Sunday, September 16, 2018

We are all mad here

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

Despite all my agreement with Peter, I have been critical of some aspects of his book A prescription for psychiatry (eg. see previous post with links from that post). Obviously I don’t know exactly what Peter’s going to say in his Salomon’s talk. He might start with a quote from Lewis Carrol in Alice in Wonderland (see tweet):-
“But I don’t want to go among mad people," Alice remarked.  
"Oh, you can’t help that," said the Cat: "we’re all mad here. I’m mad. You’re mad." 
"How do you know I’m mad?" said Alice. 
"You must be," said the Cat, "or you wouldn’t have come here.”

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

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

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

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

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

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

1 comment:

Eric Setz said...

Can’t wait to hear the results of the lecture. Loved your article but it did cause me to reflect on a couple of points.

While I totally agree with you that functional psychosis is not a brain disease I am taking issue with your use of the idiom "out of their mind" to describe those unfortunate to suffer from functional psychosis. People who are out of their ( troubled ) minds are in fact well. The degree that one is in their mind determines their degree of un-wellness and the functional psychotic is in a state of overwhelmed by their mind. The beauty of this model is that it explains why processes that focus on a rehab model or focus on making the person better result in recovery in about 70% of cases. While it is true that the whole is greater than the sum of the parts it is also true that making a part better results in the whole becoming better. Take the patient who likes music and teach them music, the one who likes art, teach them art, or the mathematical genius find a grad student to help him solve mathematical problems. No matter how, the better you make your patients the less ill they are. The medical model, where you focus on what is wrong with them and then try and fix that, while this has been extremely successful with physical illness and is important and in differentiating between organic and functional disorders, it has been a failure in treatment.
The problem in long stay asylums was not institutionalization but failure to use the correct treatment model.

Regarding belief systems and the biological model I feel the underlying problem is a failure to rigorously apply the scientific method. Make assumptions build models and test them. If addressing biochemical imbalances only results in symptom relief then obviously you are not treating the cause. Best practices that actually work are indicators of the underlying problem. If patients talk about past lives the correct approach is to check who else has experienced past lives and not to just dismiss it as delusional as it does not fit the model you are using or your belief system. You fit your model to the evidence you do not fit the evidence to your model.


Eric Setz.