Saturday, December 17, 2022

Relational psychiatry not merely an embarrassing hangover from 1970s

I have been re-reading my editorial in BJPsych Bulletin entitled ‘Critical psychiatry: An embarrassing hangover from the 1970s?’. I conclude that “Critical[/relational psychiatry] can be understood as a non-eclectic, biopsychosocial, neo-Meyerian approach to psychiatry based on Kant’s critical philosophy”. 

I just thought it may be worth explaining a bit more what I mean by this. I’m arguing that critical/relational psychiatry is not new. Although it’s often seen as a continuation of the anti-psychiatry of the 1960/70s, associated with R.D. Laing and Thomas Szasz, in fact it has a longer pedigree and was actually present in the origins of modern psychiatry in the Enlightenment. 

As described by Foucault in History of madness (see previous post), critical engagement of reason with itself in the Enlightenment brought psychiatry into existence as a distinct discipline. Early psychiatrists identified mental alienation and delusional thinking. The asylums became a specific form of institutional care, built to accommodate people needing treatment for mental illness, rather than such people being, for example, kept in the workhouse. The mentally ill were seen as deserving of poor relief on the basis of their mental state. The twentieth century saw the development of community care making the asylum increasingly irrelevant. Even in modern welfare, though, the mentally ill receive sickness and disability benefits, rather than unemployment benefit.

Anthropological understanding in the Enlightenment, viewing human beings as psychophysical entities, created the idea of the possibility of a natural scientific approach to psychology. However, Immanual Kant developed an alternative pragmatic approach to anthropology. He was clear that life could not be explained in mechanical terms and that psychology is descriptive and cannot be reduced to biology (see eg. previous post). This perspective was eclipsed by positivism later in the 19th century with the progress in understanding of physical illness in biological terms. The expectation was that mental illness would also be understood as a dysfunctional biological process (see previous post). However, it would have been better if psychiatry had stuck with Ernst von Feuchtersleben’s understanding of psychiatry (see eg. previous post) based on Kant’s critical philosophy. To reduce mental illness to brain disease is not possible in principle (see yet another previous post). 

Since then, there have been attempts to recreate an anti-reductionist perspective in psychiatry. For example, although he was not as explicit as he should have been, Adolf Meyer developed a psychobiological approach to psychiatry as an alternative to positivistic psychiatry (see eg. previous post). He was clear that psychopathology needs to be studied functionally in experiences and social interactions rather than at the level of neurobiology. This is not to deny the importance of organic conditions, such as delirium and dementia. Meyer's system never really took hold as a systematic theory, at least partly because he was prepared to compromise with biomedical perspectives, even if he disagreed with them. His views were also eclipsed by a reassertion of biomedical ideas over recent years in so-called neo-Kraepelinianism, developed as a response to anti-psychiatry (see eg. another previous post). 

Another example would be George Engel’s paper in Science in which he suggested there was a need for a new medical model, which he called the biopsychosocial model (see previous post), to replace the biomedical model. The trouble is that ‘biopsychosocial’ over recent years has become an ill-defined basis for psychiatric practice meaning that biological, psychological and social are all more or less equally relevant in all cases and at all times in psychiatric assessment. This eclecticism has been critiqued by Nassir Ghaemi and does seem to have outlived its usefulness (see eg. previous post). 

So, in summary, critical/relational psychiatry is a truly biopsychosocial model. It is not eclectic. It adopts the psychobiological model of Adolf Meyer but not his tendency to compromise with biomedical perspectives. It seeks a return to the Kantian origins of psychiatry, as, for example, expressed by Ernst von Feuchtersleben, to provide a more integrated critical perspective on modern psychiatry (see previous post). 

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