What chance post-psychiatry?

ã Phil Barker and Poppy Buchanan-Barker 2005

Recently, on BBC radio, the country’s most famous psychiatrist described schizophrenia as a ‘mental health difficulty’. This showed how far we have come with the linguistic revolution in mental health. Schizophrenia – long established as the scariest, most complex and disturbing form of human experience – now sits comfortably alongside ‘public speaking anxiety’ or ‘low self-esteem’. Could you imagine a prominent physician describing ‘leukaemia’ or ‘breast cancer’ as a ‘physical health difficulty’?

Political correctness has drained most of the meaning from what we once called ‘mental illness’. Almost no one could lay claim to full mental health, so we all must have some kind of ‘mental health difficulty’. It is not surprising that activists and consumer groups have reclaimed expressions like ‘crazy’ and ‘madness’ as a defiant act of subversion

Physicians – and other health care workers – wouldn’t dream of talking about ‘physical illness’ - far less physical health difficulties’. They deal with specific diseases or disorders, which they examine clinically, and measure reliably. Some show manifest lesions of the body – like the various cancers; others indicate a dangerous disturbance of bodily functioning – like high blood pressure. All are, however, identifiable and measurable, making physical medicine a genuine scientific enterprise.

By comparison, psychiatric ‘medicine’ is almost a contradiction in terms. The psychologist, Richard Bentall, pointed out that psychiatric diagnoses are no better predictors of what will happen in a person’s future, than horoscopes. When we become seriously ill, we expect blood tests, urinalysis, X-rays, biopsies, MRI scans and so on. These will, hopefully, identify what is wrong with us. The person with a ‘serious mental illness’ will have a conversation with a psychiatrist, who then makes a judgement based on what has been seen and heard. The parallels with astrology become even more apparent.

Collapsing the huge catalogue of human misery into the rag-bag classification of ‘mental illness’, makes no logical sense, but it makes perfect historical sense. Psychiatry may not have invented ‘mental illness’ but by attributing our various personal and interpersonal problems to some ‘disturbance of the mind’, the myth of ‘mental illness’ was born.

Some psychiatrists are trying to redeem themselves by reviving old ideas like the ‘biopsychosocial’ model. They hope this will counter the reductionism of the ‘medical model’, without altogether abandoning scientific psychiatry. The best-known advocates of a new psychiatric paradigm are Bracken and Thomas. Their idea of ‘post-psychiatry’ is, however, not as attractive as it first sounds. They wonder what psychiatry would be like if it could accommodate certain contemporary philosophical ideas - regarding the self, lived experience, community, race, power etc?

Their work has gone some considerable way to answering such questions. However, by trying to revise psychiatry, they avoid challenging the powerful forces that sustain psychiatric medicine. In particular, they avoid asking what would a world without psychiatry be like? Lets talk ‘post-psychiatry’ proper.

Imagining a world without the wise counsel and intimate comfort of a humane, insightful, scientific, ‘healer of the mind’, is difficult only for those with a psychiatric dependency. For everyone else, this is romantic fiction, spawned by Hollywood – and especially the films of Alfred Hitchcock. Instead, many ask: "what, exactly, do psychiatrists offer us today?"

• Psychological help? No! If we need or want psychotherapy or counselling we see a psychologist or some other ‘therapist’.
• Practical help? No! If we need to sort out our everyday problems, we see a social worker, or some other ‘mental health worker’
• Human support? No! If we need someone to comfort us, during a crisis– we look to nurses, support workers, members of a mutual support group, if not our family and friends.

Currently, the delivery of a psychiatric diagnosis and the prescription of psychiatric drugs is what we expect from a psychiatrist, but for how much longer? Nurses in the UK are being prepared to become ‘prescribers’, following the lead of their American cousins, where nurses have been prescribing for over a decade. Given that US nurses have also been prepared to deliver psychiatric diagnoses, this seems likely to happen here too. After all, one can hardly prescribe drugs without knowing what is wrong with someone – and that requires the delivery of a diagnosis.

All of which raises the big question: what, exactly, do people need psychiatrists for? If not for psychotherapy or counselling, or practical help, or ordinary human comfort, or medication or the delivery of diagnosis – or at least, not for long – then what?

Psychiatrists like Bracken and Thomas recognise that few of the core concepts of psychiatry make any scientific sense, and even have asked for ideas like ‘schizophrenia’ to be scrapped. As psychiatrists themselves, they stop short of suggesting that psychiatry itself might be scrapped, and who can blame them. However, what would a ‘post-psychiatric’ society be like?

Two hundred years ago – when modern psychiatry began – the abolition of slavery had not yet started. Who would have though then, that ‘post-slavery’ was possible? In the early 1900s, as Freud began to shape many of our current ideas about the mind and brain, women had yet to gain the vote. Who would have thought that a ‘post-women’s suffrage’ world would now be so easily taken for granted. In 1960, when Thomas Szasz first laid down his challenge to the orthodox logic of psychiatry, the American civil rights movement was just beginning. Who would have thought, then, that we would talk ‘post-civil rights’ so easily? In 1990 as Ronald Reagan announced funding for the infamous ‘decade of the brain’, the Soviet Union began to implode. Who would have thought that 15 years on, we would talk so casually about ‘post communist societies’? These historical timelines remind us that all institutions and ideas have a limited lifespan. Nothing endures – and that includes psychiatry.

These events also remind us that the key issues in contemporary mental health are about personhood (slavery) equality (suffrage) humanity (rights) and power (scientism or communism – take your pick).

There is no doubt that some people experience very serious problems of living. However, even if ‘mental health difficulties’ are shown to have associated biological, genetic or biochemical factors – a very big ‘if’ - would this mean that psychiatry should still be the core of the help such people need?

Twenty years ago many people with so-called ‘learning disabilities’ were still in the ‘care’ of psychiatrists. There is plenty of evidence that the cognitive, emotional, intellectual and other ‘mental’ difficulties of such people arise from brain injury or organic defect, chromosomal abnormality or other genetic influence. However, despite the obvious ‘medical’ nature of many of their problems, people with learning difficulties have almost completely escaped the dead hand of psychiatry. Such people may experience complex problems of living, with themselves and others. They may need a variety of forms of human helping –from special education to special housing. What they do not need – despite many of them having obvious brain pathology - is a psychiatrist. Indeed, the success of contemporary learning disability services has involved reclaiming the personhood of the people with the so-called learning disabilities and ditching psychiatric paternalism in the process.

Dyslexia, which affects about 10% of the population, regardless of intelligence, race or social class, may offer a more striking example. The problems associated with dyslexia focus mainly on difficulties with reading, writing and spelling, but other ‘mental problems’ such as short-term memory, concentration and personal organisation can also be affected. It is well accepted that dyslexia is biological in origin and runs in families, suggesting some genetic influence. However, no one would dream of calling dyslexia a mental illness. Like ‘learning disability’ dyslexia can be, and often is, a complex problem of human living

People with experience of dyslexia need understanding, support and practical help in learning to live with or overcome their problem. They do not need to see a psychiatrist. Although having serious problems in reading, understanding and concentrating could potentially be lethal – the person with dyslexia is not a candidate for detention under the mental health act and forcible psychiatric ‘treatment’.

However, having invented itself two centuries ago, psychiatry is not simply going to walk away from the action. Despite unremitting criticism over the past 30 years, psychiatry still reigns supreme. There is no doubt that some psychiatrists are sophisticated communicators, warm and compassionate individuals, with an encyclopaedic knowledge of both the physical and social sciences. However, one might ask, is it necessary to spend a decade training as a doctor to acquire such qualities? More importantly, do people with ‘mental health difficulties’ – like schizophrenia – need such a brilliant mind, to be supervising their everyday ‘care and treatment’. Clearly people with learning disabilities or dyslexia don’t. So, what – apart from history – is different about ‘mental health’?