Relational psychiatry should not be seen as extreme

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

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

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

A new Mental Health Act in England and Wales

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

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

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

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

Relational psychiatry has a reformist agenda

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

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

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

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

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

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

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

Dualism and psychiatry

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

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

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

The nonsense of reductionism in psychiatry

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

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

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

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

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

Understanding the biopsychosocial model

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

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

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

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

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

Objectives of Mental Health Act reform

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

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

Consultation on changes to Mental Health Act begins

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

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

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

Supporting people through mental health and capacity legislation

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

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

Oversimplistic psychiatric treatment

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

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

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

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

Towards a definition of relational psychiatry

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

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

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

What’s a relational psychiatry?

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

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

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

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

Consider the difference between these two sets of treatments:

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

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

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

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

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

Consider next the following two visions of human mindedness:

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

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

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

3) Relationality as characterising the treatment medium

Consider finally a third sense of 'relational':

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

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

Conclusions

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

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

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

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

How to change mental health services

As I said (see last post), I am grateful for Lucy Johnstone summarising our disagreements about psychiatry. Basically, I think this boils down to the best way to effect change in psychiatry. Lucy talks about creating an alternative to mainstream psychiatry. Certainly psychiatry does need to change. It is too dominated by a biomedical model of mental illness, which in fact is outdated in terms of recent conceptual developments in biology, psychology and philosophy.

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.

I'm grateful to Lucy Johnstone for this comment on my previous post about 'The overemphasis on psychiatric diagnosis', which I'm posting as a guest blog. Lucy contributed a chapter to my edited book Critical psychiatry: The limits of madness. 

I am glad Duncan thinks the Power Threat Meaning Framework, as summarised in the recent ‘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.

Dr Lucy Johnstone is a clinical psychologist, trainer, speaker and writer, and a long-standing critic of biomedical model psychiatry since her original book 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.

Person-centred care in psychiatry

I mentioned before (see post) that the Royal College of Psychiatrists had set up a scoping group to make training more person-centred. It produced its report in 2018 (see subsequent BJPsych Bulletin article and BJPsych International article).

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).

The overemphasis on psychiatric diagnosis

Having a psychiatric diagnosis for some people may be important. It identifies that they are unwell, the implications of which may have more social advantages for them than disadvantages. Others may not find a psychiatric diagnosis so helpful. For example, they may feel it hasn’t really helped them understand the problems they have with their mental health. 

I am thinking about these issues as I have just read The straight talking introduction to the Power Threat Meaning Framework (PTMF) by Mary Boyle and Lucy Johnstone. This book gives an introduction to what it calls an alternative to psychiatric diagnosis. Although it mentions psychological formulation, it doesn’t really talk about how mental health professionals undertake a history and mental state examination of people presenting with mental health problems. It provides, however, a valuable framework for obtaining and evaluating this information in terms of power, threat and meaning. 

If the aim of psychiatric assessment is to provide understanding of mental health problems, then a diagnosis may not necessarily be the most immediate concern. What is more important is to understand the family and personal context of these problems. Appreciating this context may not provide proof of what has caused them, but it may give some indications. Describing these reasons may well be more complex than what is conveyed by a single-word diagnosis. 

So, could psychiatry survive without a diagnostic system by focusing on providing understanding of mental health problems? Such a way of practising would have benefits, as it would avoid treating mental health problems as brain disease. But the trouble is that diagnosis is needed as a term for entry into the sick role in society. PTMF wants to abandon the connection between mental health problems and the sick role, which is why it is so controversial. 

PTMF admirably emphasises that damage to mental health can be caused by trauma and other external events, and that this damage is more to do with how people have been treated by others than what they have done themselves. In this sense, mental health problems are an understandable, even expected, response to people’s situations. But of course there are social consequences of mental health problems. Although psychological problems are the defining feature of why people present to mental health services, services cannot ignore the social dysfunction caused by these problems. Both psychological and physical ill health can cause social dysfunction. 

PTMF advises us not to see mental health problems as illness. However, if only because of the social dysfunction caused by both physical and mental illness, the term ‘mental illness’ can still be meaningful. Both mental and physical illness have personal implications. I’m not against other professionals besides doctors being able, for example, to sign a certificate that someone is not fit for work. But that’s essentially the same as what doctors do for illness in general. It seems unnecessarily strict to insist on not using the term ‘illness’ in relation to mental health problems. 

We do need to move on from an incorrect notion of mental illness as brain disease. But I think that getting caught up in the argument about whether mental health problems are illnesses is actually deflecting us from this more important task of critiquing mental illness as brain disease. The primary argument is that it is incorrect to reduce mental health problems to brain disease, not that mental health problems are wrongly seen as illnesses.

The need for a new medical model: A challenge for biomedicine

At the end of the last post, I said that George Engel did not define the biopsychosocial model in the eclectic way in which it tends to be used in modern psychiatry. In his seminal article in Science, he proposed his biopsychosocial model as a new medical model to challenge biomedicine. The biopsychosocial model is not only a challenge for psychiatry, but also for medicine in general. I'm not convinced people have often even read Engel's paper when they discuss the biopsychosocial model.

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.

Debate about models of mental health problems

As Anne Cooke et al (2019) say in their article, "There is considerable debate about the nature and causes of ... 'mental health problems', and therefore about the best way/s to intervene". They juxtapose the frameworks of the 'medical model' and the 'psychosocial model' and point out that there have been attempts to create an intermediate 'biopsychosocial model'.

I think the debate is more complex than this polarisation may suggest. The article defines the 'medical model' as denoting "the idea that mental health problems are best understood as 'illnesses like any other'". Even though there may be people that define and apply the 'medical model' in this way, I think most people do recognise a difference between mental and physical illness. Again, some people may want to minimise the difference between mental and neurological illness (eg. see previous post), but psychiatry is a separate speciality from neurology. The reason for this is that the two specialities deal with different kinds of medical problems. Those that want to work towards merging neurology and psychiatry at least realise we have not got there yet.

The article references Mary Boyle to define the 'psychosocial model' as a "framework that removes biology from the position of privilege in favour of a focus on the relational, interpersonal and social contexts of distress". This is fundamental to a critique of the biomedical model in that we need psychosocial explanations of mental health problems rather than reducing such problems to brain disease (see eg. previous post). 

What worries me is the way the 'biopsychosocial model' is seen as a way of reconciling the 'medical model' and 'psychosocial model' in the senses defined by the article. Engel's biopsychosocial model is is fact the same as the article defines as the 'psychosocial model' (see eg. previous post). True, the people that the article references in relation to the definition of the 'biopsychosocial model', such as Allen Frances (see eg. previous post) and Robin Murray (see eg. another previous post), do use the term in an eclectic way. But this was not what Engel meant.

Changing the medium of psychiatry to relations

Dumas-Mallett and Gonon (2020) helpfully summarise the bias in biomedical psychiatric research. They also describe how these misrepresentations are spread through the mass media and call for the public to receive correct information.

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.

Psychiatry has the wrong biology

Daniel Nicholson (who I’ve mentioned before eg. see previous post) has a paper on ‘Is the cell really a machine?'. As he says, "The conventional mechanical, reductionistic, and deterministic view is gradually giving way to an understanding of the cell that emphasizes its fluidity, plasticity, and stochasticity." Human cognition also needs to be understood in this dynamic, integrated, enactive way as it is embodied in the brain and the body more generally, and embedded in the environment, which is social and cultural, affording various possibilities of action to the person (see eg. previous post).

We need to move on from a mechanistic approach to life in general, including human life, to a more interpretative one (eg. see previous post). The advantage of seeing life as self-organising is that its plasticity is acknowledged without neglecting its ongoing stability (see another previous post). Cells and bodies are not well-defined structures but actually stabilised processes. What persists over time are their form not their matter. As David Nicholson says, “Cells are empirically revealing themselves to be inherently dynamic, self-organizing systems that respond stochastically and nonlinearly to environmental stimuli.” Cells and life in general are not determined spatiotemporal arrangements (see eg. previous post). 

Psychiatry needs to take on board this need for a more dynamic biology, not only for clinical practice but also for research (see eg. previous post). The physical disease model of mental illness is outdated because of progress in understanding not only in human cognition, but also more fundamentally about life processes (see another previous post). 

Psychiatry deconstructs itself, wow!

I made a serious attempt in a previous post to deconstruct the American Psychiatric Association in how it presented itself at an annual meeting. Actually I'd already realised (in another previous post) that Stephen Stahl and his NEI Psychopharm had done the job of hilariously self-deconstructing psychiatry, however undeliberate, in its series of videos. Unfortunately the congress opener for the 2011 NEI Global Psychopharmacology Congress that I mentioned in that post seems to have been taken down. As far as I can remember it had Stephen Stahl dancing in it. Anyway, you can laugh at the more recent 2019 NEI Congress Opener. And you can still see Stahl starring and dancing in this video about DSM-5.

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.

The violence of psychiatry

I've said before (see eg. tweet) that it's not surprising psychiatry is controversial when it has the power to detain people against their will on the basis of their health or safety or for the protection of others because of mental disorder, which are criteria that are bound to be open to interpretation. It is the dominance of the biomedical model in psychiatry that causes problems. The criteria in mental health legislation that allow coercive treatment are too wide to prevent abuse (see previous post). The UK government is currently producing a White paper for reform of the Mental Health Act but almost certainly will not go far enough - at least initially - to preserve the dignity and respect of detained patients (see eg. another previous post). There does need to be a campaign to stop psychiatric abuse (see yet another previous post).

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)