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Psychiatry

The current preference is for emphasizing that psychiatry is ‘just another branch of medicine’ like cardiology or oncology. In part this is to try and make psychiatry properly respectable by highlighting its scientific credentials, its commitment to precise diagnoses and evidence-based treatments, increasing its status within medicine and in society generally. It is also to reduce the stigma which has always been associated with mental illnesses. Stressing that these are illnesses like any other illness (‘mental illnesses are brain diseases’) should reduce prejudice experienced by sufferers and the sense of responsibility and shame felt by so many patients and families. We don’t feel ashamed or blame ourselves if a family member develops arthritis, so why do we if they become depressed? It is against this backdrop of unnecessary additional suffering that the medical legitimacy of psychiatry is, quite rightly, stressed. But it is not that simple. Psychiatry is different. Even those of us who work in it are treated as different. Psychiatry can also inspire fear. It is, after all, the only branch of medicine which can force treatment on individuals. Special laws exist in all developed countries, both to protect the mentally ill against punishment but also to force them to have treatment. There appears to be a remarkable consensus about the reality and importance of mental illnesses. 

(6) Psychiatry

Principles of Mental Health Law & Policy

Mental health law

Mental health, human rights and legislation - World Health Organization

Mental health laws

Mental Health Legislation

The first medical model

The end of the asylum era was foreshadowed by the ‘first medical model’ in the 1920s and 1930s. Interest in psychiatry had received a boost during the First World War with the need to treat shell-shocked soldiers, while at the same time the asylums had become even more overcrowded and neglected. It was only from the 1920s onwards that really effective treatments were discovered and introduced. These caused widespread changes in attitudes and restored optimism. ‘Lunatic’ was replaced with ‘mental patient’, ‘asylum’ with ‘mental hospital’, ‘certification’ with ‘involuntary admission’, and voluntary admissions became common for the first time: a truly revolutionary change in perspective.

There had been a steady improvement in the drugs used to control agitation prior to this time but two new treatments were epoch making – malaria treatment for cerebral syphilis and electro-convulsive therapy. Julius Wagner-Jauregg (1857–1940) and malaria treatment Wagner-Jauregg was the only psychiatrist to be awarded the Nobel Prize for Medicine before Sigmund Freud in 1939. He received it for his 1917 introduction of malaria treatment for cerebral syphilis (then called general paralysis of the insane, GPI).

Before effective treatments for syphilis, a small proportion of chronically infected patients went on to develop the disease in the brain with disastrous consequences. It often took 20 years to develop, by which time the patient might be a settled family man. The terror it represented for 19th-century society is vividly captured in Ibsen’s play Ghosts. Onset of mental symptoms was sudden and dramatic. The philosopher Nietzsche inexplicably embraced a horse that was being abused in the street in Turin and within days was confined to a mental hospital; he died 11 years later never having recovered. Deterioration was tragic and humiliating. It was often associated with delusions of grandeur (hence all those cartoons of patients convinced they were Napoleon), and ended in dementia.

Wagner-Jauregg’s treatment consisted of infecting the patient with malaria parasites and waiting, with careful nursing, while the high fever raged. Over 10–12 cycles this killed the syphilis germs. The malaria could afterwards be treated with quinine. This treatment was difficult and risky but the alternative held no hope. GPI was effectively cleared from mental hospitals long before effective antibiotics arrived. Malaria treatment restored optimism to mental hospitals and strengthened the professional pride of the doctors and nurses who had to manage this difficult, but effective, treatment. It also forged clearer links with general hospitals where the patients often had to go to be treated. In doing this it became clear that involuntary patients would often cooperate with treatment and this stimulated a reassessment of the need for so much compulsion.

Electro-convulsive therapy

While malaria treatment is purely of historical interest, electro-convulsive therapy (ECT) is still widely used. Psychiatrists knew that epileptic seizures often caused profound changes in mood – either exciting or calming patients in the hours after a fit. It was also thought that epilepsy was uncommon in patients with schizophrenia so the idea developed that perhaps fits protected patients against this disease. Fits were induced in schizophrenia patients from 1935 by getting them to inhale camphor or by injecting a chemical called metrazol. The results were promising, with many patients improving. Unfortunately the experience (in particular the minutes leading up to the fit after the metrazol was injected) were very unpleasant indeed, with mounting dread, so many patients refused the treatments.

An Italian, Cerletti, came up with the idea of using a weak electric current to initiate the fit and used it on his first patient in 1938 with striking results. Several psychiatrists started to use ECT and its results were truly remarkable. While it did calm very agitated schizophrenic patients, its most dramatic results were with depressed patients, many of whom made sustained recoveries. If this all sounds a bit barbaric it pays to remember that depressed patients in the 1930s (even in very good mental hospitals) often stayed for years and up to one fifth died during the admission. Initially ECT was given without anaesthetic and clearly was a frightening experience often with complications of small fractures if the fit was very strong, headache, and memory loss. For the last 50 years patients have received a short-acting anaesthetic and a chemical to block the muscle contractions so there is no fit to see and no risk of fractures. Headache and memory loss are still problems but patients don’t recall the actual seizure.

The discovery and durability of ECT is typical of many developments in psychiatry. The idea that started it (that epilepsy protected against schizophrenia) was wrong but the treatment worked, although more in depression than schizophrenia. We still don’t know why it works, but it certainly does. It remains one of the most effective treatments in psychiatry and (despite its wider reputation) the one that most patients who have had it say they would want again.

Mental health legislation

Psychiatry is unique within medicine in being able to compel treatment against a patient’s clearly expressed wishes. Consequently most countries have evolved specific legislation to permit this and to monitor it. The whole of the asylum movement was firmly based in such legislation. The developments in England in the 19th century are easy to follow because it was an early nation-state with centralized government and little scope for regional variation.

The first legislation was to regulate madhouses. All this did was to register them. It set no standards but could close an individual madhouse in the event of flagrant abuse. The purpose of the Asylum Act of 1808 and the Lunacy Act of 1845 was to ensure that care was provided and prevent exploitation of the vulnerable mentally ill. It allowed for ‘the removal of the furiously mad’ from workhouses to the asylum.

Over the next half century, public concerns shifted from the neglect and abuse of the indigent mentally ill to the spectre of malevolent incarceration of the sane to rob them of their wealth. The ‘Alleged Lunatics’ Friends Society’, with an admiral of the fleet as chairman, gained considerable parliamentary and public support in late 19th-century Britain. Georgina Weldon (a ‘spirited, attractive, wealthy and well connected woman’) filled the Covent Garden Opera House in London in 1883 for a rally to challenge her recent incarcerations, and eventually won her case. Increasing public disquiet was reflected in the 1890 Lunacy Act. This highly legalistic document, several hundred pages and 342 sections long, prioritized the protection of patients’ rights to such an extent that early and voluntary treatment became virtually impossible. The leading historian of mental health legislation, Kathleen Jones, wrote that ‘it stopped progress in mental health policy in its tracks for half a century’.

So swings the pendulum of public attitudes to mental health. Virtually every developed land is struggling to balance legal rights and therapeutic needs, to balance society’s needs with the patient’s. Asylums limped onwards for another 50–60 years, mired in legislation and inhibited from innovation apart from the welcome treatment advances in the 1920s and 1930s. It was to be another 30 years before this awesome international institution was finally challenged and moved towards its end. The move into the community

After decades of being hidden from view, the mentally ill are now very much in the public eye. Hardly a week goes by without some headline about the plight of the homeless mentally ill or an incident involving a disturbed individual. ‘Care in the Community’ has become an international preoccupation with much soul-searching and fear of violence and disorder. How has this situation come about? Is it really so disastrous and, if so, what can be done about it?

Deinstitutionalization

The number of psychiatric beds in the West has shrunk to less than a third of what it was in 1955. Nearly every large mental hospital in the UK and most in the US have closed. The few remaining house only a fraction of the patients they once did. Chronic wards where long-stay patients lived out their lives have virtually disappeared. In the mid-1950s there were 500,000 psychiatric inpatients in the USA and 160,000 in the UK. Now there are less than 100,000 in the USA and less than 30,000 in the UK. This trend is virtually worldwide. This process, inelegantly entitled ‘deinstitutionalization’ started by reducing overcrowding and then closing wards. The last 15 years has finally seen the closure of whole mental hospitals. It is usual to attribute this emptying of the asylums to the discovery of antipsychotic drugs in the early 1950s. This was clearly the major force but it is not the whole story. Fundamental changes in social attitudes towards the mentally ill were afoot before these drugs were introduced. The impact of the new drugs varied enormously – from wholesale discharges in some countries, to almost no effect in others. Social attitudes and radical rethinking within psychiatry also exerted powerful influences. Later, financial considerations entered the picture. But let us start with the drugs.

The drug revolution

Like so many important discoveries chlorpromazine’s antipsychotic effect was found by pure chance. A French navy anaesthetist researching trauma and shock noted how it calmed patients post-operatively without sedating them. Two psychiatrists, Delay and Deneke, tried the drug in St Anne’s hospital in Paris in 1952 and were astounded by the results. By the tenth patient they knew they had a breakthrough. Over the next four years chlorpromazine became the front-line treatment in psychotic illnesses and the atmosphere in psychiatric wards was totally transformed. At its most immediate the drugs humanized the wards. Staff could begin to get to know their patients rather than just controlling them. Episodes of illness were both shorter and less disturbed so that rehabilitation and early discharge (before family relationships and jobs were lost for good) became realistic possibilities. Initially the drugs were used only for treating acute episodes but by the 1970s it was realized that staying on them reduced the risk of further breakdowns. This ‘maintenance therapy’ has become the cornerstone of long-term treatment of schizophrenia and other psychoses.

Over the last 50 years a whole range of antipsychotics has been developed. Most are about equally effective but their side effects are very different. The original chlorpromazine-like drugs often made patients stiff and lethargic. Newer drugs avoid the stiffness but can cause weight gain and diabetes. Some of these drugs became available as long-acting injections which means the patient can forget about taking them as long as they get their injection every two to four weeks.

The drug revolution was not restricted to antipsychotics. The first of the antidepressants (imipramine) was introduced in 1958. These had a longer lasting effect than ECT and were more acceptable to many more patients – by the early 1980s US physicians were writing 10 million antidepressant prescriptions a year. Lithium carbonate (a naturally occurring substance) was noted in 1949 to have a calming effect. It was introduced as a long-term ‘mood-stabilizing’ treatment for manic depressive disorder in 1968 and has substantially reduced the risk of further breakdowns.

This is not the place to detail the developments in modern psychiatric drugs but just to note that the progress has been accelerating. We now have a wide range of drugs for most recognized disorders. However, these are not ‘magic bullets’. No drug will completely cure all patients with a specific disorder but, carefully chosen, drug treatments can make a real difference to the vast majority of patients with mental illnesses.

The revolution in social attitudes

The Second World War

Psychiatry changed radically during the Second World War and gained new confidence because its contribution was highly valued (both in the selection of soldiers and in the acute treatment of combat disorders). Its increased profile and importance brought many doctors into it who would never have contemplated work in asylums. Fresh minds were brought to old problems. Previously healthy men transformed into nervous wrecks by battle challenged old fatalistic genetic hypotheses. Dramatic recoveries from battle-trauma with practical treatments (e.g. barbiturate injections to release or ‘abreact’ emotions from recent terrifying experiences) confirmed the role of stress and trauma. Psychiatry became an active and optimistic, almost glamorous, branch of medicine.

Therapeutic communities

The treatment of acute war neuroses by drug treatments was not the only Second World War advance. Psychiatrists with a psychoanalytical training obtained influential military adviser posts in both the US and UK. They explored how organizations themselves could influence mental health and recovery and developed the ‘therapeutic community’.

The therapeutic community emphasized that the organization of hospitals (or prisons or schools or offices for that matter) has a major impact on the well-being of those in them. For psychiatric patients it can be an opportunity for self-learning and recovery. Army psychiatrists noted the problems of treating ordinary private soldiers for psychological problems because they, the doctors, were senior officers. Rank and status simply got in the way. They actively reduced status differences in their units, encouraging informality and stressing the patients’ capacity to work together to help each other and solve problems. This allowed neurotic and disabled individuals to learn new ways of dealing with their problems in a democratic, tolerant, and enquiring group environment.

The therapeutic community movement improved care in mental hospitals and subsequently in prisons and residential schools for disturbed children and adolescents. It is a victim of its own success, as its lessons have become so accepted (even in commercial organizations) that their origins are forgotten. Psychoanalysis has suffered a similar fate.

‘Institutional neurosis’ and ‘total institutions’ About the same time it was recognized that traditional mental hospital environments could have a profoundly damaging impact on patients. Hospitals could themselves be the cause of some of the problems that they were striving to treat. Long-stay patients (usually those suffering from schizophrenia) who had been inpatients for years or decades, were noted to be apathetic, self neglecting, and isolated. This had always been considered a consequence of schizophrenia (a so-called ‘schizophrenia defect state’) and the plight and dependency of these individuals was one of the arguments sustaining mental hospitals.

This aspect of schizophrenia (unlike the acute symptoms of hallucinations, delusions, and agitation) did not respond much to the new drugs. But the hospital itself appeared to make a difference. It had always been known that there were good mental hospitals and bad ones. A study of three hospitals of similar size and staffing with equally ill schizophrenia patients in the 1960s found markedly different levels of apathy and self-neglect. The study showed that the differences related to the levels of activity and variety provided in daily routines.

A psychiatrist, Russell Barton, went further and proposed that much of this apathy was a response to living in an institution which denied personal responsibility. The apathy was a consequence of disuse – you simply stopped looking after yourself because somebody else always did it for you. Barton called this ‘institutional neurosis’ to stress that its cause was the hospital, not the schizophrenia. He reorganized things to give his patients more independence, with remarkable results. Many patients flourished in the new regime and were soon discharged. Rehabilitation (helping patients regain their lost skills and abilities) became a preoccupation in most mental hospitals and optimism grew that most of these apathetic, disabled patients would no longer need inpatient care.

‘Institutional neurosis’ stimulated change but its extent was undoubtedly exaggerated. There is an apathetic state that develops as part of long-term schizophrenia but it had been magnified by hospital routines. There were even some patients who had recovered and the staff had simply not noticed! Many of Barton’s early patients embraced their independence effortlessly, but such ‘overlooked’ patients are now rare and ongoing support is usually needed.

Erving Goffman and total institutions The Three Hospitals Study and Russell Barton’s institutional neurosis shook up the professions but they pale alongside the international shock wave caused by Asylums (1961) – a book by the American sociologist Erving Goffman. This groundbreaking study (he worked ‘undercover’ for a year as a cleaner in the wards of an enormous mental hospital in Washington, DC), his clear and radical thinking and, not least, his elegant writing simply stunned the establishment. Goffman described in convincing detail what really went on in an asylum – not what people thought went on. Doctors and nurses thought they shared a common understanding but Goffman showed that they did not – doctors judged patients using a disease and treatment model, whereas the nurses made judgments’ based more on behaviour and on patient motives. More tellingly doctors thought they ran the units but it was clear that for day-to-day life nurses, aides (and even other patients) set the rules and culture and held the authority. Goffman was not sympathetic to the asylum.

He went further. He concluded that the dehumanizing and degradation of patients resulting from inflexible routines and the absence of individualized care were not simply the regrettable effects of poorly trained staff and lack of resources (the usual explanations). He argued that such institutions actively eroded individuality. This was particularly characteristic of what he called ‘total institutions’ such as asylums, prisons, and the army. These typically meet all their Members’ needs – e.g. food, shelter, company, leisure. They rely on rigid distinctions between staff and patients (or prisoners and warders, or officers and men) and on demeaning rituals to erode and suppress individual identity. He argued that they do this to enforce discipline and make large groups of people more easily manageable. In the hospital in which he worked he cited the highly structured admission process that included not only medical examination but delousing, bathing, and hair cutting for all patients as one such potent and symbolic degradation.

Whilst (understandably) initially unwelcome to the professions Goffman’s writings have been a major force in driving the closure of the mental hospitals. His book Asylums is still the most quoted text in modern sociology 40 years after its publication. Ken Kesey’s 1962 book One Flew Over the Cuckoo’s Nest (and its enormously successful film adaptation staring Jack Nicholson in 1975) vividly portrayed the unacceptable face of such large impersonal asylums.

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(7) Psychiatry

Mental Health Stigma, The Truth Talks: Psychiatry & Mental Disorders

Psychiatric stigma

Psychiatry7

The rights and abuse of the mentally ill

We have focused so far on the forces from within the professions that led to deinstitutionalization. However, just as with the origins of the asylums, the social climate of the time was probably as influential, if not more so. Directly after the Second World War Europe burned with a spirit of change and a thirst for social justice.

The old order was in disgrace and the rights of the common man were the priority of both returning soldiers and returned governments. Democracy and social inclusion (though not called that then) dominated the international agenda, whether in education, health, or housing. The rights of disadvantaged groups to take full part in this new society were strongly defended and the mentally ill were one such group. Their wholesale liquidation in Nazi Germany only served to underline their rights for protection.

Nowhere is this so clearly demonstrated as in changes in Mental Health Law. In the UK, for example, the 1890 Lunacy Act focused on protecting the rights of the sane not to be judged insane (with scant regard to the rights or welfare of the insane) whereas the 1959 Mental Health Act focused on protecting the rights of the mentally ill by ensuring due process and review of their care and detention. A series of scandals about the abuse of mental patients surfaced in the 1960s and 1970s. Revelation after revelation of degrading and inadequate care followed inquiries into several mental hospitals.

The reports ranged from the denial of dignity through to frank abuse and assault. These scandals painted a recurrent picture of large isolated institutions (size appears crucial, with risk escalating rapidly above about 400 patients), with a poorly trained but very cohesive staff group, many of whom had followed their parents into the job. The practices Goffman had identified were very much in evidence, with little attention to individualized treatment or care.

These revelations produced understandable revulsion and strengthened resolve to reform or remove asylums. In 1960 the UK Health Minister prophesied their demise but predicted that professional attitudes would outlive the bricks and mortar. The Italian reforms drove this home. Their charismatic originator, the psychiatrist and philosopher Franco Bassaglia, believed that the mental hospital was fundamentally unreformable and abolition was the only way forward. Law 180 in 1978 prohibited compulsory admissions to mental hospitals immediately and demanded their total closure within three years.

At this time the whole legitimacy of psychiatry was being called into question. The anti-psychiatry movement led by R. D. Laing, Thomas Szasz, and Michel Foucault had been borne aloft in the student revolts of 1968. Their books became campus bibles of the 1970s across the whole of Europe and the US. By the early 1980s the downsizing and closing of mental hospitals was an established international movement led and articulated by mental health professionals, mainly psychiatrists. However, despite smaller numbers of inpatients, the cost of mental health care increased as staffing standards came more in line with those in general medicine and as decades of neglect were addressed. The financial advantages of closing whole mental hospitals became obvious to governments who have driven this agenda for the last 20 years (often now opposed by the professionals). It is this ‘unholy alliance between therapeutic liberals and fiscal conservatives’ as one astute US observer noted which has driven deinstitutionalization over the last 30 years.

Transinstitutionalization’ and ‘reinstitutionalization’

When the asylums were built they did not take their first new patients from family homes but from prisons and workhouses. One worrying aspect of deinstitutionalization is that some of the reduction means more mentally ill patients are transferred back to prisons. As psychiatric units became smaller and more therapeutic in orientation, many of their more difficult patients (who previously would have remained for longer periods on locked wards) were denied access and ended up in prison. This regrettable trend has been exacerbated in parts of the world where the criteria for compulsory care have been so tightened that they require evidence of immediate danger. California now has more psychotic individuals in prison than in mental hospitals.

So the rate of deinstitutionalization is not quite so dramatic as hospital closures might suggest. Indeed, in the last five years or so, the signs are of a slight reverse, with more mentally ill people in some form of supervised accommodation. There are many factors involved (see below) but one is undoubtedly increasing intolerance of risk.

Care in the community

‘Any fool can close a mental hospital’ remarked a senior UK health official in the 1980s. He quickly added that the skill was not in closing the hospital but providing alternative care. Recognizable forms of modern community care have been developing since the 1930s - psychiatric day hospitals in Russia, outpatient departments in both the US and the UK, mobile clinics in the Netherlands.

However from the 1960s onwards real effort went into community services as an alternative to mental hospitals rather than simply as a complement.

District general hospital units and day hospitals

 The building of small inpatient units either in or alongside local general hospitals stood for the destigmatizing of the mentally ill and the move away from the mental hospital. These units were small, usually 40–100 beds. They catered for acute, short-term patients and could usually rely on the mental hospital for back up. They are an international phenomenon but practice reflects local customs. In the US they embody a strong tradition of general hospital liaison psychiatry; in Germany an academic psychosomatic tradition of psychotherapeutic treatment of physical illnesses; in the UK a mental hospital tradition adapted to more rapid discharge. The Italian reforms insisted on a complete break, substituting tiny, very short-term admission units.

It is sobering to reflect, however, that in the new expanded Europe over half of psychiatric inpatients are still cared for in traditional mental hospitals with little, if any, real community provision. US practice varies enormously between states, from highly community based services to extensive reliance on old mental hospitals.

Locating psychiatric units in general hospitals and keeping them small guards against many of the problems of asylums, but they have their own problems, such as being cramped and less tolerant. They may also have difficulties with very difficult patients and usually cannot offer the breadth of activities and treatments of larger units. They are, however, a first essential step out from the asylum into the community.

Community mental health teams (CMHTs) and community mental health centres (CMHCs) Breaking the dominance of mental hospitals involved moving services closer to patients. Services needed to be accessible and not too frightening so that patients and families would approach them early for help. ‘Sector psychiatry’ arose to meet the challenge. Asylums took all the patients from a defined catchment area (often a whole county or a city). The sector approach divided this into small manageable areas (40,000–100,000 population) to provide easily accessible, fairly comprehensive care. France and the UK led the way in this development. The French ‘secteur’ arose from sociological theory and emphasized crisis intervention. The service was restricted to psychotic patients and remains patchy. The UK approach was more comprehensive but entirely pragmatic, much less theoretical. Local care followed 1950s legislation requiring compulsory detained patients to be offered outpatient follow-up and requiring the involvement of social services. Collaboration was not feasible from distant mental hospitals; linking with social workers and family doctors was only realistic in small neighborhoods. The sector approach meant psychiatrists and nurses and social workers started working together in teams.

In the UK this development was made possible by ‘community psychiatric nurses’ (CPNs). These are nurses who work almost exclusively outside hospital, most often visiting psychotic patients in their homes to ensure they carry on with their medicine but also helping to solve day-to-day practical problems. Starting from two in 1953 there are now more CPNs than psychiatrists in the UK. CPNs and psychiatrists working together established multidisciplinary team practice, gradually incorporating social workers, clinical psychologists, and occupational therapists.

Community mental health teams assess the broad range of mental health problems (from depression to psychosis) and offer treatment in clinics, patients’ homes, day hospitals, and (when needed) as inpatients. They have become the norm throughout Europe and many parts of the world. The Italian reforms most clearly encapsulated this model of care, emphasizing informality, local knowledge, and flexible access.

Most CMHTs are broadly similar. In Italy and the UK the same team usually looks after patients both in and out of the hospital, but in much of Europe and the US these responsibilities are separate. In some services CMHTs see the whole range of mental health problems; in others they may restrict themselves to severe psychoses. There has been a recent move to replace CMHTs with a range of specialized teams (e.g. for crisis, for long-term support, for first onset patients). While the focus of these teams differs, their practice (staffing, assessment, reviews, etc.) is surprisingly similar. CMHTs are not the only model for provision of local services. In the US President Kennedy’s 1963 ‘Community Mental Health Centers Construction Act’ established community mental health centres. These were ambitious, relatively large units aiming to reduce fragmentation of care and provide a range of services including day care, assessment, treatment, outreach, and preventative and educational services for mental health. They were over-ambitious and proved impossible to staff and run and soon contracted to focus on day care and clinics. The model has functioned well in the Netherlands and in some parts of Europe.

Day hospitals

Day hospitals (in tandem with general hospital units) were proposed as the alternative to mental hospital care but have been overtaken somewhat by events. The need for them never fully materialized as CMHTs developed. Many of the anxiety and depression treatments they were planned for were delivered by CMHT staff with their newly acquired skills. Effective outreach to support more severely ill patients has also reduced the need for them. Day centres on the other hand (providing social, rather than health care) continue to flourish. They reduce the isolation and loneliness experienced by so many mentally ill people, particularly in large anonymous cities.

Stigma and social integration

The first twenty years of the move to community care are generally considered something of a global success. Patients who did not need to be in expensive, gloomy mental hospitals got out of them and found more rewarding lives. The support offered them by CMHTs was effective but light-touch. As mental hospitals began to close, however, patients with increasingly severe disabilities were discharged. Closures often ran far ahead of the provision of adequate alternative services, in particular, affordable local housing. Many patients became homeless (particularly in the US where this became a national scandal). Living in squalor on the streets they became a reproach to us all and often victims of petty crime and exploitation. The picture was, of course, very varied. Some states in the US had quickly developed sophisticated and admirable social provision and this was true of much of Europe. However, major cities (London, Rome, New York, Los Angeles) have struggled to cope and generally not succeeded Changes in legislation motivated by concern for civil liberties, which prevent hospitalization unless there is evidence of immediate danger (as in New York and California), exacerbated this problem. Very disabled patients rejected hospital even if there was a bed for them and the new laws wouldn’t permit their compulsion. It is telling that patients who have experienced both prefer living in poverty and insecurity on the street to being in a relatively comfortable hospital ward. This can’t simply be written off as lack of insight – most of us value personal freedom and choice above comfort. However, the sight of ‘bag-ladies’ and homeless, obviously mentally unwell individuals on our streets presents a broad moral challenge for which we have no easy answer.

Stigma

Stigma has been proposed as one of the main burdens of mental illness and there are now international programmes aimed at reducing it. Stigma is manifest by our wish to avoid specific individuals (‘establish social distance’) and in its most extreme form to expel or banish them. The mentally ill have always been stigmatized, as have sufferers from many illnesses in the past. While the more extreme manifestations of stigma such as the leper’s bell or branding people are lost in ancient history, discrimination and neglect still leave the mentally ill denied full social acceptance. Discrimination in jobs and housing is common. There is evidence that stigma against the mentally ill is less in younger people than in their elders. This is clearly an encouraging finding but its cause is unclear. Does the current younger generation understand mental illness better, having been more exposed to it? Or do people simply become more intolerant with age? Hopefully the former. We usually try to avoid (i.e. ‘stigmatize’) people who we think pose a risk to us. In the past the fear was mainly of infection (leprosy, tuberculosis, etc.) but with mental illness it is of frightening or dangerous behaviour. It would be misleading to deny that mental illness is associated with a raised risk of violence. For most patients that risk is to themselves (suicide and self-harm) but individuals with psychosis are still about four times more likely to threaten or hurt others than non mentally ill individuals. This seems a lot but it represents a tiny risk as only 2–3 per cent of the population suffers from such disorders. The real risk to most of us is from otherwise healthy but intoxicated young men. Yet most countries are preoccupied with this risk, usually driven by high-profile cases of homicide by the mentally ill. In some cases this has led to new legislation, often taking its name from the victim (e.g. Kendra’s law in the US). In the UK wholesale reform of the mental health services has been ignited by two infamous homicides, one by a neglected individual with schizophrenia and one by a chaotic drug abusing man with a severe personality disorder. Similar reforms have been initiated in Sweden after the murder of their Foreign Minister Anna Lindh.

While each of these individual incidents is a tragedy for all involved, they really do not amount to an epidemic. In England, for example, homicide by the mentally ill has remained constant at about 160 a year for the last 40 years (while homicide by the non mentally ill has increased from just over 300 a year in 1980 to over 800 in 2000). Most of these ‘mental illness’ homicides occur within the family or are by individuals with personality disorders often complicated by drug and alcohol misuse (not what most of us typically think of as ‘mental illness’). However the fear of random assault by a psychotic individual, ‘prematurely discharged from a mental hospital’, exerts a remarkably powerful hold on public opinion. In the UK you are more likely to be killed by a speeding police car than by a mentally ill stranger.

Social consensus and the post-modern society

Concern with risk and its avoidance have been suggested as core features of a post-modern society. As common core values recede, protecting our individual survival and well-being becomes a dominant preoccupation. Whether or not one finds this argument convincing it is undeniable that Western societies are increasingly individualistic with less social consensus and greater risk consciousness. The emphasis of the 1940s and 1950s on shared social capital such as public schooling and health care has given way in varying degrees to a consumerist approach with an emphasis on personalized care. This has reflected, and in turn been driven by, massively increased social mobility both locally and internationally. Families have also become less central to how we function as adults and less stable in themselves. Modern industrial societies are rarely ‘homogeneous’ – there are large sections of society with quite differing origins, religions, values, and ethnicity. Despite its obvious benefits this can make psychiatry very difficult. Differing lifestyles and behaviour are accepted as choices and tolerated as long as they do not infringe the next person’s liberties. Most of us value these freedoms very highly. An increasing tolerance of varied lifestyle choices however can mean a reduced sensitivity to mental illness. When you can choose to dress and behave almost any way you want, it is harder to realize when somebody’s strange dress and behaviour are not simply self-expression but part of an illness. The over-active, disinhibited behaviour of manic patients is regularly misinterpreted as simply irresponsible or exhibitionist. Increasing uncertainty about social norms has been complicated by a vast increase in alcohol and recreational drug consumption in Western societies. Intoxication usually makes mental illnesses worse and their treatment more difficult. It also significantly complicates the recognition of mental illness – it is tragically common to assess a young student who has been unwell for months but whose room-mates attributed it all to drug use and so delayed getting help.

Stigma, an exaggerated sense of risk from the mentally ill, family break-up, high social mobility, and increasing levels of drug and alcohol use all combine to make community care of the mentally ill much more difficult than it was when the process started. This is reflected in a small but widespread rise in compulsory treatment and a modest increase in ‘reinstitutionalization’. This is balanced by a much more sophisticated and embedded respect for individual rights than would have been conceivable a generation ago. We are likely to experience continued soul-searching about community care and probably some rebalancing of the institution/community emphasis. A large-scale return to long-stay institutions is fairly unlikely in the coming years. Community care in one form or another is with us for the foreseeable future.

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(8) Psychiatry

What is psychotherapy anyway? A dialogue between psychoanalysts

Psychoanalysis and psychotherapy

psiquiatry8

Psychoanalysis and psychotherapy

Much of what characterizes psychotherapy characterizes normal life. We all try to help our friends and family by being supportive and talking things through when they are upset.

Many asylum doctors spent time in supportive conversations with their patients aiming to calm them and restore reason. This was broadly psychotherapeutic in aim. What is special about psychotherapies, however, is that there is an explicit agreement, almost a contract, between patient and therapist to set time aside to concentrate on it. They also follow a known and agreed approach, with clarity about what will happen and how long it will take.

The National Health Service in England calls psychotherapy ‘talking treatments’ or ‘psychological treatments’ to avoid old sectarian arguments about what is ‘true’ psychotherapy. It has a rather helpful hierarchy:

Type A comprises simple psychotherapeutic understanding employed during any treatment (e.g. counseling and support from a doctor prescribing antidepressants).

Type B involves dedicated sessions devoted exclusively to psychological understanding and emotional support. These use general psychotherapeutic principles but don’t follow a strict theory or have a prescribed number of sessions. An example would be a nurse having regular meetings with a depressed patient on the ward to talk through her situation.

Type C treatments are ‘psychotherapy proper’. Here the therapist has recognized psychotherapy training and there is a clear, shared undertaking to pursue a specified course of that psychotherapy.

We have labored this because some of the older psychotherapies are more evident in Type A and Type B treatments and are overlooked when not used as ‘proper’ Type C psychotherapies.

Sigmund Freud and the origins of psychoanalysis

No story of psychotherapy can ignore Sigmund Freud. Love him or loathe him, he is a towering figure who has radically altered not just psychotherapy but how much of the Western world thinks. Forced to leave his research and make a living for himself in private practice in Vienna. Most of his clientele was ‘neurotic’ and most was female. The commonest problems he saw were either ‘neurasthaenia’ (lack of motivation, mild depression) or a series of ostensibly physical complaints (paralyses, pains, seizures, etc.) for which there was no identifiable physical cause. Before reaching Freud they would have been subject to exhaustive medical examinations and treatments without benefit.

In over 50 years and 24 volumes of writing, Freud’s ideas changed significantly and they are sometimes contradictory. The outline that follows is, of necessity, simplified and partial but there are many detailed and accessible introductions.

Freud’s thinking was heavily influenced by the scientific models that surrounded him. Darwin’s Origin of Species had located mankind squarely in the natural world (not a special divine creation) so the mind became a legitimate subject for scientific investigation. The laws of thermodynamics (which gave rise to much of 20th-century physics) dominated scientific thinking then. These proposed that energy is never lost – simply transformed. Nineteenth-century Europe was economically booming; its industry driven by mechanical innovations such as trains, factory presses, and ships’ engines, all based on harnessing ‘conserved energy’. Whether water, steam, or internal combustion engines, they all demonstrated the enormous power of damming up energy and channeling its escape through a restricted outlet. Freud’s ideas of the human mind are shot through with this metaphor – whether blocked instinctual drives or repressed memories, he believed our greatest destructive and creative achievements stemmed from forces denied their natural release.

The unconscious and free association

If the laws of energy conservation applied to the mind then new ideas and feeling had to come from somewhere. Freud observed the impact of releasing ‘unconscious’ forces after visiting the French neurologist Charcot who used hypnosis to cure hysterical disorders such as fits or mutism. Freud initially found hypnosis and suggestion successful with many of his patients but the results were only temporary. He encouraged them, under hypnosis, to recall the events leading up to their illness and concluded that traumatic memories were the cause of many of their maladies. His conclusion from this was that patients are unaware of much of their ‘thinking’ – that some mental processes were unconscious. The harder one tried to remember the harder it got. Freud responded with the technique of ‘free association’ – encouraging the patient to stop trying to remember and instead say whatever came into their mind. Through these ‘random’ remarks, supplemented by recounting dreams, repressed thoughts leaked out in obscure ways (you can almost see him imagining steam driving pistons).

The analyst used his own unconscious to ‘listen’ to these remarks, detecting patterns and so directing the patient to the source of their troubles. Hence a ‘Freudian slip’ is when someone reveals their true thoughts by mistake. Freud became obsessed with the need not to interfere with this free association. The ‘blank screen’ therapist should reveal nothing about themselves, often sitting behind the patient and never answering questions or giving reassurance. It is hard to imagine, looking at the picture of his consulting room, and knowing about the controversy that accompanied him throughout his life, how Freud could ever believe he was a blank screen. Nineteenth-century bourgeois Vienna was a very inhibited society. Not surprisingly many of the unconscious conflicts that Freud uncovered were sexual. Initially he believed that his patients had been sexually abused but he changed to a belief that these descriptions were more often fantasies and wish-fulfillments. He went on to propound his theory of infantile sexuality – that even very small children have strong ‘sexual’ feelings about their parents.

This, of course, caused uproar, and in many circles still does. The language is clumsy but the ideas do help make some sense of the intense and powerful dynamics children set up in families. The Oedipus complex is his most famous construct. Freud proposed that at about 3 years old the young boy desires his mother and sees his father as a rival for her affections (based on the Greek myth of Oedipus who killed his father and married his mother). Put like that it is pretty unhelpful, but it is an insightful way to understand how some people never learn to share important relationships. In the process of striving for exclusive intimacy they destroy what they want most. It made sense of many of the patients Freud saw (as it does even today).

Ego, id, and superego

Freud originally believed that the conscious mind was entirely rational and contrasted with the more primitive, less logical, unconscious mental processes. This may explain some of the exaggerated terminology he used when discussing it. However he was struck by the brutal, punitive consciences of some of his patients. How could something as noble as conscience drive a patient to suicide through guilt? His solution was to describe the conscience as derived from both conscious thoughts and also from powerful unconscious remnants of parental and social demands.

His map of the mind expanded from two areas (unconscious and conscious) to three. He called the primitive unconscious the id (‘it’), the conscious mind the ego (‘I’) and the conscience the superego (literally ‘over I’). All of these terms are now in common use. Defense mechanisms Early psychoanalysis was about enabling the patient to discover repressed conflicts. Initially Freud and his growing band of colleagues thought that this was sufficient. However, as analyses got longer and more complex, analysts encountered ‘resistance’ where patients appeared to block change using various psychological defense mechanisms. One of the most troublesome ‘resistances’ for Freud was that patients kept falling in love with him (or at the least seeing him as a father figure). At one level this helps – if the patient likes you they are more likely to do what you ask. However, these strong feelings (he called them ‘transference’ because he thought they were transferred from important figures in the patient’s past life) made the exploration of free association almost impossible.

Having initially seen transference as exclusively a problem Freud began to exploit it in the analysis. This ‘analysis of defense mechanisms’ became an essential part of the treatment. There were certainly many blind alleys in Freud’s work – no surprise in a man who wrote so much. He made us aware of the power of unacknowledged thoughts and how the past can continue to haunt lives. Perhaps more importantly he showed that a brave attempt to confront and understand the origins of the misery (not simply to offer support and comfort) can lead to real liberation and relief. He also (against his own wishes, no doubt) showed how an honestly entered reflective human relationship can itself be the tool for recovery from quite severe mental illnesses.

Freud was a pessimist (particularly after the carnage of the First World War) and never promised happiness. The aim of psychoanalysis, he wrote, was to help a patient ‘to work and to love’. No more, no less. The rigidity and grandiosity of many of his successors has tarnished his reputation. His claims to have been a scientist are questionable and his treatment, psychoanalysis, is under siege for its failure to prove effectiveness. However, he has probably contributed as much to understanding and tolerance in the care of the mentally ill as any other individual. His insistence on taking the patient’s past seriously and his vivid metaphors for mental processes appeal to therapists and patients alike. They have formed the basis for a humane working relationship for which he deserves more credit than is currently his lot.

Jung

Freud collected about him a glittering band of followers. As often with such creative groups there were tensions, conflicts, and schisms. Several took the approach in differing directions and their individual fames have waxed and waned. Probably Carl-Gustav Jung (1875–1961) has had the most lasting influence. While Freud called himself a ‘Godless Jew’ with little sense of the spiritual or transcendent, Jung’s theories were more mystical. They included such constructions as a racial unconscious with ‘archetypes’ (symbolic figures which we all share). Jung also emphasized the importance of opposites in the human personality and how a ‘shadow self’ develops from aspects of our personality that we fail to acknowledge. Jung probably suffered a psychotic breakdown himself and drew on some of these deeply irrational experiences.

Unlike Freud he believed that therapy could promote deep personal fulfillment and his approach is attractive to those who work with very ill patients and in artistic circles. Jung’s most persisting contribution, however, is probably his elaboration of the introvert and extrovert personality types. These have entered common language and are in daily usage by millions unfamiliar with even his name.

Psychodynamic psychotherapy

Psychoanalysis was closely associated with Jewish practitioners in its infancy and became a target for Nazi persecution in the 1930s. As a result most practitioners had to leave and most moved to the US, England, and South America. In all of these places their work and teaching came to have an enormous influence on psychiatry – much more than in their native German-speaking countries.

The Second World War put extra demands on psychoanalysts who turned their attention to traumatized soldiers and, surprisingly, the understanding of organizations (in particular the army). Out of this arose group analysis and group therapies where patients were treated in small groups of 5–8 so that they benefited from solidarity and support as well as insight. Group work led to the development of the therapeutic community where analytical and psychological insights are applied to running a unit (rather than individual treatments). This informal, communal approach (with staff and patients sharing many of the tasks of running the place) was called ‘sociotherapy’ and has become a standard feature of modern psychiatric practice, drug rehabilitation units, and some prisons.

The endlessness of classic psychoanalysis (often taking several years at three to five sessions a week) has been strongly criticized. It is prohibitively expensive and many believed that shorter therapies would focus the mind better and improve outcomes. Typical ‘short-term’ therapies now last three to six months with weekly sessions of an hour. Interpersonal therapy focuses on relationships and cognitive analytical therapy uses specific exercises like letter writing and prescription of homework as part of the treatment.

While still maintaining strict professional boundaries therapists are increasingly more active. These are usually called ‘psychodynamic’ psychotherapies because they attribute such importance to dynamic interactions between the past and the present and between conscious and unconscious processes. The individual’s life story, their ‘narrative’, is central to understanding and resolving their problems. All require the therapist to hold back from giving too much direct advice so that the patient can, with guidance, find their own solutions. These therapies are routinely combined with other psychiatric treatments (antidepressants, hospital care, etc.).

Non-specific factors in psychotherapy

Most psychodynamic psychotherapists are intensely loyal to their model, convinced of the specificity of their treatment. Unfortunately the evidence is against them. There is depressingly little research into psychodynamic psychotherapies (unlike cognitive behavioural therapies) but what there is makes interesting reading. Experienced therapists who follow their training closely do much better than novices, or those who apply their model loosely. However, which model doesn’t seem to matter so much – they are all about equally effective. Most of this research confirms the crucial importance of establishing a good therapeutic relationship.

The qualities of a good therapist transcend the different schools of thought. The essential ingredients are accurate empathy (the therapist must really understand what the patient is going through, it is not enough just to feel sorry for them), unconditional regard (the therapist has to like and respect the patient, you can’t do therapy with someone you really dislike), and non-possessive warmth (the therapist must be able to show warmth without making the patient feel beholden to them). These insights are particularly useful in psychiatric practice. Matching patients and therapists really does matter – not all of us can get on with everyone. To work with violent or sexual offenders, for instance, requires a particularly tolerant and forgiving individual.

Existential and experimental psychotherapies

Several schools of psychotherapy have evolved which utilize the techniques of psychodynamic psychotherapy without accepting the theory. Existential psychotherapy, as its name suggests, makes no assumptions about what people ‘should be like’ but focuses on helping the patient express their identity in their own chosen way. Existential psychotherapies have some affinity with Jungian approaches and have become more popular as society becomes less rigid and conformist.

Freud’s patients usually knew what their families and societies expected of them and were anguished because they could not achieve it. In the early 21st century we are more likely to experience aimlessness and emptiness rather than guilt at not living up to expectations. Alienation and confusion are now the dominant complaints so psychotherapies have become more structured to provide boundaries and containment.

These more here-and-now therapies blend imperceptibly into the personal growth movement. It can be difficult sometimes to decide whether a gestalt therapy or encounter group is a treatment to reduce suffering or an exercise to increase personal happiness and fulfillment. Perhaps it doesn’t matter what the purpose is so much as who gets it. There can be little doubt that depressed and demoralized psychiatric patients benefit greatly from activities such as these which improve general morale and self-esteem. In the treatments of self-harming young women, addressing self-esteem directly may be one of the most effective interventions.

Psychodynamic psychotherapies are currently under attack in psychiatry. They are criticized for inadequate research to establish that they really do work. Also, the requirement for therapists to undergo treatment themselves and to continue with supervision throughout their professional lives compromises objectivity and smacks of a ‘cult’ rather than a profession. Some research has been conducted in the short-term dynamic therapies and their results are generally good. However, more detailed studies to identify which aspects are effective, and which redundant, remain to be done. The opportunity may even have passed. So many of the core features of psychodynamic psychotherapy are now absorbed into routine care (the Type A and B treatments referred to above) that their contribution as specific treatments may be difficult to isolate and evaluate.

The strength of criticism is not surprising as psychoanalysis really did oversell itself. In America (North and South) between 1940 and 1970 it virtually drove all other thinking out of mental health care – most people thought that a psychiatrist was a psychoanalyst. Psychotic patients, for whom analysis had little to offer, were neglected, as were the basic skills of diagnosis and treatment. Critics accused American psychiatry in this period, with its high status and expanding workforce, of simply turning its back on the severely mentally ill and on science altogether. President Kennedy tried to refocus the profession in the early 1960s but without success and it required the pharmacological revolution to achieve it.

A more scientific and self-critical psychiatry, obliged to establish itself with hard won research data, has taken its revenge on psychoanalysis (and some would say is now making many of the same mistakes).

The newer psychotherapies and counseling

The last 40 years have seen the development of a whole series of new psychotherapies that are radically different. They pay far less attention to understanding the past. The therapists are usually more directive – they give instructions and opinions, not just further encouragement to the patient to continue reflecting. Many involve specific exercises and ‘homework’ that is reviewed in sessions. They last month are not years. The psychotherapist acts much like any other mental health professional and avoids the mystique surrounding psychodynamic therapists.

Person-centered (often called Rogerian) counseling is one such approach. The distinction between counseling and psychotherapy is variable and unclear. Counseling is often offered at times of personal crisis to people we would not usually consider as ‘ill’. Its aims are more modest than those of formal therapies. It draws on the characteristics of a good therapist outlined above, and provides a ‘safe space’ for the individual to explore their concerns. Here the therapist is non-directive. They rarely give opinions or advise the patient what to do or think, and often simply repeat the patient’s last phrase as encouragement to continue reflecting. Counseling is a skill highly prized by many mental health professionals and clearly valued by patients.

Family and systems therapies and crisis intervention

Family therapies have become very important in the treatment of psychiatrically ill children. Family therapists generally avoid implying a role for the family in causing the illness, but sometimes it is impossible for a patient to get better unless the family changes its way of responding. In anorexia nervosa, for instance, a family may have become so anxious about their daughter’s illness that they cannot allow her the freedom to take necessary risks and so mature. They may need help to back off and contain their anxiety. Sometimes the same can occur with adult patients where family therapy often helps couples shift the balance in their relationship. Family therapy usually relies on a ‘systems’ approach where the whole family is the focus, not the individual members.

‘Behavioral family management’ using a problem-solving approach helps families of schizophrenia patients. Patients break down more often if they live in highly emotional families – especially where there is tension and criticism. It may be very difficult for the family to avoid this, so the treatment is aimed at identifying flash-points in the relationships and finding alternative solutions (e.g. going into another room rather than arguing back). This has been shown to reduce breakdown rates by almost as much as medicine, but is protracted and difficult to do.

Crisis therapy is in here with systems therapies because it deals with immediate issues. You don’t have to dig around in crisis or family therapy – it’s all there in front of you. Crisis therapy is dramatic, often ultra short-term, and handles strong emotions, often with limited attention to their origins. While the family therapies are generally well established there remain doubts about crisis therapy. Some researchers suggest, for example, that debriefing after trauma can even make things worse. Presumably it interferes with the healthy processes of forgetting distressing events.

Behavior therapy 

Behavior therapy principles are about as different from psychodynamic psychotherapy as it is possible to be. They are based on learning theory which made a virtue of removing ‘consciousness’ from the equation – change is explained by reflex learning. Behavior therapy is indelibly associated with B. F. Skinner who demonstrated that you could train rats in quite complex behaviors simply by rewarding the behavior you wanted (‘operant conditioning’) or, alternatively, ‘punishing’ the behavior you wanted to stop. Behavior is ‘shaped’ in small steps, one at a time.

The unique aspect of behavior therapy is that it is irrelevant whether the subject agrees or even knows what is going on – the learning is completely unconscious. Behavior therapy can be staggeringly effective – think how easy it is to ride a bike and yet you probably have never ‘consciously’ learnt. You just tried it and each time it started to go wrong your body compensated, and now you are supremely skilled. Behavior therapy works like that. It has proved particularly effective in treatments for individuals with learning disabilities and with children. A simple example of operant conditioning is the bell-and-pad system for nocturnal enuresis (bed wetting). A bell rings as soon as the pad gets wet, waking the patient. Over time he starts to wake up when his (it is usually his) bladder is full, as that sensation becomes associated with the bell and being woken. This successful treatment is widely used despite contradictory beliefs that bed wetting is either evidence of neurotic problems or, the opposite, that it is predominantly genetic.

Behavior therapy is extensively used for phobias and for obsessive compulsive disorders. The patient is gradually exposed to the feared stimulus (e.g. a dirty hand for someone with obsessions about germs) while restricting avoidance and monitoring anxiety to ensure it remains tolerable. In practice behavior therapists still take detailed histories because, without a good therapeutic relationship, patients drop out of treatment.

Cognitive behavioral therapy

Cognitive behavioral therapy could be considered a sophisticated extension of behavior therapy, although it could also be viewed as an adaptation of psychodynamic psychotherapy. It lies somewhere between the two. It was developed by an American psychiatrist, Aaron Beck. He was a psychoanalytically trained psychiatrist who found a proportion of patients did not benefit from his psychoanalysis. On the whole they were people who valued mastery of their symptoms more than understanding them. His exploration, particularly of depression, convinced him that it was unconscious and pathological thoughts as much as feelings that were trapping his patients. He developed a therapy to enable patients to identify ‘automatic negative thoughts’ (self-critical, self-defeating beliefs and conclusions) and to train them in how to challenge and contradict them.

His method emphasized ‘Socratic Dialogue’. Socrates believed that all you needed to teach truth was to keep asking the right questions and people found the answers within. Whenever the patient expresses a pathological doubt – e.g. ‘I got it wrong at work today.

There’s no future for me’, the therapist asks them to explain it – ‘Explain to me why there is no hope.’ He contrasts the thoughts with the reality of the situation – ‘Explain how it is that you’re still being promoted at work then, despite these mistakes?’ CBT is now an essential part of psychiatric practice and training and is a standard ingredient in the treatments of depression and anxiety.

It is also being increasingly used in a whole range of disorders including schizophrenia with intractable hallucinations or delusions and also physical disorders with a significant psychological component.

Self-help

It may not be psychiatry, but the self-help movement has grown out of the psychotherapy tradition. Alcoholics Anonymous, Weight Watchers, The Depression Alliance, have all begun to apply what they have learnt, and more. Accurate empathy and unconditional regard – who better than someone who has been through it? Who less likely to condemn than someone with the same problems? Non-possessive warmth – what better source than shared suffering and real fellow-feeling? Self-help groups constitute a folk movement of our times which relieves distress and isolation and reduces stigma. Self-help books and computer programmes are increasingly available for common disorders like anxiety and depression. It is too early to judge their impact but they certainly get the popular vote.

After 200 years of psychiatry it seems strange for psychotherapy to be restricted to its own short chapter. Can it really be considered independent from psychiatry or psychiatry independent from it? Psychotherapy has been a defining characteristic of the psychiatric craft – just as a surgeon operates, a radiographer reads x-rays, an obstetrician delivers a baby. Asylum doctors of 150 years ago spent time talking with distressed patients to bring understanding, comfort, and relief. In the second half of the 20th century this personal relationship was why most staff came into the profession.

Yet as we start the 21st century psychiatry and psychotherapy are increasingly considered as parallel activities. Is psychiatry changing fundamentally? Time will tell if they are to grow together again or to continue to pursue increasingly independent paths. 

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(9) Psychiatry

WORLD HEALTH ORGANIZATION - Schizophrenia

Schizophrenia - Full documentary on how schizophrenia effects individuals and relationships

SCHIZOPHRENIA-NEWS - Schizophrenia Special in Nature Journal May 22,2014

NATIONAL INSTITUTE OF MENTAL HEALTH - Schizophrenia

schizophrenia

 

Schizophrenia is a serious disorder which affects how a person thinks, feels and acts. Someone with schizophrenia may have difficulty distinguishing between what is real and what is imaginary; may be unresponsive or withdrawn; and may have difficulty expressing normal emotions in social situations. Contrary to public perception, schizophrenia is not split personality or multiple personality.  The vast majority of people with schizophrenia are not violent and do not pose a danger to others. Schizophrenia is not caused by childhood experiences, poor parenting or lack of willpower, nor are the symptoms identical for each person. After noting that one percent of the world's population suffers from this disability and describing its symptoms, experts discuss how this insidious disease affects the human brain and a person's ability to function socially. Fortunately, some afflicted individuals are able to achieve a high state of functioning, including Dr. John Nash Jr., who won a Nobel Prize in Economics. However, most spend their lives struggling to cope with hallucinatory voices and the potent drugs designed to control all of the troubling symptoms of the illness. Case studies and interviews help illustrate how various people are trying to live with this disease. 
The signs of schizophrenia are different for everyone. Symptoms may develop slowly over months or years, or may appear very abruptly. The disease may come and go in cycles of relapse and remission.
Behaviors that are early warning signs of schizophrenia include:

  • Hearing or seeing something that isn’t there
  • A constant feeling of being watched
  • Peculiar or nonsensical way of speaking or writing
  • Strange body positioning
  • Feeling indifferent to very important situations
  • Deterioration of academic or work performance
  • A change in personal hygiene and appearance
  • A change in personality
  • Increasing withdrawal from social situations
  • Irrational, angry or fearful response to loved ones
  • Inability to sleep or concentrate
  • Inappropriate or bizarre behavior
  • Extreme preoccupation with religion or the occult

Schizophrenia affects about 1% of the world population. In the United States one in a hundred people, about 2.5 million, have this disease. It knows no racial, cultural or economic boundaries. Symptoms usually appear between the ages of 13 and 25, but often appear earlier in males than females. If you or a loved one experience several of these symptoms for more than two weeks, seek help immediately.

Psychiatry under attack –inside and out

Psychiatry has always been controversial – there never was an extended ‘Golden Age’ of peace and tranquility when everyone was in agreement. You probably read these texts after some heated discussion about the rights and wrongs of something psychiatrists do. Because it deals with the mind, and because psychiatrists can act against our wishes, it will always generate a degree of suspicion and fear. And it isn’t good enough simply to put this down to ignorance and say that if people knew more they wouldn’t have such concerns. There are very real questions to be asked about psychiatry – both about its legitimacy, its status as ‘just another medical specialty’, and also about how it is practised. The power of modern medicine invariably brings ethical challenges and controversies and psychiatry has its fair share. These will be taken up more in later. This text will focus on the contradictions and tensions which are inherent in psychiatry that stem from its very nature, rather than problems with practice.

Mind–body dualism

The French philosopher René Descartes (1596-1650) is often blamed for how we distinguish between the mind and the body in Western thought (often referred to as ‘Cartesian dualism’). His ‘cogito ergo sum’ (‘I think therefore I am’) is snappy and memorable; it expresses his scepticism about certainty in knowing about the material world. It is hard to understand why he has been singled out for all the ‘blame’ for an issue which exercised most of his empiricist philosopher contemporaries. He didn’t invent the problem of the mind; he simply put some of the issues better and they remain essentially unresolved 350 years later. What the mind is, and how it interacts with the material world, still remain mysteries. Most of us do think there is a difference and most of us accept that there is an interaction. We have to live our lives believing we can directly influence the material world (e.g. I decide to stretch out my arm and expect to turn on the computer). We also need to believe that we can know the minds of others (e.g. I’m sure that you will go to the library or hand in your essay). Without these beliefs we would effectively be paralysed.

The mind–body question is unavoidable in psychiatry. The relationship between the mind and the brain is the big issue. It would be simple if psychiatry were just about ‘brain diseases’ in the way that nephrology is about kidney diseases or cardiology is about heart diseases. Psychiatry, however, is concerned with ‘mental’ illnesses. We know that many mental illnesses involve disorders of the brain (e.g. disturbances in transmitter chemicals between cells in depression and schizophrenia) but not all brain diseases are mental illnesses or the responsibility of psychiatrists. Multiple sclerosis and Parkinson’s disease are both undeniably brain diseases but it is neurologists, not psychiatrists, who deal with them. These neurological disorders often cause psychiatric problems, just as a wide range of physical disorders can. Many psychiatric disorders include physical symptoms (e.g. tiredness and pain), just as physical disorders include psychiatric symptoms (e.g. depression, anxiety, and even hallucinations).

Psychiatric disorders are those where the main disturbances are in  thoughts, feelings, and behaviour. Physical diseases don’t just have physical causes and cures and mental diseases have mental causes and cures. Illnesses can have physical causes and even physical cures (e.g. a depression caused entirely by Parkinson’s disease which is effectively treated by antidepressant tablets) and still be ‘mental illnesses’. The division is based on the main disturbance and on the skills needed to help the patient. ‘Mental disorders are brain disorders’ has been a popular slogan with some psychiatrists and patient groups. Its purpose is to emphasize the similarity between mental and physical illnesses, reducing stigma and blame. These are admirable goals but it is an oversimplification.

Psychiatry has to struggle with an ambiguity fought out on two main battlegrounds.

Nature versus nurture: do families cause mental illness?

Whether you’re tall or short, whether you’re good at sport or hopeless, most of us believe this depends on a mixture of our genes (the biological potential we were born with) and our upbringing (our diet, exercise regime, even the sort of school we went to). Nothing controversial in that. The moment we mention psychology, however, the balloon goes up. Is IQ inherited or could everyone do just as well with the same opportunities? Is personality or criminality something we’re born with or can we change it? Can we avoid depression by healthy living? Few issues polarize us as much as how changeable we believe human behaviour to be. The disagreements are not just calm, academic ones but fuel (and are fueled by) political and social beliefs reflecting fundamentally different worldviews.

Psychiatry originally was very much at home in the ‘nature’ camp – mental illnesses ran in families and were inherited weaknesses. It was our job to ameliorate them and make life as bearable as possible, hoping for a speedy recovery. Freud and his followers began to change all that, shifting the balance to ‘nurture’. Psychoanalysis is firmly based on the belief that what happens to us in early life, and the memory of those experiences, is the cause of many illnesses. Even more convincing, Freud showed that addressing those memories could cure some mental illnesses. So an individual’s personal history (their ‘narrative’) wasn’t just the context for understanding their illness but possibly its origin.

Psychoanalysis dominated psychiatric thinking and training from the 1940s to the 1970s. The attraction of psychoanalysis to the Americas should come as no shock. After all, these societies were established by those who escaped the pessimistic fatalism of Europe with its fixed social orders and hereditary monarchies and aristocracies. Those who moved west were those who rejected this and grasped the opportunity for each individual to shape their own future. No surprise then that they espoused a psychology that enshrined this capacity for growth, where the individual could overcome early limitations and forge their own destiny. The role of nurture and experience was strengthened by observations of battle trauma in both world wars. The revelation of the eugenic and racist policies of Nazi Germany (including the liquidation of ‘genetically inferior’ psychiatric patients) finally guaranteed nurture’s moral unassailability.

An attraction of emphasizing nurture is that it holds out much greater possibility of cure. If mental illnesses are essentially caused by relationships then they should be curable by relationships (i.e. psychotherapy). However, the downside of this approach is its potential for blame – in particular blaming parents. Freud himself quickly realized these risks when he began to suspect that the reported sexual abuse by parents (which he originally considered the cause of his patients’ neuroses) might be fantasies. The great German psycho pathologist and philosopher Jaspers pointed out that, while understanding the personal relevance of symptoms was essential in psychiatry, it was not the same as understanding what caused the illness. Such fine distinctions have not, however, generally characterized this debate publicly.

The origins of schizophrenia

This controversy has raged most fiercely over the origins of schizophrenia. Schizophrenia had always been known to run in families and it had been observed that these families could seem ‘odd’ (eccentric or withdrawn), often with strained or intensely over-involved relationships. As schizophrenia is a disorder expressed in thinking and relating there is an obvious possible link between it and early upbringing. Family life is, after all, conducted through thinking and relating and aims to equip the growing child with skills in these areas. As psychoanalytical thinking was applied to schizophrenia (something that Freud explicitly avoided) a number of theories were proposed, some of which had enormous influence and have entered the language.

The ‘schizophrenogenic mother’

The most notorious (and probably the most damaging) of these was that of the cold, hostile, and yet controlling parent – the ‘schizophrenogenic mother’ (literally ‘schizophrenia-causing mother’). This was proposed by the analyst Frieda Fromm-Reichmann who, along with Harry Stack Sullivan, engaged in long-term intensive psychoanalysis with hospitalized schizophrenia patients in the USA. Her most famous patient, Joanna Greenberg, later described her experiences in her best-selling autobiographical novel I Never Promised You a Rose-Garden. Fromm-Reichmann described a powerful, but cold and rejecting mother figure who bound the patient close to her, preventing the growth of healthy independence and sense of self. Schizophrenia was then understood as a disorder of ‘ego-development’ resulting in weak personal boundaries (hence the confusion of internal and external experiences in hallucinations). Fromm-Reichmann’s conclusions are preposterous by current standards. She based them entirely on her patients’ reports in analysis and never actually bothered to meet or interview the mothers. It is reputed that her ideas derived from the analysis of only 11 patients. Despite its early rejection within the profession, the conviction lives on those families can ‘cause’ schizophrenia. This has led to endless self-blame by parents and, in some circumstances, their rejection and exclusion by mental health staff.

The ‘double-bind’

The anthropologist Gregory Bateson proposed that persistent, logically faulty, and contradictory communication with a child prevented it forming a proper sense of itself and its relationships to the external world. Bateson was influenced by Bertrand Russell and A. N. Whitehead’s mathematical writings. One of their proposals was that the number which designated a series of numbers could not itself be a member of that series – as the designating number was of a ‘logically different order’. Bateson said that there were similarly logically different levels of communication and that we sent messages to each other (often in an oblique manner) where one part of the message indicated how the main part should be understood. He called these oblique messages ‘meta-communications’ (i.e. Communications about communication). Typically meta-communications were emotional and non-verbal and became family assumptions (e.g. ‘mother can only love her children and always feel positive about them’).

Bateson called it a double-bind when the non-verbal message and verbal message contradicted each other (e.g. an obviously angry mother saying she didn’t mind at all that the child had broken a glass and holding her arms out for an embrace). A double-bind required three components: a clear simple message, a contradictory meta-communication, and an absolute ban on the contradiction being acknowledged. All three were necessary but it was probably the family culture of denying the contradiction that was most pathological. After all, all families give contradictory and confusing messages. The term ‘double-bind’ is now used loosely to imply any contradictory communication but Bateson’s theory was much more precise.

These theories have all been conclusively demolished by careful scientific examination. One approach was to get independent researchers to listen to tapes of families with and without schizophrenia and rate the occurrence of double-binds, or to interview families and rate them for coldness, hostility, over involvement, etc. Reliable differences were simply not found. Adoption studies, however, delivered the coup de grace. Very rigorous studies of children adopted away at birth to healthy families found rates of schizophrenia when they grew up just as high as if they had been brought up with their schizophrenic mother. Similarly twins adopted away at birth to different families demonstrated the same difference in rates between identical and non-identical twins found in those brought up in their natural families. None of these risks are 100 per cent and clearly upbringing and environment have quite a lot of influence.

While family influence as the cause of schizophrenia has been conclusively dismissed it remains implicated in the course of the illness. Individuals with schizophrenia in highly emotionally charged families are likely to break down more often. This could, of course, be because families with more severely ill members are more stressful. However, training families to respond less emotionally does reduce the rate of breakdown, so high expressed emotion probably does have an effect.

Social and peer-group pressure

While family influence has been questioned, wider social influences have received increasing recognition in the last half century. For example, the rise in eating disorders (anorexia nervosa and bulimia) has spread from the West, closely tracking the cultural ideal of thinness in women. The epidemic of self-harm (particularly overdosing and cutting in younger women) is clearly affected by group norms and expectations. Local outbreaks can often be linked to specific events such as suicide attempts in TV soap operas. Alcohol and drug use are highly variable between different cultural groups (both between and within nations) and the power of group expectations on such behaviours is undeniable. These are enormously important public health issues and the status of these behaviours as ‘mental illnesses’ will be picked up again in later.

Evolutionary psychology

The fading relevance of the nature–nurture argument has recently been revived by the rise of evolutionary psychology. A more sophisticated understanding of Darwinian evolution (survival of the fittest) has led to theories about the possible evolutionary value of some psychiatric disorders. A simplistic view would predict that all mental illnesses with a genetic component should lower survival and ought to die out. ‘Inclusive fitness’, however, assesses the evolutionary value of a characteristic not simply on whether it helps that individual to survive but whether it makes it more likely that their offspring will survive. Richard Dawkins’s 1976 book The Selfish Gene gives convincing explanations of the evolutionary advantages of group support and altruism when individuals sacrifice themselves for others.

A range of speculative hypotheses have since been proposed for the evolutionary advantage of various behaviour differences and mental illnesses. Many of these draw on ethological games-theory (i.e. The benefits of any behaviour can only be understood in the context of the behaviour of other members of the group). So depression might be seen as a safe response to ‘defeat’ in a hierarchical group because it makes the individual withdraw from conflict while they recover.

Mania, conversely, with its expansiveness and increased sexual activity, is proposed as a response to success in a hierarchical tussle promoting the propagation of that individual’s genes. Changes in behaviour that look like depression and hypomania can be clearly seen in primates as they move up and down the pecking order that dominates their lives.

The habitual isolation and limited need for social contact of individuals with schizophrenia has been rather imaginatively proposed as adaptive to remote habitats with low food supplies (and also a protection against the risk of infectious diseases and epidemics). Evolutionary psychology will undoubtedly increasingly influence psychiatric thinking – many of our disorders fit poorly into a classical ‘medical model’. Already it has helped establish a less either–or approach to the discussion. It is, however, a highly controversial area – not so much around mental disorders but in relation to social behaviour and particularly to gender specific behaviour. Here it is often interpreted as excusing a very male-orientated, exploitative worldview. Luckily that is someone else battle.

Why do families blame themselves?

If so many of the family theories have been discredited why spend so much time on the issue here? Family theories in mental illness continue to exercise a remarkably powerful hold over us despite the evidence. And not just in schizophrenia but in depression, anorexia nervosa, personality disorder, drug and alcohol abuse, etc.

Parents seem to have an endless capacity to blame themselves for what happens to their children (and perhaps children to blame their parents). This is probably because we need to believe it. Just as we need to believe in free will and our influence on the outside world, family members need to believe that they influence each other. If we didn’t why would we bother? The evolutionary psychologists would say that parents need to believe it to invest years and years bringing up their children. We’re biologically programmed to look after our children so we need some belief system to support it (just as they might say we’re biologically programmed to mate and need to believe in love to support it). It is proposed that such a belief is a mechanism for sustaining our attention to our biological task.

The downside is, of course, guilt and blame. If we believe we have an influence we feel we have failed if things do not work out well. It is inescapable. Even in expressed emotion work where therapists insist emphatically that no one is to blame and that the aim is solely to find more effective coping strategies, families do feel blamed. ‘If only we weren’t so over-involved he would not have so many relapses.’ ‘Other families must have dealt with it better otherwise how would the therapist know what to advise?’ For some families feeling responsible, despite the guilt, is preferable. It implies the logical consequence that there must be something they can do to influence the outcome.

Cultures which value resignation are less likely to blame themselves (high expressed emotion is less common in India than in Europe).

The anti-psychiatry movement

Arguments over mind and brain and nature and nurture have always been part of psychiatry and are likely to remain so. They supported the most sustained and celebrated ‘external’ onslaught on psychiatry. This occurred during the 1960s and 1970s in what came to be called the ‘anti-psychiatry movement’. The mental hospital scandals of the early 1960s and publication of Erving Goffman’s Asylums had prepared the ground for a devastating attack. This was not to be a criticism of some of psychiatry’s practices or of failures in the system; this was to be an assault on the very legitimacy of psychiatry.The anti-psychiatry message was that psychiatry did not so much need improving as scrapping. At its best it was confused and confusing and at its worst a truly evil instrument of oppression masquerading as a benign medical practice. Three charismatic authors came to personify the movement. Two were practising psychiatrists. Their books became campus bibles in the late 1960s and the 1970s at a time of widespread student unrest and they were hugely influential in the Paris student revolt of 1968 and its international consequences.

Thomas Szasz, a Hungarian immigrant to the US, rose to fame with his book The Myth of Mental Illness in 1961. In this he argued that ‘mental illnesses’ were fabrications to deny socially deviant individuals their legal rights. He argued vigorously against involuntary treatment and for the separation of psychiatry and the state and the abolition of the insanity defence. He believed that those judged mentally ill should be treated equally and held accountable for their actions (i.e. psychotic individuals should have the right to refuse treatment and be sent to prison if they break the law, even when demonstrably unwell). He often drew on hysteria as his model of mental illness (probably reflecting his experience as a psychoanalyst in New York), which has limited the power of his case. It has been suggested that his extreme libertarian standpoint and opposition to compulsion stemmed from his experiences under Soviet occupation. He is regularly quoted by the Church of Scientology in their opposition to state run and coercive psychiatry.

Michel Foucault was a French philosopher who believed that the concept of mental illness was an aberration of the post-Enlightenment age. He objected to the classification of identities, arguing that the existence of madness did not entail the identity of madman. His book Madness and Civilisation challenged the very basis of psychiatric practice and cast it as repressive and controlling (rather than curing and liberating). His work had enormous influence in Continental Europe (most evident in Basaglia’s reforms in Italy). However, his writing is dense and difficult to absorb and he is more often quoted than read.

The most accessible and influential of the anti-psychiatrists was R. D. Laing. A Glaswegian psychoanalyst with a brilliant mind and lucid prose style, he turned the psychiatric world upside down with a series of best-selling books. An original and impulsive man, his views changed throughout his career and like Freud he didn’t feel the need to acknowledge these radical changes or explain them. His first, and most influential book, was The Divided Self: An Existential Study in Sanity and Madness (1960). He called his position ‘existential phenomenology’ (don’t ask!) and proposed that the delusional thinking of the schizophrenia patient was simply a different take on the world.

He argued that this could be challenging but it was essentially creative and, with enough imagination and moral courage, could be understood. However, these different worldviews threaten our security so we seek to deny them by imposing a diagnosis and ‘pathologizing’ them.

The book is filled with vivid descriptions of patients Laing had treated, accompanied with the most moving and imaginative interpretations of their dilemma. The impression given of psychosis by The Divided Self was of a tormented and rather heroic individual communicating vivid, authentic experiences, only to be met with a cowardly and mean-spirited rejection from society. R. D. Laing (1927–1989): the most influential and iconic of the anti-psychiatrists of the 1960s and 1970s not deny the suffering; his was essentially a romantic view of madness which (paradoxically) increased recruitment into psychiatry at the same time that it attacked it. Like Szasz, Laing never called himself an anti-psychiatrist (a term coined by his colleague David Cooper in 1967), and continued to practise, albeit in unorthodox ways.

Laing’s second ‘phase’ was his belief that families contributed to schizophrenia by denying the emerging identity of their child. Sanity, Madness and the Family: Families of Schizophrenics, with Aaron Esterson, cast schizophrenia as a response to repressive and rejecting parenting. The film inspired by it (Family Life, 1971) struck an international chord. Laing’s third phase was inspired by his extensive experimentation with LSD, so common at that time.

The Politics of Experience and the Bird of Paradise, published in 1990. The remains of the psychiatry department in Tokyo – students burnt it down after R. D. Laing’s lecture in 1969 1967, conceived of psychosis as a psychedelic voyage of discovery in which the boundaries of perception were widened, and consciousness expanded.

Laing was an improbable candidate for such an influential role. He started his psychiatric career as an army psychiatrist. His personal life was turbulent, with several marriages and many children. As a lecturer he ranged from the inspirational to the frankly intoxicated and unintelligible. His ability to galvanize anti-establishment feeling was so powerful that after a lecture to the student body in Tokyo in 1972 they went off and burnt down the department of psychiatry! He remained a radical until his death, aged 62, surprising all who knew him by collapsing while engaged in the outrageously bourgeois activity of playing tennis on the French Riviera.

Anti-psychiatry in the 21st century

The contradictions inherent in psychiatry which generated the anti-psychiatry movement in the 1960s and 1970s have not gone away. Mind and brain, freedom and coercion, the right to be different (perhaps even the duty to be different), nature and nurture remain live issues. Many (though by no means all) ex-patient groups have become militantly anti-psychiatric, often referring to themselves as ‘survivors’ rather than patients, clients, or service users. In Germany and Holland the state contributes to hostels and crash pads for individuals who have ‘escaped’ routine mental health services. The most high-profile anti-psychiatry group is probably the Church of Scientology. While much of their focus is on controversial treatments such as brain surgery and ECT, they are critical of the whole endeavour. They would argue that we should avoid artificial and technological approaches to human suffering and seek alternative personal routes to relief.

Overall, however, there is now much less concerted opposition to psychiatry as a discipline. This may, in part, be due to a somewhat exaggerated faith in the rapid expansion of ‘biological’ explanations and an optimism that genetic and genomic advances will soon render the whole issue academic. However, while there is less conceptual opposition to psychiatry, there is no shortage of disquiet about various aspects of its practice.

 

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(10) Psychiatry

Violence in the heart of Europe · ​Terrorist attack in Brussels kills 35 and wounds more than 150

Ending political abuse of psychiatry: where we are at and what needs to be done

Psychiatry and Human Rights Abuses

Political Abuse of Psychiatry-An Historical Overview

Psichiatry101

Open to abuse

Controversies in psychiatric practice

The very nature of psychiatric practice lays it open to potential misuse and abuse. It involves a highly unequal power relationship with very dependent and vulnerable patients whose opinions and complaints can so easily be dismissed as ‘part of the illnesses. Add to this the subjective nature of a diagnostic process which relies on psychiatrists’ assessments of the patient’s motives and mental state with no visible markers for diseases. The history of psychiatry doesn’t inspire that much confidence either. There have been shameful episodes of political abuse, some hare-brained theories, and treatments that appear to us both dangerous and barbaric. The very visibility of modern-day psychiatry (out from behind the institutions’ walls), plus a well informed public and a willingness to admit if things go wrong, is probably the greatest safeguard against such abuses. Psychiatry is also, thankfully, fully engaged in the worldwide movement of scientific, evidence-based medicine - facts and figures take precedence over authority and opinion. So while we focus in this chapter on what it can get wrong, let’s not forget that it more often gets it right and that progress has been substantial.

In the public imagination the greatest risk of psychiatric abuse comes from its immense power. The evil psychiatrist is portrayed in films manipulating the minds of his victim for his own ends, taking pleasure in subjugating the distressed and suggestible. Hannibal Lecter in Silence of the Lambs is one such -immensely skilled at reading his victim’s mind and using that power to trap and exploit them. In other films psychiatrists develop megalomaniacal delusions of using their power to rule the world.

There have been cases where this has happened on a small scale–where psychiatrists, convinced of their own infallibility, have wreaked havoc. Experiments with altering gender identity to confirm that it was socially determined is an extreme example, the mutilation of hundreds of individuals in a craze to remove sources of infection in teeth and bowels that were deemed the cause of mental illness and the wholesale use of lobotomy in the 1940s and early 1950s are others. However most of psychiatry’s excesses have stemmed from the very opposite, from psychiatrists’ sense of impotence and frustration turning to ever more desperate interventions to help tormented patients.

This dynamic is changing. Professions are no longer so powerful and independent. Deference and respect for authority are under global attack. The current risks in psychiatric practice may come less from professional isolation and arrogance than from social compliance. Monitoring psychiatrists may be only half of the job – we need to keep a wary eye on the other powerful players (multinational drug companies, governments, pressure groups) who can manipulate psychiatry. This is a diffuse and changing subject so what follows is just indicative.

Old sins

Like all of medicine, psychiatry’s history includes what now appear dangerous and even barbaric treatments. Before being too critical think what it must have been to live at a time when early and sudden death was a constant threat and excruciating pain had to be endured, often for weeks and months on end. There were few certainties and even fewer effective treatments. What doctors were willing to do two centuries ago, and what patients were prepared to endure, have to be judged against quite different standards? Folk treatment of the mad was also far from gentle, despite our tendency to romanticize pre-industrial societies. Disabled individuals were often accepted and occasionally revered but the more disturbed were often excluded (which could mean death) or mistreated as witches or such like.

Early psychiatrists used the standard medical treatments of their time including bleeding, purging, and cupping (attaching hot cups to the back to ‘draw out’ toxins). The early asylums moved away from these, emphasizing moral treatments, although various desperate measures were tried to calm ‘furiously’ agitated patients. These included cold baths (still used well into the 20th century) and a series of ingenious devices which worked by simply exhausting the patient, such as the notorious ‘whirling chair’. However, the major sins of the asylum era were those of neglect – restraint rather than attention, undignified and humiliating conditions rather than active abuse. Long-term fluctuating illnesses are particularly prone to accumulate far-fetched theories and treatments. This is a mixture of desperation and pure chance (an illness may simply recover just when some irrelevant treatment is being used). There was a vogue for removing otherwise healthy organs in the mentally ill in the late 19th century because they were thought to be the site of ‘sepsis’ (low grade infection). Thousands of healthy teeth and tonsils were removed and even large parts of the bowel. In Trenton State Hospital, New Jersey, Dr Henry Cotton championed this approach right up until his death in 1933 (including taking out all the teeth from his own two sons and even subjecting one to an abdominal operation). These treatments were controversial but still supported by distinguished psychiatric figures.

The Hawthorn effect

A complicating factor is that the fuss and attention surrounding treatments can make a real difference even if the treatment itself is ineffective. This was shown with insulin coma treatment. Insulin had been long used in psychiatry to stimulate appetite and calm agitated patients (who could otherwise literally starve to death). A course of insulin comas was believed to be effective in schizophrenia and this became a common treatment from the 1930s through to the 1960s. It was a potentially dangerous treatment requiring skilled and attentive nursing – if the coma went too deep the patient could die. It was the first psychiatric treatment subject to a controlled trial to establish its effect. Half the patients were put into a light sleep using tranquillizers and half into an insulin coma, without the staff knowing which was which. The results were the same for both groups, forcing the conclusion that it was the nursing attention and hope inspired by the treatment that made the difference, not the insulin. The treatment was abandoned. This effect is known as the ‘Hawthorn’ effect and psychiatric research always has to account for enthusiasm.

Enthusiasm shouldn’t be written off in psychiatry. Much of medicine may be best conducted in a dispassionate, scientific frame of mind but psychiatry requires hope and optimism from its staff. Patients have so often lost hope and need help regaining it. Hope is therapeutic in its own right as the insulin coma study indicated. Many studies have confirmed that optimism makes a difference to outcome (even in cancer patients). It can, however, lead to over-enthusiasm and treatments, including effective treatments, being given well beyond their indications.

Electro convulsive therapy and brain surgery

ECT was certainly overused after it was introduced in the 1930s right through to the 1960s. It continued to be used in schizophrenia and for disturbed behaviour although it had become clear that its main effect is in depression. The original treatments were given without anaesthetic. Ostensibly to ‘treat’ disturbed behaviour, its application, and the threat of it, was undoubtedly sometimes misused as punishment. Sensationalist and misleading portrayals, such as the unmodified ECT given to Jack Nicholson in One Flew Over the Cuckoo’s Nest, continued to fan the controversy. In many countries ECT is almost impossible to obtain in public psychiatry – in Italy and Greece and Spain for instance and in California in the US. In England and several US states a ban has been proposed several times but not legislated. Some of this is undoubtedly because of its earlier overuse – many of its fiercest critics are people who received it inappropriately without benefit. However, even for those who support it, there is something very off-putting about it. It seems such a ‘crude’ assault on that most delicate and important of our organs, the brain. ECT is experienced as an affront to our nature as creative and sentient beings - particularly so as we really do not know how it works. It is vigorously opposed by groups such as the Church of Scientology.

Even more shocking than the overuse of ECT was the crusade of brain surgery conducted by Watts and Freeman in the early 1950s in the US. Brain surgery in psychiatry followed the observation of a freak accident in a Pittsburgh steel mill where a foreman, Phineas Gage, survived a bar passing through his head. The only damage noted was some change in personality – he became more easy-going (but also a bit more disinhibited and foul-mouthed). Severing the connections to the front part of the brain (where the bar had passed) was tried as a last-ditch attempt to reduce intolerable chronic anxiety or disturbed behaviour. It is called leucotomy in Europe and lobotomy in the US and was introduced by a Portuguese psychiatrist Egon Moniz in 1935. He received the Nobel Prize for it in 1949 and, in an ironic twist of fate, was shot dead by a disgruntled patient in 1955.

Psychosurgery probably can help a very limited group of individuals absolutely disabled with severe obsessive compulsive disorder or chronic depression. It appears to work by making the patient uninterested in their symptoms, rather than abolishing them. The patient experiences the obsession thoughts but doesn’t ruminate on them and is able to ignore them. There are changes in personality with the operation – the patient is said to become somewhat ‘blunted’.

Brain surgery evokes the same disquiet as ECT. It seems altogether too invasive and brutal. The explanation of how it works is superficial and unconvincing. Freeman and Watts developed a very simple version of the operation that only required a local anaesthetic. Playing down the risks, they travelled across the US carrying out thousands of these operations in large mental hospitals. Between 1939 and 1951 over 50,000 such operations were performed in the US, 3,439 by Freeman alone. Modern techniques are very different (usually involving the destruction of a couple of cubic millimeters of brain tissue) and highly regulated. Only a couple of dozen operations a year are conducted in the UK and the same number in the US. Nevertheless it remains a highly charged issue and one where people rarely change their opinions.

Political abuse in psychiatry

Psychiatry has always had twin obligations – care for the individual patient and protection of society. This ‘social control’ aspect has to be weighed carefully against individual rights, especially in compulsory treatment. The balance remains a hotly debated issue in most countries. The vastly differing psychiatric care offered to blacks in South Africa under apartheid and in the US Southern States during segregation has often been characterized as political abuse. Similarly the high rate of compulsory detention of ethnic minority patients (particularly blacks of African and Caribbean origin) in England has been cited as an intolerance of different cultures that borders on the repressive. This is probably ‘politics with a small p’. Inequitable access to care is a characteristic of many health care systems. It may be inexcusable but it is hardly a deliberate policy aimed at persecuting a specific group.

The use of psychiatry explicitly to repress or silence dissident political opinions in the former Soviet Union was, however, conscious persecution. The Soviets used a diagnosis of ‘sluggish schizophrenia’; meaning withdrawal and strangeness which developed slowly without positive symptoms (hallucinations, thought disorder, etc.). Sluggish schizophrenia was used to detain people with dissident political views who opposed the state but demonstrated no clear signs of mental illness. Of course some mentally ill individuals do oppose the state which they believe is persecuting them. The Soviets incarcerated vast numbers of clearly healthy individuals in their forensic psychiatric clinics. This was a scandal that has seriously damaged psychiatry’s credibility (particularly in Central and Eastern Europe).

One positive outcome of the Soviet psychiatric abuses was the development of an international movement within psychiatry to challenge such practices. United Nations and Red Cross organizations regularly visit and monitor prisons and detention centres throughout the world and now routinely include mental hospitals in their work. China has recently had to submit to international scrutiny over its dealings with the Falun Gong sect. International awareness provides the strongest protection against political abuse.

Psychiatry unlimited: a diagnosis for everything

Psychiatry has moved centre stage in public health. Four mental illnesses rank in the World Health Organization’s top ten global causes of lifelong disability. Depression is currently number two and predicted to be the number one by 2020. Forty-four million Americans have been treated for depression. Is this good news or bad news? It could be a long-overdue recognition of the burden of mental illness as reduced stigma improves detection and recording (and presumably treatment and recovery). Alternatively, it could be that modern living and an ageing population is associated with greater stresses and more mental illnesses. However, rates for established severe mental illnesses such as schizophrenia and bipolar disorder appear static. Could the rise in mental illness be illusory? Are there other factors at play and could psychiatry go astray if we don’t keep an eye on them? Psychiatry operates now in vastly different circumstances from those in which it originated. Medicine enters the 21st century well equipped to detect and control the failings of the early 20th century (professional arrogance and ignorance). Current risks may, however, stem more from psychiatrists unwittingly acting out the agendas of others (as Foucault has insisted they always have). Who else has an agenda?

The patient

Psychiatric diagnoses arise in a dialogue between patient and doctor. The patient offers his concerns and the psychiatrist tests these against the range of illnesses he or she knows. Both parties in this exchange can influence the threshold for what is ‘psychiatric’. How do we as individuals interpret our experiences? What do we just accept (even if unpleasant and difficult) and what do we consider unacceptable, worthy of reporting and needing help? We seek help much more readily now and seek it from professionals where previously we might have put up with it or turned to friends and relatives. Anxieties over child-rearing, disappointments in relationships, bereavement, and distress after trauma – all are now considered legitimate territory for psychiatric assessment and possible intervention.

Society has rejected the stiff upper lip and embraced psychology and psychotherapy. It has become immeasurably more tolerant and decent as a result. Our emotions and inner life are taken seriously, we are expected to share them and ‘understand our feelings’. Consequently we seek help with understanding them and relief from them if they become unbearable. These changes have led to an enormous rise in demand for counselling and psychotherapy and also for antidepressants and medications to reduce anxiety. Of the antidepressants prescribed in the UK 96 per cent are prescribed by family doctors. Most of these are for individuals who will never see a psychiatrist and many who would hardly have been considered unwell a generation earlier. This is not all a bad thing – many patients benefit from these treatments. But there are risks. As treatment thresholds get lower there is less risk that patients who need treatment will be neglected but an increased risk that others who won’t benefit do get treatments. Relying on medicines for relief may also inhibit us exploring alternative strategies. Persisting with an unhappy marriage and hoping that the pills will make it better is not a sensible long-term strategy. Similarly our expectations change imperceptibly and personal resilience may be eroded.

Treatments we seek from psychiatrists may even make us worse. Excessive prescription of valium and other sedatives led to an epidemic of dependence which proved enormously difficult to reverse. Some studies indicate that routine counselling after severe road traffic accidents or after stillbirths may slow down recovery, not just not help. Perhaps some experiences are best simply put behind one and forgotten. In natural disasters, providing counselling may distract energy and resources from the promotion of self-help and social cohesion.

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