1 Boring Old Man

Psychiatry beyond the current paradigm

by Pat Bracken, Philip Thomas, Sami Timimi, Eia Asen, Graham Behr, Carl Beuster, Seth Bhunnoo, Ivor Browne, Navjyoat Chhina, Duncan Double, Simon Downer, Chris Evans, Suman Fernando, Malcolm R. Garland, William Hopkins, Rhodri Huws, Bob Johnson, Brian Martindale, Hugh Middleton, Daniel Moldavsky, Joanna Moncrieff, Simon Mullins, Julia Nelki, Matteo Pizzo, James Rodger, Marcellino Smyth, Derek Summerfield, Jeremy Wallace and David Yeomans

The British Journal of Psychiatry. 2012 201:430–434.

[full text @ Mad in America]

Conclusion: Psychiatry is not neurology; it is not a medicine of the brain. Although mental health problems undoubtedly have a biological dimension, in their very nature they reach beyond the brain to involve social, cultural and psychological dimensions. These cannot always be grasped through the epistemology of biomedicine. The mental life of humans is discursive in nature. As Harre` & Gillet put it ‘We must learn to see the mind as the meeting point of a range of structuring influences whose nature can only be painted on a broader canvas than that provided by the study of individual organisms’. Reductionist models fail to grasp what is most important in terms of recovery. The evidence base is telling us that we need a radical shift in our understanding of what is at the heart [and perhaps soul] of mental health practice. If we are to operate in an evidence-based manner, and work collaboratively with all sections of the service user movement, we need a psychiatry that is intellectually and ethically adequate to deal with the sort of problems that present to it. As well as the addition of more social science and humanities to the curriculum of our trainees we need to develop a different sensibility towards mental illness itself and a different under-standing of our role as doctors. We are not seeking to replace one paradigm with another. A post-technological psychiatry will not abandon the tools of empirical science or reject medical and psychotherapeutic techniques but will start to position the ethical and hermeneutic aspects of our work as primary, thereby highlighting the importance of examining values, relationships, politics and the ethical basis of care and caring.

Such a shift will have major implications for our research priorities, the skills we teach our trainees, the sort of services we seek to develop and the role we play in managing risk. This represents a substantial, but exciting, challenge to our profession to recognise what it does best. We will always need to use our knowledge of the brain and the body to identify organic causes of mental disturbance. We will also need knowledge of psychopharmacology to provide relief from certain forms of distress. But good psychiatry involves active engagement with the complex nature of mental health problems, a healthy scepticism for biological reductionism, tolerance for the tangled nature of relationships and meanings and the ability to negotiate these issues in a way that empowers service users and their carers. Just as operating skills are at the heart of good surgical practice, skills in working with multiple layers of knowledge and many systems of meaning are at the heart of our work. We will never have a biomedical science that is similar to hepatology or respiratory medicine, not because we are bad doctors, but because the issues we deal with are of a different nature.

Understanding the unique contribution psychiatry makes to healthcare can only increase our relevance to the rest of medicine. All forms of suffering involve layers of personal history, embedded in a nexus of meaningful relationships that are, in turn, embedded in cultural and political systems. Kleinman & van der Geest have rightly critiqued the way in which medicine in general has come to see ‘caregiving’ in purely technical terms. Similarly, Heath has argued for the importance of relationships and narrative understanding in general practice. Psychiatry has the potential to offer leadership in this area. Retreating to an even more biomedical identity will not only sell our patients short, but risks leading the profession down a single narrow alley, when what is needed is openness to alternative routes.

We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time…
Little Gidding  T.S. Eliot 1942

My assignment was to a base in England where I was paid more than I’d ever made in my life, lived on an estate in a 16 room house on the National Registry, worked less than I’d ever worked, and had ample leave time to travel all over Europe for three years. It was the best conscription scenario ever devised in history. But there was a dilemma, almost from the start. I really liked practicing medicine, something that had never occurred to me. I was a scientist of the hard core variety and fate had played a trick on me. It got me doing what I obviously should have known was what I was supposed to be doing without my even knowing what was happening.

I’ve told this story a jillion times, and it always feels ingenuous to me, to claim that I had an identity crisis when I already had the identity, but I don’t know what else to call it. As much as I enjoyed medical school, residency, and fellowship, I think I had told myself that doctor was a credential. In fact, the post-doc I was pursuing was aimed towards a PhD in Mathematics. Seeing doctor as an identity was as confusing and unsettling a state as I’d ever felt. And over that first year, what I came to was almost verbatim what you read in this commentary – except replace the current paradigm of psychiatry with Internal Medicine practice. So I applied to the kind of psychiatry they are describing in this piece.

I found it, and was beyond pleased to have been so lucky. Flash forward a decade, I was directing a Residency, teaching medical students, practicing. All of that changed in a day, though it took a while for me to know it. For obvious reasons, I’d kept up with Biological Psychiatry being a science guy from conception. But what came was not just a new commitment to hard science, but rather something of a disdain for what the new post-DSM-III psychiatry replaced, and I had been part of that – actually a disdain for everything that’s in that article. It was spoken as a refutation of psychoanalytic theories, but in practice, it was any thoughts about the mind or the "layers of personal history, embedded in a nexus of meaningful relationships that are, in turn, embedded in cultural and political systems." That stuff was too flaky for what followed. When the new psychiatric paradigm came to the street where I lived, it was biological reductionism² and it was apparent to me I didn’t have another identity crisis in me, at least not that one, so I slid into a challenging but cloistered practice as a psychotherapist – and fit there just fine.

I was cloistered, but I’m not blind. And being in Atlanta throughout the reign of Dr. Nemeroff, I watched the transformation of psychiatry from a distance. I interpreted what was happening, the strutting and the crowing, as something like "it’s their turn." I blamed the changes in practice for so many of my colleagues on Managed Care when I thought about it, which wasn’t often. I withdrew from the meetings I’d attended in the past for obvious reasons. And I kept a low profile as people on the wrong side of disdain often do. What I didn’t do was pay enough attention to see the invasion by the Pharmaceutical Industry and the collusion of academic psychiatry – the things I now write about. I still feel no small amount of guilt about what I didn’t see happening, but I also think that if I had seen it earlier, I wouldn’t have been able to do anything but wave my hands. It was a downhill steam-roller with an enormous momentum, and people like me were persona non grata. I knew all of that, but I didn’t know who was pouring the jet fuel into that tank.