Tuesday, February 23, 2021

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.

Saturday, February 20, 2021

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).

Monday, January 18, 2021

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. 

Wednesday, January 13, 2021

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).

Friday, January 01, 2021

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.