Tuesday, March 29, 2022

Including people with personal difficulties in mental health services

The Royal College of Psychiatrists has cancelled a Personality Disorders course (see statement), following concern on Twitter about a flyer for the event (eg. see tweet). I wasn’t totally happy either about the College’s January 2020 position statement on personality disorder (see previous post). 

There is of course some truth in the statement in the flyer that personality disorder is a “thorn in the flesh of many clinicians”. It may not be seen as a proper mental disorder because it’s not mental illness. Some psychiatrists may prefer dealing with what they see as the substance of real mental illness. It’s also commonly a label for people seen as difficult. The minority that seek treatment, according to the flyer, do so “often in a dysfunctional manner” by causing problems. The course was supposed to equip psychiatrists to deal with these kind of people with which they can’t win either way whether they get involved or not.

I guess we all have personality difficulties, some more than others. Psychopathic disorder meaning a “persistent disorder or disability of mind which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned” was removed from specific mention in the Mental Health Act 1983 as a kind of personality disorder by the 2007 amendments, although the definition of mental disorder became very broad. I have expressed concern that the proposed removal of learning disability from the Mental Health Act will in a way potentially encourage the reintroduction of the notion of psychopathic disorder (see eg. previous post). More generally, psychiatry does need to become more inclusive in its services for people with personal difficulties, whatever pattern of problems may be present because their personality.

Tuesday, March 01, 2022

Social critique of psychiatry

Joanna Moncrieff, who I’ve mentioned before several times (see eg. previous post), analyses the mental health system from a Marxist perspective in a recent article. Marxist theory has been used in critical mental health writings (see eg. my review of book edited by Bruce Cohen). Psychiatry has been seen as a mechanism of social control of behaviour regarded as threatening the stability of the capitalist system. Framing social problems as individual pathology can divert attention away from the political and socioeconomic origins of mental health problems. Interestingly, Jo takes a kind of 'labelling theory' view of mental illness as  “simply the collection of challenging situations that remain when [for example] those that are amenable to the criminal justice system … are taken out of the picture” (see my review of Thomas Scheff’s classic book).

Jo wants to question the notion that mental illness is located in the individual. However, as I pointed out in a previous post, Aubrey Lewis noted that maladaptive behaviour is only pathological if it is accompanied by a disturbance of psychological functioning. Social criteria play no part in the diagnosis of mental illness as such. In a way, that fits with Jo's perspective as she doesn’t really accept the term ‘mental illness’, although she persists with it as “there are no widely accepted alternative ways to describe the problems in question”. 

The social function of psychiatry cannot really be denied as psychiatry manages madness on behalf of society. As Jo notes, “One of the functions of mental health services is to provide support and care for people when they are unable to look after themselves”. I would say this is a reasonable function of the state to support those with mental incapacity and includes intervening to prevent harm to others as well as the person themselves. Modern psychiatry did not really come into existence in the way we understand it now until the local authority asylums were built. The early alienists identified insane individuals who were deserving of poor relief on the basis of their mental state. As I said in the section on Foucault in a previous post, the birth of the asylum needs to be seen as a later phase of what Foucault called the ‘great confinement’, when the mad were extracted from places of confinement and placed into asylums specifically designed for their treatment. Similarly in modern welfare, the mentally ill receive sickness and disability benefits distinguished from unemployment benefits.

Jo says a Marxist analysis “suggests that the [psychiatric] institutions were closed because of the desire to reduce public spending”. I’m sure there was this element in the intention to replace the asylums by community care, although properly implemented community care may well in fact cost proportionately more. But the prime motivation was what David Clark called the 'dismay and disgust with the asylum system'. Attempts were made to make hospitals more therapeutic by opening the locked doors (see eg. my webpage). Essentially, the asylum became irrelevant to the bulk of mental health problems. I do agree with Jo that it is a national scandal the way mentally ill and learning disabled people who are difficult to manage or place have been shipped out of the NHS, but it isn’t just the privatisation of services that’s the problem but also their level of security and risk aversive nature (see eg. my eletter).

I also agree with Jo about the problems of increasing social inequality and poor social mobility over recent years, even if I don’t frame this within a Marxist critique of neo-liberal capitalism as she does. There have also been problems with a target culture created by the Risk Society, which has contributed to a reinstitutionalisation of mental health services over recent years (see eg. previous post). I'm certainly not against the mental health system becoming more transparent and democratic as Jo wants. It should be about encouraging the independence of people as much as they want and are able to be.