Evolution or revolution? Four reasons why Western psychiatry is unlikely to change by incremental steps.

Five years ago, when I worked as a clinical psychologist within the UK’s psychiatric system, a senior colleague urged me to be patient. After hearing me – again – express my frustrations at the speed of change, and the stubborn endurance of bio-medical approaches to human suffering, he would urge me to aim for modest, incremental improvements in the existing system, to not expect too much too quickly, and to strive for ‘evolution not revolution’.

But how realistic is it to expect that the biological skew of Western psychiatry can be sustainably changed one small step at a time?

During the last decade of my career in psychiatric services I experienced mounting recognition that a paradigm shift – something akin to a revolution – would be necessary if, as a society, we were to meaningfully promote or restore positive mental health to our fellow citizens. Further reflection has highlighted four reasons for my pessimism about the potential for organic change to the existing system:

1. The degree of change required

Despite the emphatic discrediting of the bio-medical, ‘illness like any other’ approach to mental health problems, the routine discourse heard throughout mainstream psychiatric services continues to be dominated by assumptions of brain diseases and chemical cures. A fly on the wall of a typical inpatient unit, or community mental health team, across the Western world would witness professionals wrangling about correct diagnoses and corresponding medication combinations. Where pockets of more enlightened psycho-social practice exist, they will typically be viewed as optional add-ons, supplementary to the core biological treatments.

The distance yet to travel to realise a more appropriate response to human misery and overwhelm is vast and daunting. Meanwhile, numerous people who seek help from psychiatry are experiencing interventions that are of limited benefit and often damaging. Given these circumstances, the adoption of an evolutionary approach to change is difficult to justify on both practical and moral grounds.



2. Vested interests

Two powerful institutions benefit hugely from the current ‘diagnose and medicate’ approach to mental health problems and will use their considerable muscle to quash attempts to promote sustainable change.

The misdemeanours of the pharmaceutical industry have been well documented. The concept of brain disorders that demand indefinite medication is such a lucrative one that drug companies will stoop to any depths to maintain the biochemical imbalance myth: sponsoring bogus brain diseases (for example, suggesting that social phobia is synonymous with being ‘allergic to people’ [1]); bribing doctors to promote ineffective drugs for unapproved uses [2][3]; influencing the stance of service-user organisations through their funding [4]; and speaking directly to the general public through media advertising [5].

The psychiatry profession is the second major stakeholder who would be terminally damaged by a paradigm shift away from bio-medical approaches to mental health. The power, status and remuneration of consultant psychiatrists is dependent upon the perception that their medical expertise is central to the treatment of mental health problems, in the same way that other specialisms (such as oncology, gynaecology, neurology) rely on the overarching skills of their medical practitioners.

Unsurprisingly, given what is at stake, the psychiatry profession’s substantial power continues to be deployed to counteract any effort to shift the tone of mental health services away from bio-medical dominance. One widely used strategy is to neutralise alternative approaches by removing their more radical elements so that what remains appears different from the dominant orthodoxy only in degree of emphasis [6] – what might be referred to as the, ‘we’re already doing this’ approach. For example, some years ago I recall a psychiatrist claiming his was already a recovery-orientated service on the basis that it strove to cure people of their mental illnesses.

Given these vested interests, innovators espousing alternative approaches to mental health are likely to be ignored, discredited or neutralised.



3. The general public’s liking of simplistic explanations

When faced with complexity, human beings are drawn to explanations that require minimal effort. Bio-medical accounts of mental health problems offer such a seductively simple message. If a person is acting bizarrely, hearing voices and overly suspicious, biological psychiatry can label him as suffering with ‘schizophrenia’, suggesting the presence of an underlying brain abnormality. Similarly, withdrawal, despair and a lack of enjoyment of life can conveniently lead to a diagnosis of ‘depression’ and the implication that the person’s malfunctioning neurones are somehow causative of the presentation.

Over the last three decades, many of the so-called ‘public education’ initiatives around the issue of mental health have promoted these kinds of lazy – and spurious – explanations [7]. Similarly, current ‘mental health first aid’ courses adopt an illness approach to human suffering [8], while celebrities like Stephen Fry and Ruby Wax continue to espouse ‘broken brain’ explanations for their personal struggles [9].

Although, when left to their own devices, the general public lean towards psychosocial factors (bereavement, trauma, environmental stress) as the primary causes of mental health problems [7], the bio-medical, ‘illness-like-any-other’ accounts can be seductive. These simplistic explanations negate the need to further question our own roles and responsibilities for the prevalence of human suffering; labelling people as ‘mentally ill’ conveniently avoids reflection about the contributions of families, work colleagues, neighbours and fellow citizens via processes such as scapegoating, discrimination and victimisation. Consequently, piecemeal advocates of alternative approaches, scattered across the existing psychiatric system, are unlikely to harness the widespread support of the general public necessary to realise the desired radical change in the way we address mental health problems.



4. The lack of political will

A fundamental and sustainable shift away from bio-medical approaches to human suffering will not be achieved solely by changes to psychiatric provision; whole-system transformation to the legal and political domains will also be required.

Mental health legislation across the Western world constitutes a form of legalised discrimination, denying people with mental health problems fundamental civil liberties afforded to all other citizens [10]. Yet it is rare to hear high-profile politicians advocating for reform, their silence a contrast to campaigns to change laws that perpetuate sexual and racial discrimination. It seems that these legal generators of misconceptions – portraying psychiatric service users as people with internal defects that render then inherently risky – will remain immune to change for decades to come unless there is an injection of revolutionary energy that allows the rejection of laws (such as the UK’s Mental Health Act) to be seen as part of the ‘last great civil rights movement’ [11].

Furthermore, the current ‘illness-like-any-other’ approach, in locating the cause of mental health problems in the brains of individual sufferers, gets our politicians off the hook. If it is assumed that diseased brains are primarily responsible for human misery and overwhelm, the well-documented contributions of societal ills – homelessness, poverty, intra-family violence, high-crime neighbourhoods, unemployment, discrimination – can all be conveniently ignored by the government of the day.

Taking all of the above into account, it seems unrealistic – even naïve – to expect that radical change away from bio-medical approaches to human suffering can be achieved organically, one step at a time, by innovative practitioners embedded within the existing psychiatric system. A hefty dose of revolutionary energy is needed to ignite the system from its current self-serving inertia. But how can such a catalyst be developed? I will share my thoughts on this topic in a future post but, in the meantime, would be interested in the views of others.

References

(1) Moynihan, R., Heath, I. & Henry, D. (2002). Selling sickness: the pharmaceutical industry and disease mongering. British Medical Journal, 324 (7342), 886 – 91.

(2) Neville, S. (2012). GlaxoSmithKline fined $3 billion after bribing doctors to increase drug sales. The Guardian 3 July 2012. Retrieved 21 January 2014 from,

http://www.theguardian.com/business/2012/jul/03/glaxosmithkline-fined-bribing-doctors-pharmaceuticals

(3) Harris, G. & Carey, B. (2008). Researchers fail to reveal full drug pay. New York Times 8 June. Retrieved 21 January 2014 from, http://www.nytimes.com/2008/06/08/us/08conflict.html?ref=josephbiederman&_r=0

(4) Goldacre, B. (2012). Bad Pharma: how drug companies mislead doctors and harm patients. Harper Collins: London. (pp 266-71).

(5) Gilbody, S., Wilson, P. & Watt, I. (2005). Benefits and harms of direct to consumer advertising: a systematic review. Quality and Safety in Health Care, 14(4), 246 – 50.

(6) Boyle, M. (2013). The Persistence of Medicalisation: Is the presentation of alternatives part of the problem? In S. Coles, S. Keenan & B. Diamond (Eds.), Madness Contested: Power and Practice (pp 4 – 22). PCCS Books.

(7) Read, J. and Haslam, N. (2004). Public opinion: bad things happen and can drive you crazy. In J. Read, L.R. Mosher & R.Bentall (eds.) Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia (pp 133 – 45). Routledge.

(8) Davidow, S. (2016). Mental health first aid: your friendly neighborhood mental illness maker. http://www.madinamerica.com/2016/04/mental-health-first-aid-your-friendly-neighborhood-mental-illness-maker/

(9) BBC ‘In the Mind’ programme. http://www.bbc.co.uk/inthemind

(10) Sidley, G. (2015). Tales from the Madhouse: An insider critique of psychiatric

services. PCCS Books pp 62 – 67.

(11) Dillon, J. (2013). ‘The personal is the political?’ In M. Rapley, J. Moncrieff & J. Dillon (Eds.), De-Medicalizing Misery (pp. 141 – 57). Basingstoke: Palgrave Macmillan.

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