Wednesday, September 22, 2021

Steps towards improving mental health advocacy

VoiceAbility and over 50 other signatories have written to the Secretary of Health and Social Care (see webpage) calling on the government to make an unequivocal commitment to improving advocacy as part of the reform of the Mental Health Act (MHA) (see eg. previous post). I think an opt out approach to advocacy is essential in any new legislation. Extension to informal patients is also important, although priority will need to be given to detained patients. I have supported VoiceAbility’s call as a step to what is needed in the new Bill.

I would also emphasise what the letter says about ensuring high quality advocacy services. I think the best way to do this is for Independent Mental Health Advocates (IMHAs) to work much more closely with mental health lawyers and independent professional experts, ideally, I would say, in an integrated nationally provided advocacy service. As the letter says, such an improvement in advocacy would need to be properly funded. I came across the agreed common themes from the Mental Health Act Reform Group (which became the Mental Health Alliance) formed in the context of the last time the MHA was reviewed leading to the 2007 amendments. This was before advocacy had been introduced by those amendments. As far as I know, there has not been an official review of the effects of the introduction of those changes. I suspect any such review would confirm that there is a very variable advocacy service nationally. I think this is partly because of current piecemeal commissioning arrangements, which may be better replaced by a nationally provided service.

I think the government still needs to provide adequate resources nationally for advocacy, as originally suggested by the Mental Health Act Reform Group. The interests of detained patients need to be better represented, if necessary before the Mental Health Tribunal, on matters both of detention and treatment (see eg. previous post). I think there are savings that can be made by abolishing Second Opinion Approved Doctors (SOADs) and reorganisation of the Tribunal (see another previous post) that could be invested in advocacy.

Sunday, September 19, 2021

Accepting uncertainty in psychiatry

Psychiatry has difficulty dealing with the limits to its knowledge about mental illness (see eg. previous post). Owen Whooley in his book On the heels of ignorance: Psychiatry and the politics of not knowing highlights how psychiatry has dealt with its ignorance by holding out the expectation that it will eventually find the answers to mental illness. Of course these are never fulfilled. People do need understanding and treatment for their mental health problems and these aims may explain, but do not justify, exaggerated misrepresentations about what psychiatry does know (see eg. another previous post). 

Psychiatry needs to accept the inevitable uncertainty of its practice. Actually, psychiatry’s expertise should come from recognising this is the case. It may worry that it will lose its authority if it shares this truth with people, but the profession’s continued existence should not depend on psychiatrists having to, as Whooley says, “affirm the ‘knowability’ of mental illness”. “We are all complicit” in accepting psychiatry’s “inflated hype”. 

Friday, September 17, 2021

Is my brain health mine?

Current editorial in The Lancet talks about promoting good brain health. Ironically, it uses the concept of ‘brain health' to encourage a focus on social determinants of mental ill health. It suggests this might be a way of moving on from a reductionist view of mental illness. 

I suppose such an editorial reflects how seriously we need to take the neuro-turn in modern culture (see previous post). We now tend to view ourselves in terms of our brain. But, to quote from Thomas Fuchs (see previous post), "I'm rather glad not to be my brain, but only to have it". 

Disease has been understood as physical pathology since the mid-nineteenth century (see eg. previous post). Doctors also need to be person-centred (see eg. another previous post). The trouble is that primary mental illness does not have a physical representation as such in the brain, although of course the brain mediates our thoughts, emotions and behaviour, including mental illness. My brain can be diseased, causing for example delirium and dementia, but primary mental illness is functional not structural (see eg. previous post).

Does the health of my brain have to do with me and not just my brain? Is it not my health that’s at issue rather than my brain’s?

Thursday, September 16, 2021

The implications of enactivism for psychiatry

I don’t think I fully appreciate all the nuances in the recent debate in Philosophy, Psychiatry and Psychology (PPP) about the implications of enactivism for psychiatry. I’ve mentioned before (eg. see previous post), the book by Sanneke de Haan entitled Enactive Psychiatry. It was published before Kristopher Nielsen had completed his PhD thesis, in which he had independently developed his own ideas about the psychiatric implications of enactivism. There are differences in their views and they disagree about the significance of these differences. In the PPP journal, Nielsen (2021a) compares the two perspectives, followed by comments by de Haan (2021) and Richard Gipps (2021) (see his previous guest blog post), and a rejoinder from Nielson (2021b). 

As I said in a recent previous post, I think enactivism can be a way of revitalising Engel's biopsychosocial model. Mental processes need to be understood in a dynamic, integrated and enactive way, as they are 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 organism (see eg. my article). Mental illness cannot be isolated in material processes in the brain, excluded from people's relationship with their environment. 

In some ways, such an anti-reductionist position is not new (eg. see another article of mine). I do think, though, that enactivism can be seen as a more thoroughgoing basis for anti-reductionism. Like Sanneke, I worry that Kristopher's position is not explicitly anti-reductionist enough. There is evidence for this in his interview with Awais Aftab. Kristopher still wants to understand mental disorders in an "entitative and more mechanistic way". He may well make too much of the biological functionality of human values, although I think there is merit in seeing mental illness as failed adaptations, as did Adolf Meyer (see eg. previous post). I summarised, in another previous post, how Sanneke demarcates 'abnormality' from 'normality'. I'm also not sure what Kristopher means by somatic and mental disorders being "probably continuous with each other". As I've highlighted before (eg. see previous post), the organic/functional distinction of mental disorders, which was abolished by DSM-IV, needs to be reinstated. 

I also have questions about the implications of Sanneke's views. For example, how do they relate to American pragmatism (eg. see previous post)? For all her emphasis on the existential dimension in mental disorders, how does her perspective relate to existentialism as a philosophy (see eg. another previous post)? 

As I've also been emphasising in this blog, there are links with other phenomenological perspectives, such as that of Thomas Fuchs (see eg. previous post); cultural perspectives, such as that of Laurence Kirmayer (see eg. another previous post); and other critical perspectives in psychiatry, not least Foucault (see eg. last post). I have been trying to bring them together under an umbrella term of relational psychiatry. 

This is not some grandiose project, but an attempt to encourage psychiatry to move on from its misguided belief that primary mental illness will be found to be a physical disease. Relational psychiatry also has practical implications, and is not merely an out of touch academic dispute about the implications of enactivism for psychiatry. There is some urgency about the need to improve the treatment of people with mental health problems. A recent focus of this blog, for example, has been on the current reform of the Mental Health Act (see eg. previous post), as the rights of people with mental illness can be abused.

Thursday, September 09, 2021

Foucault understood relational psychiatry

John Iliopoulos (see his guest blog post) has an article in BJPsych Advances on 'Foucault understood critical psychiatry'. As I’ve said before (see eg. previous post), John corrects the common misunderstanding that Foucault was against the Enlightenment (also, see further previous post). As he says, “The Enlightenment may have been marked by the triumph of rationalism, but it was also an age of critique”. Reason may decide the truth of shared meaningful knowledge, but its limits were recognised in Kant’s pragmatic anthropology (see previous post).

Modern psychiatry had its origins in the Enlightenment in two major phases. From the late 18th century, anthropological understanding, in the sense of understanding human beings as psychophysical entities, saw madness as a “private truth outside the common horizon of reason”. Psychiatry’s role was to detect such delusional thinking. However, by mid-19th century, positivism saw mental illness as a dysfunctional natural mechanistic process. Foucault’s analysis critiques the marginalisation of the anthropological attitude by positivism in psychiatry.

As John says, abnormality in general became the object of psychiatric knowledge, not merely delusion. I’m not sure if I agree with what John seems to imply that the potential this perspective creates to explode “the diagnostic field uncontrollably” merely relates to a positivistic attitude to mental illness. My previous post highlighted how Foucault in the History of madness recognised that mental illness already incorporated neurosis by the end of the 18th century. But in the 19th century, the development of pathological abnormality undermined the concept of functional disorder (see another previous post). In fact, positivism encouraged speculation about the biological basis of neurosis, such as Beard’s neurasthenia (see previous post). 

I would also emphasise the importance of anatomoclinical understanding in Foucault’s account more than John seems to do (see eg. previous post). After all, Foucault moved on to the Birth of the clinic after the History of madness. He must have done this because he wanted to understand how the development of the idea of illness as physical pathology was implicated in psychiatry.

As John says, Foucault is actually “sceptical of the anti-psychiatric quest for non-oppressive modes of psychiatric power and the humanist and postmodern efforts to moralise or relativise psychiatric truth”. Instead, his critique highlights the value of the anthropological outlook of alienists in the origins of modern psychiatry. Fundamentally, he did not think mental illness should be reduced to brain disease (see yet another previous post).