Psychiatry must stop objectifying people

At its worst, psychiatry treats patients as needing their brains cured. People may be considered by psychiatry to have a brain abnormality when there is no confirmed evidence this is the case. Even though psychiatric research has not established a physical basis for functional mental illness, psychiatry tends to act as though it will be established, or at least that biological factors will be shown to be involved in some way.

Patients, of course, have thoughts and feelings. They are mediated by the brain, no doubt. But that doesn’t mean those thoughts and feelings can be reduced to the brain, which is a mere object not a person, albeit part of the person. The brain does not have meaning, whereas what is important with mental illness is to try and understand the reasons for which the person may be presenting. Objectifying patients is not understanding them, however difficult it may be to be sure of what has caused their problems. 

Psychiatry does need to stop objectifying people by implying their thoughts and feelings are caused by the brain. People are not mere machines and psychiatry’s tendency to treat them in this way can be part of the problem rather than the solution to mental illness.

Obtaining the truth about psychiatric medication

Andrew A. Nierenberg in an editorial in Psychiatric Annals defends psychiatry against the Make America Healthy Again (MAHA) action plan to curb psychiatric overprescribing (see previous post). What he particularly objects to is Robert F. Kennedy, Jnr, resurrecting Robert Whitaker’s book Anatomy of an epidemic “to vilify psychiatry” and for saying that his cousin’s withdrawal from an SSRI antidepressant was worse that his own withdrawals from heroin. 

I commented on reviews of Robert’s books in a previous post. I’m not convinced Nierenberg takes Whitaker’s arguments seriously enough even if there may be some overstatement in his views (see eg. another previous post). 

I think what Kennedy is pointing to with opiate withdrawal is that such physical experiences tend to be short-lived over a few days, whereas antidepressant withdrawal can be prolonged and even occur some time after stopping. Personally I’ve always argued that this is because antidepressants create a belief system that they have been correcting a biological abnormality, which is difficult to resolve on discontinuation (see eg. previous post).

As Nierenberg also points out, Kennedy has implicated SSRIs in mass shootings. I have always been sceptical that SSRIs can cause violence through a physiological mechanism, such as akathisia (see eg. previous post). Psychiatry itself at times has seemed to take on the projection of blame for not preventing mass shootings (see eg. another previous post). Why people run amok in American society does need to be taken seriously (see yet another previous post).

With such a polarised debate about psychiatric medication, it’s not easy for patients to negotiate the truth. I’ve complained multiple times in this blog about psychiatry marginalising critique by calling it anti-psychiatry as does Nierenberg (see eg. previous post). I agree with him that we do need to create a clearer position for patients.

Psychiatry must be clear that most mental illness is not due to brain abnormality

I reviewed Samei Huda’s book The medical model in mental health: An explanation and evaluation (2019) when it first came out (see review). Jo Moncrieff and I also responded to his Asylum article entitled ‘Critical psychiatry: Dead ends and avenues of opportunity’ (see both articles).

Samei has taken forward his commentary on critical psychiatry in a recent BJPsych Bulletin article ‘Critical psychiatry in the UK: Potentially useful but in need of regeneration’. As he recognises, critical psychiatry aims to improve practice. This acknowledgement may indicate that critical psychiatry has at least moved on from anti-psychiatry, which Martin Roth (1973) condemned as  “anti-medical, anti-therapeutic, anti-institutional and anti-scientific” (see eg. previous post).

Samei accuses critical psychiatry of not fully taking on board the evidence against some of its views. His critique is not dissimilar to Anthony Clare's critique of anti-psychiatry (see eg. previous post) or Awais Aftab's promotion of integrative and critical pluralism as a variant of critical psychiatry (see eg. another previous post). The claim being made by Clare, Aftab and Huda is that mainstream psychiatry is not really as damned as critical psychiatry makes out.

As I've often said, critique psychiatry seeks to move on from the reductionism and positivism of much of modern psychiatry. Similarly, I've often said psychiatry needs to move on from a system based on a ‘disease’ model of primary mental illness. Despite Samei, I do think mainstream psychiatry is as damned as critical psychiatry makes out. Quite simply, most mental illness is not due to brain abnormality. This is not what most people hear from psychiatry and has consequences for their understanding and treatment of their mental health problems (see eg. recent post).

Will the Nottingham inquiry help improve mental health services?

The Nottingham Inquiry has heard 57 days of evidence with the aim of obtaining a clear understanding of the events, acts and omissions that led to Valdo Calocane, who had a diagnosis of paranoid schizophrenia, killing three people and seriously injuring three others (see previous post). Closing submissions will be held in September. 

There are substantial rates of mental disorder in people convicted of homicide. But most perpetrators of homicide do not have severe mental illness or a history of contact with mental health services. There is therefore a danger in identifying the mentally ill in general as at risk of homicide. 

The campaigning by the families of the victims of the Nottingham attack to improve mental health services, as well as police services, is welcome. It is worth watching the beginning of the Channel 4 News podcast to understand their perspective. 

It does seem to me that services did not manage the initial presentation of Calocane well when he was a student at Nottingham University. He seems to have received a rather fragmented and dysfunctional input from mental health services leading to him eventually being discharged. This blog has highlighted this rather fragmented and dysfunctional nature of services for some time (see eg. previous post). The government has recently announced another call for evidence for a new mental health strategy to transform mental health care (see press release). 

The Nottingham Inquiry legal team has produced a review of mental health homicides from all publicly available independent reviews of mental health homicides since the conclusion of the Ritchie Report in 1994, together with information from an  a Inquiry questionnaire inviting friends and family to share their experience of mental health homicides. Data, therefore, depends on a case being subject to a publicly available report and/or being volunteered through the Inquiry questionnaire. 96% of cases were not subject to a Community Treatment Order (CTO) at the time of the homicide and 92% had never been subject to a CTO. 

I don't think the issue is really about CTOs. They were mistakenly seen as a way to reduce homicide and suicide by patients in mental health services. In many ways, mental health services are still facing the same issues about homicide by psychiatric patients as before CTOs were first introduced (see previous post). The focus needs to be on improving services for people. Making them more defensive may well make them worse.

Has critical psychiatry failed?

The Critical Psychiatry Network (CPN) was formed in 1999 (see eg. my editorial). The Royal College of Psychiatrists has rejected its application three times to be a special interest group of the college. CPN argues that the wish to find a physicalist basis for primary mental illness is damaging psychiatry (see eg. my article). That’s not always a message most psychiatrists want to hear. They tend to think neuroscience has made major advances which are helping the understanding of mental illness, even though most mental illnesses do not have a neurological cause. There is of course a reason why psychiatry is a separate speciality from neurology. Despite the best efforts of CPN, mainstream psychiatry unfortunately still tends to rely too much on unfounded speculations about the nature of mental illness. It needs to move on from the wish to create a physical disease model of mental illness.

I actually think that institutional psychiatry does not really want to change (see eg. previous post and another). It is more focused on obtaining more money for services than changing its way of thinking about how to do psychiatry (see another previous post). In this sense, critical psychiatry could be said to have failed, as in many respects psychiatry has only become even more biomedical over recent years. Just take child and adolescent psychiatry as an example, where when I first trained medication was hardly used (see eg. yet another previous post). 

Mainstream psychiatry likes to make out that CPN’s criticisms are not quite as damaging as it suggests because it is broader than just taking a biomedical perspective. It will often suggest that its approach is biopsychosocial rather than biomedical. But seeing biological, psychological and social as all more or less equally relevant in all cases and at all times is an ill-defined basis for practice. What matters more is trying to understand the reasons for mental health problems rather than blaming underlying brain processes (see eg. previous post). The message patients tend to hear from psychiatry is that a psychiatric diagnosis means there is something wrong with their brain. Psychiatry needs to change to be explicit that for the vast majority of psychiatric presentations that is simply not the case.

Primary mental illness should not be looked for in the brain

People often understand that something has gone wrong in their brain when they receive a psychiatric diagnosis. For example, people have been told that ADHD is a neurodevelopmental condition affecting the prefrontal cortex of the brain (see previous post). Neurodiversity in general is commonly seen as having a neurological basis (see another previous post). Similarly, schizophrenia has been said to originate from disruption of brain development, despite the need for caution about drawing any conclusions from the evidence about biological abnormalities in schizophrenia (see yet another previous post). We continue to believe that brain functions must be localised in the brain in some way.

Phrenology was the first doctrine to suggest that cortical functions could be localised in the brain (see previous post). Features of the skull, the bumps of which could be felt on the scalp, were said to be indicators of specific faculties of mind in the underlying brain. This was eventually recognised as nonsense. Nonetheless, people continue to believe that brain functions must be localised in the brain. 

But subjective experience cannot be naturalised as physical processes. It doesn’t make sense to do so. Mental states have a meaning which the brain as an object lacks (see previous post). As far as mental disorder is concerned, not all of it is due to brain disease (see another previous post). It is people that are conscious, not their brains (see yet another previous post). Mental illness shows through the brain, but not necessarily in it. Reduction of functional mental mental illness to brain disease is just not possible in principle. The brain isn’t alive; it is people that are. The mystery of the nature of the relationship of consciousness to physical events in the brain has not been solved and never will be. This is what psychiatry, and people in general, find difficult to accept.