Breaking psychiatry’s chains
There is a need for new ways to make sense of madness.
Pure Madness: how fear drives the mental health system, Jeremy Laurance, Routledge, 2003.
The Creation of Psychopharmacology, David Healy, Harvard, 2002.
My first encounter with what I later came to know as the policy of ‘care in the community’ took place in the early 1960s when my uncle emerged from nearly 30 years in the asylum and came to stay with us.
Uncle John was a gentle soul and became a much-loved member of the family, but he had episodes of acute psychosis and would sometimes disappear for months on end, only to return in a severely dishevelled state. I remember my mother grinding up tablets of Largactil (the major tranquilliser chlorpromazine) to put in his tea in the hope of dampening his florid auditory hallucinations. I cannot recall my uncle having any contact with mental health services (beyond occasional returns to the asylum); my parents certainly received no help in looking after him.
In his book A history of psychiatry, Edward Shorter sums up the history of the asylums of the nineteenth century as ‘the story of good intentions gone bad’, as ‘progressive and humane aspirations’ were ‘relentlessly and repeatedly disappointed’ (1).
This judgement applies a fortiori to the community care policies of recent decades as successive governments have failed to provide adequate resources for alternatives to institutional care. When then health minister Frank Dobson proclaimed in parliament in 1998 that ‘care in the community has failed’, I thought this a mean-spirited jibe against all those involved in the drive to release the mentally ill from the warehouses in which they had been confined.
Anybody who ever visited the back wards of the old asylums knows that, whatever the inadequacies of care in the community, it marked an advance in the treatment of people with serious mental illness. The glib global condemnation of community care fails to recognise the dramatic improvements in mental health services in recent years, and the range of imaginative initiatives that now exist.
In Pure Madness, Independent health editor Jeremy Laurance criticises the coercive drift of government policy towards the mentally ill (2). He particularly focuses on the provisions in the new Mental Health Bill for compulsory treatment orders that can be enforced in the community as well as in hospital, and for compulsory admission of people with severe personality disorder deemed to be a danger to society.
Although Laurance does not refer to David Healy’s critical histories of the reliance of modern psychiatry on drugs, Healy’s work lends considerable support to the call for a shift away from using medication to control behaviour towards a more user-friendly policy (3).
Both Laurance and Healy challenge the ascendancy of biological psychiatry from a perspective that emphasises the importance of wider social and cultural influences in both the causation and the treatment of mental illness. It is worth looking closely at this historic conflict.
Biological or social?
The dominant tradition in psychiatry espouses an individualistic and reductionist outlook, seeking to explain mental illness in terms of neuroanatomy or neurophysiology, genetics or, more recently, cognitive neuroscience. This approach is associated with ‘physical treatments’ (such as insulin therapy, psychosurgery and ECT) and with drugs (such as anti-psychotics, anti-depressants, anxiolytics). Emerging out of the asylums, and now based in general hospitals, it has not balked at imposing physical – and later, chemical – containment on people manifesting disturbed behaviour.
The rival tradition emphasises the social and cultural factors that seem to create a greater risk of severe mental illnesses such as schizophrenia in poor or marginalised communities (notably among ethnic minorities in Britain). It recognises the role of family and other relationships in influencing trends towards recovery or relapse. From the ‘social’ and ‘milieu’ therapies of inter-war America, to the post-war therapeutic communities, to today’s community care initiatives, it seeks to achieve recovery through providing a supportive environment. Social psychiatry prefers psychotherapeutic ‘talking’ methods to the use of drugs or physical containment.
Healy singles out two key moments marking the ascendancy of the biological model. The first was the 1962 amendment to the US food and drugs legislation in response to the thalidomide scandal in Europe. The second was the publication in 1980 of the third revision of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSMIII).
The strange fruit of thalidomide
As a result of the 1962 amendment, drug companies were obliged to satisfy the regulatory authorities that their products were both safe and effective. Healy comments on the irony that this measure, introduced to ‘guard people from unfettered capitalism’, in practice had the opposite effect. It meant that drug companies were encouraged to produce drugs to treat specific diseases in which trials had confirmed that the benefits exceeded the risks.
The model was the ‘magic bullet’ concept of antibiotics targeted on the specific bacteria responsible for specific diseases. But this model was quite inappropriate to psychiatry, where diagnostic categories were poorly defined and drugs were used to curb particular symptoms rather than treat underlying mechanisms (which were ill understood).
If drugs could only be marketed for the treatment of specific diseases, then it was first necessary to create specific diseases. Thus, for example, Healy attributes the inflation and popularisation of the diagnosis of depression to the need to market anti-depressants as medications suitable for this condition. ‘The dynamic towards specificity’ he observes, ‘is, in health care at least, the best way yet invented to make money’.
The 1962 amendment also institutionalised randomised controlled trials (RCTs) in psychiatry. Yet, as Healy notes, these ‘evolved into something more than a means of working out the optimal package of care’. The ‘convenient ability to demonstrate a treatment effect in small samples increasingly seduced companies, clinicians and policymakers and ultimately changed the face of psychiatry’.
The methodological difficulties facing these trials are enormous: they use heterogeneous and unrepresentative populations, the diagnostic categories lack precision, they rely on quantitative scales of dubious reliability, the effectiveness of treatment is influenced by the quality of the therapeutic relationship within which it is delivered. Drugs marketed as ‘anti-depressants’ or ‘anti-psychotics’ are not specific, says Healy, ‘in the sense that they work regardless of the non-specific milieu in which they are delivered’.
The central problem of psychiatry, Healy concludes, is that ‘the majority of people who meet the criteria for a diagnosis of a particular psychiatric disorder cannot be shown to benefit specifically from the available treatments’.
Indeed, while a substantial minority do not seem to benefit from medication at all, others suffer a range of more or less debilitating side-effects.
The Trojan Horse
In the 1950s and 60s the dominant influence of Freudian psychoanalysts in American psychiatry was codified in DSMI (1952) and DSMII (1968). In the 1960s and 70s this orthodoxy came under attack from both the social and the biological wings of psychiatry. Socially oriented psychiatrists endorsed a radical critique of institutional care and pharmaceutical containment: some even rejected the framework of psychiatric diagnosis as inherently authoritarian and adopted the label of ‘anti-psychiatry’.
From the biological camp, a group dubbed the ‘neo-Kraeplinians’ (after the German psychiatrist Emil Kraeplin who first defined schizophrenia as ‘dementia praecox’ in the 1890s) sought to bring psychiatric disorders within a medical framework. For Healy, ‘the creation of DSMIII was the Trojan horse by which they [the neo-Kraeplinians] effected entry to the citadel of psychoanalysis’.
The 1980 classification in DSMIII defined a range of familiar conditions, such as schizophrenia, depression and anxiety, as discrete disease entities. Furthermore, it created a range of new disorders – panic disorder, social phobia, obsessive compulsive disorder – which provided the drug companies with targets at which to aim their products.
This scheme marked the ascendancy of a biomedical perspective over the social and psychoanalytical traditions. Yet the conflict between ‘romantic anti-psychiatry’ and ‘pragmatic medical psychiatry’, did not lead to the triumph of either, but rather led, according to Healy, to the takeover of both by a psycho-pharmaceutical complex. Though this was based firmly on the biological model, it extended its reach far into society.
The two main categories of drugs that reflected the ascendancy of the psycho-pharmaceutical complex in the 1980s and 90s were the atypical anti-psychotics (risperidone, olanzapine, clozapine) and the selective serotonin reuptake inhibitors (SSRIs, most notably fluoxetine, aka prozac).
Healy describes how what he regards as the ‘mythical’ concept of ‘negative’ or ‘type 2’ symptoms of schizophrenia was promoted by the drug companies to persuade psychiatrists to switch patients from older drugs of the chlorpromazine group (with their well-recognised side-effects) to the new drugs (which turned out to have their own, scarcely less serious, side-effects).
The success of the atypicals was, according to Healy, the result of ‘wishful thinking and aggressive marketing’. The even more spectacular sales of prozac and the other SSRIs reflect the success of the drug companies in marketing the concept of depression as a deficiency of serotonin. By the late 1980s, the prevalence of depression, estimated at 0.5 percent of the population in the 1950s, had reached 10 percent. By the 1990s, Healy concludes, ‘the rise of psychopharmacology and biological psychiatry was complete’.
The fall of the house of Kraeplin
In the late 1990s, social psychiatry, with the support of a growing movement of past and present clients and patients of the mental health system, began to challenge the ascendancy of the biological model. In his 1997 book The Dialectics of Schizophrenia (4), psychiatrist Philip Thomas put forward both a critique and an alternative approach, which features prominently in Laurance’s book.
In a chapter entitled ‘the fall of the house of Kraeplin’, Thomas exposes the incoherence of the concept of schizophrenia as a disease and endorses the proposal that psychiatrists should ‘drop the diagnosis and study the symptoms’. He dismisses as ‘mindless psychiatry’ the attempts of some proponents of the biological model to explain schizophrenia in terms of cognitive neuroscience (describing Churchland’s ‘mind-brain identity theory’ as a ‘digital version of Descartes’ clock’).
Thomas details the debilitating side-effects of anti-psychotic medication, and notes that 20 percent of patients fail to respond to medication and 60 to 80 percent relapse if medication is stopped. He also questions the long-term efficacy of drugs even when they are effective in suppressing hallucinations and delusions.
Thomas’ most important innovation is his promotion of the self-help initiatives of patients and users of the mental health system. His model is the Hearing Voices Network established by people who experience auditory hallucinations to help them to deal with these experiences and their consequences.
Thomas uses the philosophy of phenomenology to explore the subjective – and the inter-subjective – aspects of the experience of mental illness, particularly in relation to auditory hallucinations. From this perspective, auditory hallucinations can be understood in terms of the history of the person hearing voices and their social relationships. Through this approach, Thomas proposes a more democratic and less paternalistic relationship between the psychiatrist and the patient, and between the mental health system and the system user.
Given the radicalism of Thomas’ challenge to the psychiatric status quo in 1997, it was a surprise to read his endorsement of the government’s mental health policy in 2001. A major feature in the British Medical Journal (co-authored by Patrick Bracken, a fellow community psychiatrist in Bradford) opens with the statement: ‘Government policies are beginning to change the ethos of mental health care in Britain.’ (5) It proceeds to identify the government as the leading force in promoting ‘a very different kind of psychiatry and a new deal between health professionals and service users’.
The article does not entirely ignore the proposed new mental health legislation, but regards it benignly as fostering a debate that ‘offers the opportunity to rethink the relation between medicine and madness’. But by embracing the fashionable mystifications of post-modernism, the authors lose sight of that most modernist of realities – the capitalist state (which is currently proposing to declare several thousand people mad prior to locking them up).
Ultimately, ‘post-psychiatry’ expresses the wish to transcend the limitations of contemporary psychiatry, without challenging the forces that sustain it.
Good cop, bad cop
Jeremy Laurance recognises the contradiction between the coercive and progressive aspects of the government’s mental health policy (6). He explains how the system of public inquiries and lurid media reporting of homicides have led to an exaggerated perception of the dangerousness of people with severe mental illness.
Laurance also the exposes the difficulty of predicting violence in individuals said to have an anti-social personality disorder (which one authority compares with weather forecasting – accurate over a few days, but highly unreliable for any longer period). On the basis of official figures, he reckons that the new mental health legislation might prevent 32 suicides and three homicides a year – but at the cost of a major extension in state coercion.
While condemning the authoritarian wing of New Labour, Laurance praises its commitment to improving community services for people with mental illness – making this one of the top three priorities of the health department, approving a programme of investment, and even appointing a Tsar to supervise the programme and welcoming consumer involvement in it. He argues that the way to improve public safety is by engaging people with mental illness in services rather than coercing them.
But the apparent contradiction within the government’s mental health policy may be more in the style of the ‘good cop’/’bad cop’ routine, through which the forces of law and order break down their suspects’ resistance. Though mental health professionals are right to warn the government of the danger that pushing them into a more authoritarian role will undermine their legitimacy in the eyes of the public, the politicians remain confident that they can compensate for this by promoting more therapeutic initiatives.
In his conclusion, Laurance recommends the re-orientation of the mental health system around the needs of users and their families. Following the approach of Thomas and other promoters of greater user involvement, he emphasises the need to listen to people with mental illness and to provide them with ‘someone to talk to; a safe place to be; meaningful activity’.
These are understandable requests from people who have experienced unsympathetic psychiatrists and nurses, wards in which threats and assaults are commonplace and in which the daily routine is one of mind-numbing tedium. But they scarcely provide a programme for the future of psychiatry. The endorsement of this sort of minimalist agenda reflects a drastic curtailment of psychiatric aspirations.
When August Pinel struck the chains off the inmates of the Bicetre and Salpetriere asylums in Paris in the 1790s, he expressed the conviction of the Enlightenment that the healing power of reason could reach even the most deranged. A similar spirit inspired the pioneers of psychoanalysis and community care – and the discoverers of neurotransmitters and the developers of psychotropic medications.
If psychiatry is to move forward it is necessary, but not sufficient, to resist state coercion and to listen to patients. If the house of Kraeplin has indeed fallen – it is certainly in advanced decay – then an alternative classification of mental illness is required. In this respect, it is unfortunate that Bruce Charlton’s important contribution to the question of psychiatric nosology has not received the attention it deserves (7).
Nor indeed, despite token gestures towards user involvement (as in the recent guidelines on schizophrenia) has there been much consideration of David Healy’s more radical suggestions (backed by Charlton) about removing medical control over the supply of psychotropic medications.
Dr Michael Fitzpatrick is the author of MMR and Autism, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).
Buy Pure Madness: how fear drives the mental health system by Jeremy Laurance from Amazon (UK). Buy The Creation of Psychopharmacology by David Healy from Amazon (UK) or Amazon (USA).
spiked-issue: Mental health
(1) A history of psychiatry: from the era of the asylum to the age of prozac, Edward Shorter, John Wiley, 1997
(2) Pure Madness: how fear drives the mental health system, Jeremy Laurance, Routledge, 2003
(3) See for example, The Creation of Psychopharmacology, David Healy, Harvard, 2002; The Antidepressant Era, David Healy, Harvard, 1997
(4) The Dialectics of Schizophrenia, Philip Thomas, Free Association, 1997
(5) ‘Post-psychiatry: a new direction for mental health’, Patrick Bracken, Philip Thomas, British Medical Journal 2001; 322: 724-7 (24 March)
(6) Pure Madness: how fear drives the mental health system, Jeremy Laurance, Routledge, 2003
(7) Psychiatry and the Human Condition, Bruce Charlton, Radcliffe, 2000
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