Demarcating 'abnormality' from 'normality'

I've said before (eg. see previous post) that insisting on avoiding pathologising in mental health services can be misleading. I understand why people may want to do this because, for example, they think that pathologising mental problems implies brain disorder, when this is not the case.

Sanneke de Haan in her book Enactive psychiatry (see previous post) discusses what she calls 'sense-making' (see another previous post). Organisms need to make sense of their environment to survive. We need to understand the organism-environment as a system not an isolated individual, let alone its brain. 

How do we distinguish pathological from normal sense-making? Of course there are differences between people. It is normal to struggle with life at times. The appropriateness of sense-making depends on context and sense-making needs to be attuned to the real world. Norms can vary over time and shared sense-making or the common sense of people in cultural context is what matters. People can still be eccentric but the stance one takes on oneself and one's situation can mean that one fails to recognise the inappropriateness and inflexibility of one's ways of interacting. One's stance can become unbalanced. Problematic sense-making can cause suffering, although not necessarily so. Patterns of sense-making may be identified which are abnormal.

As I've also pointed out, the concept of illness goes back further than our modern understanding since the middle of the nineteenth century of illness as physical lesion (see eg. previous post). We use the same criteria to decide whether an illness is mental or physical and, even though the concept of illness as physical lesion is relatively recent, we tend to think that we are extending the principles of physical illness to the concept of mental illness. 

In fact, the concept of psychological illness had been opened up before the application of the anatomoclinical method in medicine (see previous post). The recognition of psychosomatic illness focused on the doctor-patient relationship creating a new space for mental pathology (see previous post). We may now have more modern understandings of psychosomatic medicine (eg. see previous post), but, as I've pointed out before (eg. see previous post), those that want to move away from the concept of mental pathology, do not seem to deal with the issue of psychosomatic pathology very well. 

Of course madness has always been recognised. Still, medical psychology created a descriptive psychopathology (see eg. previous post) and how we make sense of delusional thinking is still an important issue (see previous post). Normalising mental pathology can fail to do justice to the sense in which something may have gone wrong in mental functioning.

Psychiatry in need of a paradigm

In his letter to the editor of Acta Psychiatrica Scandinavica, Gordon Parker argues for "multiple niched paradigms" in psychiatry. Parker's letter was written in response to a letter from Tilman Steinert arguing that psychiatry needs a new paradigm. Parker contends that psychiatry doesn't need a single over-arching paradigm, but instead should "determine which paradigm (of many current and candidate ones) best explains why this individual is suffering this condition at this particular risk period".

I agree with Parker than psychiatric assessment should be individualised, but I'm not sure this is to do with paradigms as such. Like Steinert, I too was trained in a hierarchical approach to psychiatric assessment and diagnosis, with organic factors trumping psychotic, then neurotic then personality factors. Karl Jaspers understood the history of modern psychiatry as a conflict between two factions of somatic and psychic approaches rather than a simple chronological development. Georges Lanteri-Laura divided modern psychiatry into three sequential paradigms (see previous post), although I tend to prefer the implication of what Jaspers was saying, that there's always been a conflict in the origins of medical psychology in its attempt to move on from Cartesianism (see my editorial).

I also agree with Steinhart that psychiatry has got quite muddled in how it understands mental disorder. As he says, there's a need for "an effort of rethinking, sorting, and grouping of available findings". That's partly been the motivation of this blog! For example, Pat Bracken has argued for the need to move from reductionism to hermeneutics in psychiatry (see previous post). A BJPsych 2012 special article talked about the need to move beyond the current paradigm in psychiatry (see another previous post). More recently, as another example, I've pointed out the value of enactive psychiatry (see eg. previous post).

George Engel proposed his biopsychosocial model as a middle way between biomedical reductionism and Thomas Szasz's 'myth of mental illness' position, which Engel called exclusionist. Since Engel's time, psychiatry has become quite muddled about what 'biopsychosocial' means (see eg. previous post). We do need to be clearer about the aetiology of mental disorder (eg. see previous post). I also think the mistaken abolition of the distinction between organic and functional mental disorders by DSM-IV has clouded perspectives (see eg. another previous post).

It seems to me that Gordon Parker has not really taken these issues seriously. I suspect this is because he wants to perpetuate the current eclecticism of psychiatry to avoid dealing with fundamental ideological issues. Psychiatry found it difficult coping with the onslaught from so-called "anti-psychiatry" and, to my mind, has still not really recovered a balanced perspective (eg. see my editorial).

Relational psychiatry

I wrote in my book chapter:-

Critical psychiatry is the name for an approach that encourages a self-critical attitude to psychiatric practice. An adverse consequence of the term 'critical' is that it tends to have a negative connotation. In this sense, 'critical' means 'inclined to find fault, or to judge with severity'. However, 'critical' also has other meanings, such as 'being characterised by careful, exact evaluation and judgement'. Also, it may have something to do with a crucial turning point, in this sense meaning 'of the greatest importance to the way things might happen'. These latter senses are included in the way I am using the word 'critical' in relation to psychiatry.

There is a problem about how oppositional to be about the current state of modern psychiatry (see eg. previous post). Critical psychiatry has never hidden the fact that it grew out of what mainstream psychiatry has called “anti-psychiatry” (see eg. another previous post).

I have also always emphasised the extent to which critical psychiatry actually is mainstream psychiatry (see eg. previous post). Even though critical psychiatry is a minority position within psychiatry, the dominance of biomedical psychiatry perverts what psychiatry should be. Although psychiatry says it adopts the biopsychosocial model of mental illness, unfortunately it still has a tendency to positivism and reductionism (see eg. my editorial).

I have always wondered if there should be a more positive name for critical psychiatry. I’d be interested in how people react to the notion of ‘relational psychiatry’, instead of critical psychiatry. Understanding how people relate to themselves, to others and to their situations is crucial for making sense of and managing mental health problems (see previous post). An advantage of the term ‘relational psychiatry’ may be that it is more easily understandable than enactive psychiatry, which has had recent uptake (see another previous post). It also links with traditional interests in psychiatry in therapeutic communities (see eg. previous post).

Another advantage of relational psychiatry is that it may make explicit the social dimension of person-centred care in psychiatry (see previous post). Despite all the hype about neuroscientific progress in psychiatry, patients still feel stigmatised and there is ongoing conflict about psychiatric practice. People may be able to converge round relational psychiatry to provide both a conceptual and practical way forward.