Sunday, April 18, 2021
Wednesday, April 14, 2021
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.
Friday, April 02, 2021
Tuesday, March 30, 2021
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?
Saturday, March 13, 2021
Tuesday, February 23, 2021
Saturday, February 20, 2021
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).
Monday, January 18, 2021
Wednesday, January 13, 2021
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).
Friday, January 01, 2021
Tuesday, December 22, 2020
Sunday, December 20, 2020
Saturday, December 19, 2020
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'.
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.
Friday, December 18, 2020
Lucy thinks that there is evidence that paradigms in psychiatry are changing. I'm not so convinced. As I have always said, the wish to find a physical basis for mental illness will never go away completely. However, I think the realisation of the extent to which that wish cannot be fulfilled can change. As it keeps emphasising, mainstream psychiatry is actually more pluralistic than simplistic critiques of the biomedical model seem to imply. The balance of perspectives can change and I think this should be the aim of any critique of psychiatry.
I have no objection to alternatives being set up. However, these do need to have firm conceptual foundations. I just think that Lucy's understanding of the notion of 'illness' is wrong. She's right that mental illness should not be understood as brain disease. But she doesn't want to use the term 'mental illness'. Of course I know that people have used, and continue to use, the term to mean brain disease. But this is mere conjecture, however much it may seem to make sense to them. Even mainstream psychiatry admits that it has not yet proven that mental illness is brain disease. The reason for this is that it cannot. The change that needs to happen is that mental illness should no longer be seen as brain disease.
A Straight Talking Introduction to ...’ series, offers a valuable way of gathering information about people’s problems, and usefully emphasises the role of adversity in distress. We have significant agreements in our views, and, as we have discovered over the years, some significant disagreements too. Nevertheless, in contrast to many Twitter debaters, we are mature enough to remain civil and respectful in our discussions!
The principal points of disagreement in this case are:
Firstly, Duncan's statement: "PTMF wants to abandon the connection between mental health problems and the sick role, which is why it is so controversial". This doesn’t really capture the PTMF position. For a start, we don’t accept the concept of ‘mental health problems’ as somehow different or separate from emotional distress and suffering. We do, however, acknowledge the obvious fact that such suffering can be sufficiently overwhelming to interfere with one’s life. In such a case, formal exemption from duties by something equivalent to a doctor’s certificate may be needed. However, this doesn’t have to take the form of a psychiatric diagnosis, and in fact the main PTMF document shows that assessments of eligibility and rights do not have to be, and are not always, diagnostically-based (pp. 297-9). It discusses various alternatives, such as expanding the current custom of using a generic, non-medical term like ‘stress’, or more radically, as advocated by some service users: "... a universal rights, asset-based perspective as an alternative to the humiliating requirement to demonstrate enough impairment to access essential financial support" (Beresford et al., 2016).
Secondly, Duncan argues that "getting caught up in the argument about whether mental health problems are illnesses is actually deflecting us from this more important task of a critiquing mental illness as brain disease". But if we substitute the term ‘emotional distress and suffering’ for ‘mental health problems’ in his sentence, then we can see how problematic Duncan's statement is. People can, of course, choose to describe their difficulties in any terms they please, but as professionals we need to acknowledge the giant, unevidenced leap from ‘emotional distress’ to ‘illness’ with all its well-documented consequences – stigma, shame, social exclusion, effects of psychiatric drugs, obscuring of personal meaning, and so on.
I have been noticing various attempts to square this circle – to retain the concept of ‘illness’ and everything that depends on it – by claiming that ‘illness’ is really just a shorthand for the personal experience of suffering and consequent dysfunction. This manoeuvre simply doesn’t work (as explored by James Barnes in this blog post). As I put it in a recent interview, in real life, people who come into contact with mental health services .....
.... are all bombarded with messages about “mental illness” being “as real as a broken arm”, and needing to be managed by drugs “just like diabetes”. Even the dubious compromise that is the “biopsychosocial” model — a way of acknowledging some role for psychosocial factors while at the same time instantly relegating them to “triggers” of a disease process — is not much in evidence on the ground. And furthermore, the biomedical message is reinforced by the fact that these labels are applied by doctors and nurses, working in hospitals and clinics, who use not just the labels themselves but the whole medicalized discourse of symptom, patient, prognosis, treatment, relapse, and so on.
Furthermore, I pointed out that:
I have yet to hear any real life service user say, “Although the doctor told me I have schizophrenia I’m not too worried, because ‘illness’ is really being used as a metaphor for suffering in this case and it doesn’t exclude personal meaning”. I am sure readers are aware that the consequences of being diagnosed — such as being sectioned, forcibly injected, and so on — are not just metaphorical ... Essentially, we need to acknowledge that we are not dealing with patients with illnesses, but people with problems. We cannot make the necessary shift to a more appropriate and humane system unless we are prepared to drop the whole biomedical discourse altogether.
I believe that this radical process of change is already underway, and that what we are witnessing, in increasingly fractious social media exchanges, is the painful process of moving from one paradigm of care to another. In such a situation, the interminable ‘debates’ which so quickly slide into personal attacks can actually be a distraction, which is why I now largely avoid them. We need to focus on developing alternatives. The PTMF is an imperfect, evolving attempt to contribute to this process, and to reach a point where we can acknowledge that human emotional suffering, even in its more devastating forms, is neither disease nor illness.
Users and Abusers of Psychiatry (first edition 1989). She has worked in adult mental health settings for many years, alternating with academic posts. She is the former Programme Director of the Bristol Clinical Psychology Doctorate, which was based on a critical, politically-aware and service-user informed philosophy, along with an emphasis on personal development. She has written and trained extensively on the subject of psychological formulation as an alternative to psychiatric diagnosis. Lucy is lead author, along with Professor Mary Boyle, of the Power Threat Meaning Framework, published by the British Psychological Society in January 2018. This ambitious document offers a conceptual alternative to the diagnostic model of psychological and emotional distress. Lucy currently works as an independent trainer.
Wednesday, December 16, 2020
What I tend to emphasise about person-centred care is the fundamental change in perspective required to shift from a physical disease model of mental illness, and illness in general, to a holistic perspective (eg. see previous post). Human beings are organisms, not machines (see eg. previous post), so medicine needs to focus on persons, not just their bodies. Certainly for mental illness, there’s not much point just focusing on the brain (see eg. another previous post).
Monday, December 07, 2020
Monday, November 30, 2020
As I said in my article,
The appeal of Engel’s model was its critique of biomedical reductionism. In his original paper, Engel talked about neutralizing “the dogmatism of biomedicine” (p. 135). He commented on the enormous investment in diagnostic and therapeutic technology that emphasizes “the impersonal and the mechanical” (p. 135). He quoted from Holman (1976), who argued that:
[T]he Medical establishment is not primarily engaged in the disinterested pursuit of knowledge and the translation of that knowledge into medical practice; rather in significant part it is engaged in special interest advocacy, pursuing and preserving social power (quoted on p. 135).
Engel acknowledged the interest in the biopsychosocial model amongst a minority of medical teachers, but also emphasized the difficulties in overcoming the power of the prevailing biomedical structure.
As Engel explained, “medicine's crisis derives from the same basic fault as psychiatry's” (p.129). By defining disease in terms of somatic parameters, physicians can make the incorrect inference that they "need not be concerned with psychosocial issues which lie outside medicine's responsibility and authority” (p.129). Medicine has tried to correct this imbalance over recent years by attempting to make its training and practice more patient-centred. It hasn’t always been very successful in this aim and medicine still needs to be rethought in the way suggested by Engel (see eg. post on my personal blog). Healthcare has corrupted its mission and still needs to change (see another post on my personal blog).
Historically there have been various culturally derived belief systems about illness and disease. It wasn't so long ago that people in the West still believed in humoural explanations of illness (see eg. previous post). As Engel pointed out, "the biomedical model is now the dominant folk model of disease in the Western world" (p.130). However, even within the West there is still much take up of alternative and complementary medicine. Nor have traditional indigenous views globally been completely colonised by biomedicine (see previous post).
The problem with trying to conceptualise mental health problems as physical disease is that it leads to polarised positions between biomedical reductionism and a stance which argues that ‘mental health problems should not be seen as illness’. Representatives of the latter view, which Engel called ‘exclusionist’, would be Thomas Szasz (see eg. previous post), Lucy Johnstone (see another previous post) and Peter Kinderman (see eg. yet another previous post). There have even been these Szaszian tendencies within the Critical Psychiatry Network (see eg. previous post).
As Engel said, “the reductionists are the true believers, the exclusionists are the apostates” (p.130). But, in fact, both biomedical reductionists and the Szaszian position are wrong, as illness is not so much a physical disease as a "person-centered, harmful, and undesirable deviation or discontinuity . . . associated with impairment or discomfort" (p.130 of Engel paper, quoting from Fabrega, 1975). A technical distinction is made in the literature between illness as an experience and disease as physical pathology. In these terms, mental illness should not be reduced to physical brain disease (see eg. my Lancet Psychiatry letter).
Illness is most frequently first identified by people having symptoms or noticing signs. Building on the dissection of the body in medieval Europe, the Cartesian view of disease as the breakdown of the bodily machine did not take an organismic view. This more wholistic viewpoint in fact tended to take an equally erroneous vitalist perspective (see eg. previous post). In the nineteenth century, the application of the anatomoclinical method, relating signs and symptoms to physical pathology, was remarkably successful. But as Engel said, "at a cost" (p.131). From his point of view, “We are now faced with the necessity and the challenge to broaden the approach to disease to include the psychosocial without sacrificing the enormous advantages of the biomedical approach” (p.131).
People may have underlying disease which hasn’t yet presented with symptoms and signs. Furthermore, patients need to be interviewed by doctors to understand their presentation. Broader socioeconomic conditions may well be important. Psychosocial factors determine even whether patients present to doctors. How patients react to treatment options can also affect outcome. The doctor-patient relationship itself is a powerful factor in treatment. All of these factors are outside a narrow biomedical framework which Engel called the “requirements of a new medical model” (p.131).
As Engel said, medicine has to “take into account the patient, the social context in which he lives, and the complementary system devised by society to deal with the disruptive effects of illness, that is, the physician role and the health care system” (p.132). The boundaries between health and disease are not absolute and both patients and doctors can have views about what counts as the sick role. It is patients and doctors, as far as possible together, that determine what should be regarded as illness/disease.
Monday, November 23, 2020
Monday, November 16, 2020
The trouble is that they do not want to go as far as questioning biological psychiatry per se. That's what's really needed to make progress. Biomedical psychiatry holds out the attractions of a predictive and systematic way of understanding and treating mental health problems. No wonder people hope it may be true and psychiatrists act as though we have got there, or at least are not far away from it.
But as the article says we're being misled. It’s not only the message that is wrong but also the expectation about what can be achieved. Do we really think we can solve the problem of consciousness (see previous post), or more generally how life originates from inanimate matter? As Kant said, this is an insight which is denied to us (see another previous post).
But that doesn't mean that psychiatry is defunct. It should never have had such fanciful notions. Nonetheless people still need understanding and treatment for their mental health problems.
Saturday, November 14, 2020
More seriously, Stahl explains that he had to take Psychiatra-Gain to deal with the boredom he was feeling in working with patients (see another video). This created his Alice in Wonderland worldview (see video). It leads to trying out lots of medications on patients in a fun way (see video), although the original psychotropics are still the best (see another video). Thank goodness someone at least is taking psychiatry seriously.
Thursday, November 12, 2020
More generally psychiatry's tendency to reduce people to objects means that its practices are too restrictive and not therapeutic enough. This tendency has increased over recent years with the overemphasis on risk. Community care has become as bureaucratic at times as the worst institutional practices of the asylum.
My hope is that the government will produce a green paper to discuss these issues more widely, but I suspect it will go straight to a White paper because of the independent review led by Simon Wessely. There needs to be renewed debate about these issues, as it has been paused by the coronavirus pandemic. My personal hobby horse has been that detained people should have a right to a second medical and non-medical opinion of their choice. Both detention and treatment decisions should be adjudicated by a single judge in the Mental Health Tribunal (doing away with the need for medical and lay members). Second Opinion Approved Doctors (SOADs) will also no longer be needed and anyway have tended to become a 'rubber-stamping’ exercise. The Mental Health Act arm of the Care Quality Commission needs to be given the specific responsibility of preserving the dignity and respect of detained patients. Its role in maintaining basic human rights needs to be reinforced.
(With thanks to a tweet from @Heather28258253)