The publication of the US dictionary of psychiatry, the DSM, got into some of the usual blogs I read because of people’s doubts about its perceived medicalisation of “human distress”. Now I see the furore has spread across the Atlantic by a critical report against clinical psychiatry by the Division of Clinical Psychology, representing (the Guardian says) 10,000 practitioners.
As a GP I encountered every variety of psychological disorder, including some that now have a name but didn’t then, and a couple that have since been declassified (you’re not allowed now to experience distress for homosexual inclinations, and are required to treat it politically by campaigning for same-sex marriage). I sectioned people to mental hospitals, referred them to counsellors and cognitive therapists, dealt with them myself and, in mercifully few cases, suffered the grief of their suicide or even their killing of others. And if you ask what my working model was for such situations, the answer is “eclecticism”. With a medical bias, given my training. People often got better.
The argument over the existence of mental illness has been going as long as I have. I did a year of social psychology at university, and remember the visiting consultant from Fulbourn Hospital being heckled by socially enlightened Marxists who knew for sure he was just a tool of capitalist oppression. Our reading list included The Myth of Mental Illness by Thomas Szasz, but no textbook of psychiatry.
R D Laing’s The Divided Self was also required reading (and still on my shelf), as its conventionally new-left author dismissed the illness model of schizophrenia in favour of a phenomenological and existentialist approach. Ironically his career was later blighted by (on his own admission) alcoholism and clinical depression, whose very existence as illnesses the anti-psychiatry movement denied.
In the forty years since, schizophrenia, depression and alcoholism have all continued to blight lives, trendy books notwithstanding. But existentialism, like Marxism, has long since disappeared. Crude brain disorder as a cause has also been debunked, though I did meet one patient who’d had a prefrontal leucotomy. Paradoxically body surgery is still used for gender disorders, and even birth certificates are doctored for this, but not the brain. ECT has gone the way of straitjackets, even though it worked. Tricyclics gave way to Prozac as the wonder brain drug for all, which in its turn has come to be seen a useless placebo serving the interests only of the drug companies. Amitriptyline’s great for neuropathic pain, by the way – a shame about the depression.
But the psychologists, for their part, making the same criticisms as forty years ago, are still informed by discredited (though once scientific) psychoanalytic theory, by even less theoretically-based counselling skills and at best by cognitive therapy, which was being pushed as the only way forward near the end of my career, but which wasn’t obviously more successful than anything else. And psychologists can only pick up the pieces of those “poisoned” by the psychiatrists because they themselves had nothing useful to offer in the acute stage, when the patient thought his wife was a spy or was suicidal because she became convinced she was a failure at everything.
Well, the fact is that human mental disorders are extremely distressing and dangerous, and if we don’t understand them fully, we all have to muddle by as best we can with whatever tools we have, and especially kindness and empathy … which are still in short supply, it seems, in public health services on both sides of the Atlantic. But as science, it remains pretty clear that our certain knowledge is very small indeed, and thoroughly disputed. I guess part of that is because contemporary science isn’t really at all sure the mind even exists, so it can only treat brains. And psychologists have historically treated the brain as a black box and concentrated on the Cartesian ghost in the machine (and his mother, of course).
My actual point in discussing all this is not to bemoan the confusion, ignorance and culture wars in this field. You can’t win them all. In any case, the antipsychiatry case has, in my view, been significantly exaggerated. But my purpose is to point out that throughout it all we, typically, convince ourselves that we are the enlightened generation that understands what all previous ages could not. The march of science has led us to the scenario of two rival sciences slugging out the most basic concepts whilst being certain of nothing: yet we fool ourselves it is actually secure knowledge.
Take as an example the discussion of Jesus’s miracles, and specifically the casting out of demons. Some charismatics see demons everywhere, and can spend a lifetime casting them repeatedly out of the same unfortunate people. Mind you, that’s about the same cure-rate as for many psychiatric diagnoses – and considerably less than Jesus’s cure-rate using the same paradigm. But apart from that it’s very hard for a modern person to consider demonisation seriously, especially in connection with what we, if not psychologists, call mental illness. If we are psychologists we’re committed to “mental distress” as a model, which still excludes the “demonic” category a priori. And that would be fine if, in nearly every discussion of the New Testament outside or inside churches, people didn’t say, “We now know, of course, that mental illness isn’t caused by demons.” Cue for jettisoning biblical inerrancy.
And we know that how? By not knowing for sure whether either the disease model or the distress model has any validity whatsoever, and how they work if they do. It seems that, cut to the bone, the certainties of our society reduce to, “Some of us choose to believe ill-defined diseases cause minds to malfunction. Some of us choose to believe ill-defined circumstances cause minds to malfunction. None of us chooses to believe demons do so.” We may well be right on any of those three counts – but let’s not pretend the deciding factor is better evidence. It’s primarily just worldview conditioning, tinged with a smug sense of our own superiority.