridge the “national centre for the education of psychiatrists” (Forrester & Cameron, 2017: 248).

One of the main driving forces was Charles Myers, who set up the Psychological Laboratory at Cambridge. After the war, he wanted to develop the medical, educational and industrial aspects of psychology. He left Cambridge in 1922, at least partly because of opposition from an emphasis on experimental psychology.

Cambridge psychology needs to be reminded of this root in medical psychology. The British Psychological Society closed the British Journal of Medical Psychology in 2001 and continued it as Psychology and Psychotherapy: Theory, Research and Practice the following year. The first editorial of the newly titled journal said that “the term ‘medical psychology’ is itself becoming anachronistic”. I’m not convinced psychology should be quite so dismissive of this aspect of its history.

Psychiatry should be more scientific

An advertisement article in the Guardian paid for by the Royal College of Psychiatrists uses Mary-Ellen Lynall (who I've mentioned in a previous post) to promote young doctors coming into psychiatry. I'm not sure if it really improves recruitment by speculating that "brain inflammation may be a cause of depression and in five or 10 years we could have a blood test to detect whether that inflammation is present", because this is merely misguided wishful thinking (eg. see previous post).

What worries me is that the apparent motivation for this campaign is that newly qualified doctors don't think psychiatry is very scientific. That's not surprising considering what's promoted as apparent advances in psychiatry, including seeing brain inflammation as the cause of mental illness (eg. see another previous post). Junior doctors are right to laugh at psychiatry if that's all that's on offer.

Psychiatry isn't just about physical disease, as the advertorial indicates. It's a human science, and not just focused on the brain. Nor is the rest of medicine just focused on the body and psychiatry needs to promote itself as a truly patient-centred scientific medical discipline (eg. see another previous post).

Defending Engel's biopsychosocial model

Linda Gask has an essay in The Lancet Psychiatry entitled 'In defence of the biopsychosocial model'. Progress does need to be made on clarifying George Engel's biopsychosocial model (see previous post).

Engel’s model promotes a holistic psychiatry in the same way as critical psychiatry and is a challenge to biomedical dogmatism. His original Science paper was written in response to a paper published in JAMA by Arnold Ludwig (1975) called ‘The psychiatrist as physician’.

Ludwig was concerned about the state of psychiatry, which he saw as under attack from what we now identify as 'anti-psychiatry'. His response was to accept that modern-day psychiatry is vulnerable to such charges. His solution was to retreat to the medical model. As far as Ludwig was concerned, psychiatry should deal with medical illness, including neuropsychiatric and medicopsychiatric disorders, rather than nonpsychiatric problems, which are more appropriately handled by nonmedical professionals. This position is what has more recently been called a 'remedicalised psychiatry' (see previous post). Ludwig was clear that psychiatry's viability was dependent on an understanding of mental illness as due to known, suggestive or presumed brain dysfunction. Interestingly, he predicted, “I am not optimistic that there will be any sudden and dramatic resolution of these issues” (p. 604). Subsequent history could be said to have proved him wrong in the sense that psychiatry has become more biomedical since the publication of DSM-III in 1980 and the development of brain imaging. Modern psychiatry has become more biomedical than even Ludwig anticipated.

Engel, by contrast, was not happy with Ludwig's proposal for change. As far as he was concerned, all medicine, not just psychiatry, was in crisis. He believed doctors had become insensitive to the personal problems of patients and preoccupied with procedures. In short, medicine is too disease-oriented rather than patient-orientated. For Engel, the biopsychosocial model has real advantages, by taking account of cultural, social and psychological considerations as well as biological. Furthermore, it avoids the polarisation between biomedical reductionists, amongst which Engel would have included Ludwig, and exclusionists, like Thomas Szasz, who deny mental illness. Szasz, in fact, had the same biomedical understanding as reductionists of the nature of illness as physical lesion, but did not believe in mental illness because a biological basis has not been established. I have always tried to be clear that there are aspects of Szasz's views which do not coincide with my views about critical psychiatry (eg. see previous post). My views are more identified with Engel's.

What is of interest is that both Ludwig and Engel were trying to salvage psychiatry in the context of ‘anti-psychiatry’. This is why this situation is relevant to critical psychiatry, which has its origins in anti-psychiatry (see my book chapter). I am suggesting that Engel’s biopsychosocial model is a viable form of critical psychiatry.

Many psychiatrists, like Linda in her essay, would say that their approach to psychiatry is biopsychosocial, taking into account psychosocial factors as well as biological. I agree that most psychiatrists are pragmatic in their approach. However, even though most psychiatrists are not narrowly biomedical, they are still biomedical (see previous post), in the sense that they generally believe that mental illness, or at least major mental illness, such as schizophrenia and bipolar I disorder, is due to brain abnormalities, even though the evidence is against this conjecture. More than the empirical evidence, the philosophical argument about the relationship between mind and body is against such speculation. Psychiatrists now rarely become involved in this conceptual debate because they expect that brain research will find the solution to mental illness.

As pointed out by Linda, the biopsychosocial model has been critiqued as being too eclectic by Nassir Ghaemi, leaving psychiatry with no overall theoretical structure as "all theories are possible and all perspectives are valued" (p.1) (see my book review). I agree that psychiatry can be eclectic with, for example, biological and psychotherapeutic treatments being combined without any systematic theory to support such a therapeutic strategy. There is also commonly a split in the aetiological understanding of mental illness, with major psychotic illness being seen as biological in origin, and more minor, neurotic illness seen as having psychosocial causes.

The real origin of eclecticism in modern psychiatry, though, is not in the biopsychosocial model but in the mainstream response to ‘anti-psychiatry’. Anthony Clare’s Psychiatry in dissent, mentioned by Linda, was a response to anti-psychiatry (see previous post). It eschewed a well-defined theoretical basis for practice. In this way, Clare avoided the worst excesses of reductionism and the objectification of patients that caused particular concern to anti-psychiatry. This approach is what is now often labelled as ‘biopsychosocial’ and I worry that Linda is using the term in this way. Most psychiatry is only semi-critical in this sense (see previous post). The true meaning and implications of Engel’s biopsychosocial model have been diluted.