La subjetividad - introduccion Dr.Wajner
La subjetividad incluye al stress y a la calidad de vida,interrelaciona a
ambos factores-variables en la enfermedad y la curacion.
El stress es deformidad,estiramiento,un concepto desde la fisica incorporado
para hablar de la subjetividad de la alienacion social,del malestar en la
cultura,del sentir la ansiedad,angustia y el miedo.La irrupcion de la muerte
y su peligro en los afectos y emociones.
Calidad de vida es como se vive la vida,las enfermedades,las
limitaciones,como estructurar un proyecto de vida con la muerte.Ambas dan
cuenta de la subjetividad del ser enfermo y la nuestra en relacion a
nuestros pacientes,conceptos abandonados por la actual medicina hegemonica.
Hay cuestionarios sobre la calidad de vida:SF-36,Minnesota,entre otros que
sirven para determinar el pronostico en los pacientes,por ejemplo con
insuficiencia cardiaca congestiva.
El deseo de vivir,el goce de lo enfermo,el sentir la muerte participan del
camino que construimos al vivir y al enfermar.
El consultorio con su encuadre dramatico,el lugar y tiempo de la queja nos
puede dar una escucha de la subjetividad del cuerpo del otro y un intentar
ayudarlo a mejor transitarla.
Algunas ideas diferentes:
T. Dethelefsen y R.Dahlke:La enfermedad como camino.1983.hacia la curacion
entendida como redencion-iluminacion:expansion de la conciencia y un cuerpo
como reflejo de estados de la misma.
O en estas-nuestras sociedades excluyentes desiguales en
alimentacion,vivienda,salud y educacion de sus integrantes a los que enferma
e imposibilita la cura,que funcion tenemos como medicos?
Intermediarios en el sistema de salud recetadores de tecnologia y farmacos o
ayudantes del cambio de conductas?
Cuando aprendamos a escuchar lo no dicho,lo actuado,lo oculto,lo gestual
daremos un pequenio paso hacia el cambio de nuestro pasivo rol
social,superando el autoritarismo del pensamiento unico,
desprivilegiando nuestra posicion social,siendo la voz de los sin
voces:nuestros pacientes.
Aconsejo leer y discutir el texto de :Los limites de la psiquiatria del BMJ
2002;324:900-904 ( 13 April )
(lo envio al final)
Dr.Alejandro Wajner
...............................................................
Este es el articulo del BMJ:
............................................................................
.
The limits of psychiatry
Duncan Double, consultant psychiatrist.
Norfolk Mental Health Care NHS Trust, Carrobreck, Norwich NR6 5BE
dbdouble@dbdouble.co.uk
Much of the expansion of psychiatry in the past few decades has been based
on a biomedical model that encourages drug treatment to be seen as a panacea
for multiple problems. Psychiatrist Duncan Double is sceptical of this
approach and suggests that psychiatry should temper and complement a
biological view with psychological and social understanding, thus
recognising the uncertainties of clinical practice
The increasing accountability of doctors following the deaths of children in
the Bristol Royal Infirmary's paediatric cardiac surgical unit has focused
attention on the foundations of medical practice. Ian Kennedy, who chaired
the Bristol inquiry,1 provides a direct link with earlier cultural critics
of medicinesuch as Ivan Illichin his Reith lectures in 1980 about
"unmasking" medicine.2
Illich made specific comments about psychiatry in his critique of
medicalisation and the limits to medicine.3 He attended the 1977 world
federation for mental health conference in Vancouver, Canada, where he
debated the issue of whether mental health professionals are necessary.4 He
maintained that "do it yourself" care was preferable. The central concern of
Illich's work was the legitimacy of professional power, whether in health
systems or in other systems, such as education.
There is no direct equivalent in general medicine of the "anti-psychiatry"
movement, commonly seen as a passing phase in psychiatry and associated with
the names of R D Laing and Thomas Szasz.5 Illich came from outside medicine,
whereas the proponents of anti-psychiatry came from within psychiatry, even
if their influence was subsequently marginalised by mainstream
psychiatrists.
The cultural role of psychiatry is more obviously open to criticism than is
the case in the rest of medicine. This is because of its direct relation to
social control through mental health legislation. Although diagnosis of
mental illness should not be predicated on social conformity, in practice
this criterion may be applied. During the 1970s and 1980s, for example,
reports that the authorities in the Soviet Union were incarcerating
substantial numbers of dissidents in mental asylums caused widespread
concern in the West. Over recent years, the use of psychiatry as a tool of
state repression in China seems to be increasing.6
A modern critique of psychiatry needs to move on from the perspective
exemplified by Illich and the proponents of anti-psychiatry that psychiatry
should not be imposed on anyone, as this view is not consistent with a
practice in which compulsory treatment has been integral. It was only after
the Mental Health Treatment Act 1930 that voluntary treatment became an
option in Britain. None the less, because of the potential for abuse, a
critical perspective that scrutinises the role of coercion in psychiatric
treatment is still required in the current debate about the reform of the
Mental Health Act in the United Kingdom.
I outline here the expansion of psychiatry over the past half century and
offer a sceptical view of this development.
Summary points
----------------------------------------------------------------------------
----
Expectations of solutions to mental health problems continue to rise
----------------------------------------------------------------------------
----
This raises the question of the legitimacy of psychiatric interventions for
common personal and social problems
----------------------------------------------------------------------------
----
Much of the expansion of psychiatry has been based on a biomedical model
----------------------------------------------------------------------------
----
This approach encourages drug treatment to be seen as a panacea for multiple
problems
----------------------------------------------------------------------------
----
Refocusing psychiatry on the patient as a person emphasises the uncertainty
of psychiatric practic
Growth in mental health service activity and technology
Despite the reduction in psychiatric beds in England over recent years ,
mental health service activity has increased considerably. The annual
number of antidepressant prescriptions, for example, has more than doubled
over the past seven years (Similarly, the number of consultant
psychiatrists has more than doubled over the past 22 years As the number of
psychiatric beds has decreased, the number of people in
prison with a mental disorder has risen, with a higher proportion of women
inmates having mental health problems than men.7 Authors in the United
States suggest that prisons are replacing mental hospitals, but the data
could be explained either as the "psychiatricisation" of criminality or as
the increasing diagnosis of mental illness in prisoners not previously
recognised as being mentally ill.
As more resources have been provided for mental health services, more
resources are perceived to be needed.8 Disillusionment is inevitable in a
system of mental health care where an increase in professional staffing
cannot completely resolve the perceived unmet need of the population.
Demand is unavoidably high as mental health problems are common. The
proportion of men and women with a neurotic disorder in a given week was
found to be 12.3% and 19.5% respectively in the psychiatric morbidity
survey, the largest epidemiological study of the prevalence of psychiatric
disorders conducted in the United Kingdom.9
As the expectation of solutions to mental health problems rises through the
increasing availability of the mainstay psychiatric treatments (psychotropic
drugs and "talking" therapies, such as counselling), the traditional
boundaries of psychiatric disorder have broadened. Everyday problems
regarded as the province of other social spheres become "medicalised" by
psychiatry. Mental health care may function as a panacea for many different
personal and social problems.
The diagnosis of attention-deficit/hyperactivity disorder in children, for
example, has increased dramatically over recent years, paralleled by an
increase in the prescription of stimulant drugs in the United States.10 This
trend is also apparent in England and is likely to be reinforced by recent
guidelines from the National Institute for Clinical Evidence.11 The
behaviour of children in whom attention-deficit/hyperactivity disorder is
identified overlaps with behaviours commonly displayed by children when they
feel frustrated, anxious, bored, abandoned, or in some other way stressed.
The obvious critical view is that the social phenomenon of mass drugging of
children indicates not a genuine increase in mental disorder but rather a
displacement strategy for the difficult task of improving family and school
life. It is indeed likely that recourse to drug treatment discourages self
responsibility and thereby exacerbates the underlying difficulties that it
is supposed to remedy.
Attention-deficit/hyperactivity disorder has also become established over
the past 10 years as an adult disorder, and it is now regarded by some as
the most common chronic undiagnosed psychiatric disorder in adults.12
The expansion of psychiatry is also reflected in the marketing of selective
serotonin reuptake inhibitors for neurotic conditions other than depression.
Paroxetine, the drug with the greatest net ingredient cost to the NHS in
England in 2000, is now approved in the United states for use in multiple
disorders: depression, generalised anxiety disorder, social anxiety
disorder, panic disorder, obsessive-compulsive disorder, and post-traumatic
stress disorder. Selective serotonin reuptake inhibitors have even been
promoted and used as lifestyle drugs.13
Two disorders illustrate further the process of medicalisation. Firstly,
social anxiety disorder could be seen as the process of medicalising
shyness. The disorder is characterised by a marked and persistent fear of
social or performance situations in which embarrassment may occur. It is
said to be the third most common psychiatric disorder in the United States,
after major depression and alcohol dependence. Lifetime prevalence has been
estimated at 13.3%.14 Some claim that the condition is not just ordinary
shyness and that it is a common public health problem.15 None the less,
although definitions of the syndromes of shyness and social phobia may
differ, the distinction is difficult to make empirically. Furthermore, we
should be sceptical about the potency and benefits of drugs for this
condition.
Secondly, the diagnosis of post-traumatic stress disorder was officially
recognised after an essentially political struggle to acknowledge the
suffering of the Vietnam war veterans. Subsequently, the diagnosis has
become increasingly associated with less extreme experiences, encouraged by
compensation claims for psychological damage. However, medicalisation of
traumatic human suffering runs the risk of reducing it to a technical
problem. Providing debriefing and counselling, for example, may not be the
most appropriate focus of humanitarian relief operations in wars and other
disasters.16
Psychiatry is a branch of medicine
Psychiatry should use modern scientific methods and base its practice on
scientific knowledge
Psychiatry treats people who are sick and need treatment for mental illness
A boundary exists between normal and sick people
Mental illness is not a myth; there are many mental illnesses. It is the
task of scientific psychiatry to investigate the causes, diagnosis, and
treatment of these mental illnesses
The focus of psychiatric physicians should focus on the biological aspects
of mental illness
There should be an explicit and intentional concern with diagnosis and
classification
Diagnostic criteria should be codified, and a legitimate and valued area of
research should be to validate such criteria by various techniques.
Psychiatry departments in medical schools should teach these criteria and
not belittle them, as has been the case for many years
Statistical techniques should be used in research efforts directed at
improving the reliability and validity of diagnosis and classification
Box 2: Assumptions of Meyer's biopsychological model22
The boundary between mentally well and mentally ill people is fluid because
normal people can become ill if exposed to sufficiently severe trauma
Mental illness is conceived along a continuum of severity from neurosis
through borderline conditions to psychosis
An untoward mixture of noxious environment and psychic conflict causes
mental illness
The mechanisms by which mental illness emerges in an individual are
psychologically mediated
Postmodernity provides doctors with an opportunity to redefine their roles
and responsibilities
Diagnoses are not diseases
The number of diagnostic categories has increased in the Diagnostic and
Statistical Manual of Mental Disorders of the American Psychiatric
Association from 106 in DSM-I in 1952 to 357 in DSM-IV in 1994.17 This
increase has occurred in the context of attempts to make psychiatric
diagnosis more reliable by the introduction in 1980 of DSM-III.
DSM-III encouraged the reification of psychological conditions. Social
phobia and post-traumatic stress disorder, for example, were first included
in international classifications in DSM-III.
Box 3: Summary of "post-psychiatry" (from Bracken and Thomas23)
Faith in the ability of science and technology to resolve human and social
problems is diminishing
This creates challenges for medicine, particularly traditional psychiatry
Psychiatry must move beyond its "modernist" framework to engage with recent
government proposals and the growing power of service users
Post-psychiatry emphasises social and cultural contexts, places ethics
before technology, and works to minimise medical control of coercive
interventions
(Credit: NATIONAL PORTRAIT GALLERY)
R D Laing: "The experience and behaviour that gets labelled schizophrenic
is a special strategy that a person invents in order to live in an unlivable
situation"
Confidence in psychiatric classification was dampened by the classic study
of Rosenhan.18 In this, "pseudo-patients," who were accomplices of the
experimenter, gained admission to different hospitals, each presenting with
a single complainthearing a voice that said "empty," "hollow," or "thud." On
admission to the psychiatric ward, each pseudo-patient stopped simulating
any symptom of abnormality. All of them received a psychiatric diagnosis,
mainly schizophrenia. Rosenhan concluded from this experiment that
psychiatric diagnosis is subjective and does not reflect inherent patient
characteristics. As a follow up, staff of a research and teaching hospital
were informed that at some time during the following three months, one or
more pseudo-patients would attempt to be admitted. No such attempt was made.
Yet about 10% of 193 real patients were suspected by two or more staff
members to be pseudo-patients. After the publication of Rosenhan's study,
psychiatric diagnoses have become more rigidly defined by operational
criteria as in DSM-III.
(Credit: UPSTATE MEDICAL UNIVERSITY HEALTH SCIENCES LIBRARY)
Thomas Szasz: "Classifying thoughts, feelings, and behaviors as diseases is
a logical and semantic error"
(Credit: NATIONAL LIBRARY OF MEDICINE)
Alfred Meyer: "A diagnosis usually does justice to only one part of the
facts and is merely a convenience of nomenclature"
This attempt to make psychiatric diagnosis more reliable was associated with
a return to a biomedical model of mental illness. The approach has been
called neo-Kraepelinian, as it promotes many of the ideas associated with
the views of Emil Kraepelin, regarded as the founder of modern psychiatry
(box 1).19
Diagnosis does not need to be exclusively in terms of a biomedical model. It
can be about creating an understanding of the reasons for a patient's
presentation. Indeed, focusing on the somatic nature of a hypothetical
underlying disorder tends to deny the patient as a person and objectifies
patients so that they become merely bodies needing treatment. Although
biological explanations are importantas the brain is the substrate for
cognition, emotions, and behaviourunderstanding personal action is not
helped by eliminating the meaning of people's distress and the psychological
and social origins of their difficulties.
An adverse consequence of the biomedical model is that it encourages a
tendency to believe that people are powerless to do anything about their
condition. Such an implication may be obvious, for example, in the case of
alcoholism,20 but the same principle also applies to other mental health
problems, even psychosis, despite such symptoms and behaviour being more
difficult to understand.
(Credit: NATIONAL LIBRARY OF MEDICINE)
Emil Kraepelin: "Clinical observation must be supplemented by thorough
examination of healthy and diseased brains"
The somatic model has always tended to dominate psychiatric thinking, but
psychological and psychodynamic explanations were more widely accepted over
50 years ago. Adolf Meyer, the foremost American psychiatrist in the first
half of the 20th century, insisted on regarding his philosophical approach
to psychiatry, with its emphasis on the understanding of the person, as an
advance over the mechanistic philosophy of the 19th century.21 His work is
now largely neglected in the modern biological consensus in psychiatry. He
warned against going beyond statements about the person to wishful
"neurologising tautology" about the brain (box 2 summarises the assumptions
of his biopsychological view22).
Psychiatry needs to return to a biopsychological view to limit its
excessesin other words, it needs to temper and complement a biological view
with psychological and social understanding, thus recognising the
uncertainties of clinical practice. Such an approach conforms to the new
direction that has been called "post-psychiatry" (box 3).23
The Critical Psychiatry Network
The Critical Psychiatry Network has recently been formed to provide a
network to develop a critique of the current psychiatric system. Its aim is
to avoid the polarisation of psychiatry and anti-psychiatry. Anti-psychiatry
may have failed because its main proponents were ultimately more interested
in personal and spiritual growth. Moreover, its message became diluted and
confused by combining conflicting viewpoints. The Critical Psychiatry
Network is dedicated to establishing a constructive framework for renewing
mental health practice (www.criticalpsychiatry.co.uk).
ambos factores-variables en la enfermedad y la curacion.
El stress es deformidad,estiramiento,un concepto desde la fisica incorporado
para hablar de la subjetividad de la alienacion social,del malestar en la
cultura,del sentir la ansiedad,angustia y el miedo.La irrupcion de la muerte
y su peligro en los afectos y emociones.
Calidad de vida es como se vive la vida,las enfermedades,las
limitaciones,como estructurar un proyecto de vida con la muerte.Ambas dan
cuenta de la subjetividad del ser enfermo y la nuestra en relacion a
nuestros pacientes,conceptos abandonados por la actual medicina hegemonica.
Hay cuestionarios sobre la calidad de vida:SF-36,Minnesota,entre otros que
sirven para determinar el pronostico en los pacientes,por ejemplo con
insuficiencia cardiaca congestiva.
El deseo de vivir,el goce de lo enfermo,el sentir la muerte participan del
camino que construimos al vivir y al enfermar.
El consultorio con su encuadre dramatico,el lugar y tiempo de la queja nos
puede dar una escucha de la subjetividad del cuerpo del otro y un intentar
ayudarlo a mejor transitarla.
Algunas ideas diferentes:
T. Dethelefsen y R.Dahlke:La enfermedad como camino.1983.hacia la curacion
entendida como redencion-iluminacion:expansion de la conciencia y un cuerpo
como reflejo de estados de la misma.
O en estas-nuestras sociedades excluyentes desiguales en
alimentacion,vivienda,salud y educacion de sus integrantes a los que enferma
e imposibilita la cura,que funcion tenemos como medicos?
Intermediarios en el sistema de salud recetadores de tecnologia y farmacos o
ayudantes del cambio de conductas?
Cuando aprendamos a escuchar lo no dicho,lo actuado,lo oculto,lo gestual
daremos un pequenio paso hacia el cambio de nuestro pasivo rol
social,superando el autoritarismo del pensamiento unico,
desprivilegiando nuestra posicion social,siendo la voz de los sin
voces:nuestros pacientes.
Aconsejo leer y discutir el texto de :Los limites de la psiquiatria del BMJ
2002;324:900-904 ( 13 April )
(lo envio al final)
Dr.Alejandro Wajner
...............................................................
Este es el articulo del BMJ:
............................................................................
.
The limits of psychiatry
Duncan Double, consultant psychiatrist.
Norfolk Mental Health Care NHS Trust, Carrobreck, Norwich NR6 5BE
dbdouble@dbdouble.co.uk
Much of the expansion of psychiatry in the past few decades has been based
on a biomedical model that encourages drug treatment to be seen as a panacea
for multiple problems. Psychiatrist Duncan Double is sceptical of this
approach and suggests that psychiatry should temper and complement a
biological view with psychological and social understanding, thus
recognising the uncertainties of clinical practice
The increasing accountability of doctors following the deaths of children in
the Bristol Royal Infirmary's paediatric cardiac surgical unit has focused
attention on the foundations of medical practice. Ian Kennedy, who chaired
the Bristol inquiry,1 provides a direct link with earlier cultural critics
of medicinesuch as Ivan Illichin his Reith lectures in 1980 about
"unmasking" medicine.2
Illich made specific comments about psychiatry in his critique of
medicalisation and the limits to medicine.3 He attended the 1977 world
federation for mental health conference in Vancouver, Canada, where he
debated the issue of whether mental health professionals are necessary.4 He
maintained that "do it yourself" care was preferable. The central concern of
Illich's work was the legitimacy of professional power, whether in health
systems or in other systems, such as education.
There is no direct equivalent in general medicine of the "anti-psychiatry"
movement, commonly seen as a passing phase in psychiatry and associated with
the names of R D Laing and Thomas Szasz.5 Illich came from outside medicine,
whereas the proponents of anti-psychiatry came from within psychiatry, even
if their influence was subsequently marginalised by mainstream
psychiatrists.
The cultural role of psychiatry is more obviously open to criticism than is
the case in the rest of medicine. This is because of its direct relation to
social control through mental health legislation. Although diagnosis of
mental illness should not be predicated on social conformity, in practice
this criterion may be applied. During the 1970s and 1980s, for example,
reports that the authorities in the Soviet Union were incarcerating
substantial numbers of dissidents in mental asylums caused widespread
concern in the West. Over recent years, the use of psychiatry as a tool of
state repression in China seems to be increasing.6
A modern critique of psychiatry needs to move on from the perspective
exemplified by Illich and the proponents of anti-psychiatry that psychiatry
should not be imposed on anyone, as this view is not consistent with a
practice in which compulsory treatment has been integral. It was only after
the Mental Health Treatment Act 1930 that voluntary treatment became an
option in Britain. None the less, because of the potential for abuse, a
critical perspective that scrutinises the role of coercion in psychiatric
treatment is still required in the current debate about the reform of the
Mental Health Act in the United Kingdom.
I outline here the expansion of psychiatry over the past half century and
offer a sceptical view of this development.
Summary points
----------------------------------------------------------------------------
----
Expectations of solutions to mental health problems continue to rise
----------------------------------------------------------------------------
----
This raises the question of the legitimacy of psychiatric interventions for
common personal and social problems
----------------------------------------------------------------------------
----
Much of the expansion of psychiatry has been based on a biomedical model
----------------------------------------------------------------------------
----
This approach encourages drug treatment to be seen as a panacea for multiple
problems
----------------------------------------------------------------------------
----
Refocusing psychiatry on the patient as a person emphasises the uncertainty
of psychiatric practic
Growth in mental health service activity and technology
Despite the reduction in psychiatric beds in England over recent years ,
mental health service activity has increased considerably. The annual
number of antidepressant prescriptions, for example, has more than doubled
over the past seven years (Similarly, the number of consultant
psychiatrists has more than doubled over the past 22 years As the number of
psychiatric beds has decreased, the number of people in
prison with a mental disorder has risen, with a higher proportion of women
inmates having mental health problems than men.7 Authors in the United
States suggest that prisons are replacing mental hospitals, but the data
could be explained either as the "psychiatricisation" of criminality or as
the increasing diagnosis of mental illness in prisoners not previously
recognised as being mentally ill.
As more resources have been provided for mental health services, more
resources are perceived to be needed.8 Disillusionment is inevitable in a
system of mental health care where an increase in professional staffing
cannot completely resolve the perceived unmet need of the population.
Demand is unavoidably high as mental health problems are common. The
proportion of men and women with a neurotic disorder in a given week was
found to be 12.3% and 19.5% respectively in the psychiatric morbidity
survey, the largest epidemiological study of the prevalence of psychiatric
disorders conducted in the United Kingdom.9
As the expectation of solutions to mental health problems rises through the
increasing availability of the mainstay psychiatric treatments (psychotropic
drugs and "talking" therapies, such as counselling), the traditional
boundaries of psychiatric disorder have broadened. Everyday problems
regarded as the province of other social spheres become "medicalised" by
psychiatry. Mental health care may function as a panacea for many different
personal and social problems.
The diagnosis of attention-deficit/hyperactivity disorder in children, for
example, has increased dramatically over recent years, paralleled by an
increase in the prescription of stimulant drugs in the United States.10 This
trend is also apparent in England and is likely to be reinforced by recent
guidelines from the National Institute for Clinical Evidence.11 The
behaviour of children in whom attention-deficit/hyperactivity disorder is
identified overlaps with behaviours commonly displayed by children when they
feel frustrated, anxious, bored, abandoned, or in some other way stressed.
The obvious critical view is that the social phenomenon of mass drugging of
children indicates not a genuine increase in mental disorder but rather a
displacement strategy for the difficult task of improving family and school
life. It is indeed likely that recourse to drug treatment discourages self
responsibility and thereby exacerbates the underlying difficulties that it
is supposed to remedy.
Attention-deficit/hyperactivity disorder has also become established over
the past 10 years as an adult disorder, and it is now regarded by some as
the most common chronic undiagnosed psychiatric disorder in adults.12
The expansion of psychiatry is also reflected in the marketing of selective
serotonin reuptake inhibitors for neurotic conditions other than depression.
Paroxetine, the drug with the greatest net ingredient cost to the NHS in
England in 2000, is now approved in the United states for use in multiple
disorders: depression, generalised anxiety disorder, social anxiety
disorder, panic disorder, obsessive-compulsive disorder, and post-traumatic
stress disorder. Selective serotonin reuptake inhibitors have even been
promoted and used as lifestyle drugs.13
Two disorders illustrate further the process of medicalisation. Firstly,
social anxiety disorder could be seen as the process of medicalising
shyness. The disorder is characterised by a marked and persistent fear of
social or performance situations in which embarrassment may occur. It is
said to be the third most common psychiatric disorder in the United States,
after major depression and alcohol dependence. Lifetime prevalence has been
estimated at 13.3%.14 Some claim that the condition is not just ordinary
shyness and that it is a common public health problem.15 None the less,
although definitions of the syndromes of shyness and social phobia may
differ, the distinction is difficult to make empirically. Furthermore, we
should be sceptical about the potency and benefits of drugs for this
condition.
Secondly, the diagnosis of post-traumatic stress disorder was officially
recognised after an essentially political struggle to acknowledge the
suffering of the Vietnam war veterans. Subsequently, the diagnosis has
become increasingly associated with less extreme experiences, encouraged by
compensation claims for psychological damage. However, medicalisation of
traumatic human suffering runs the risk of reducing it to a technical
problem. Providing debriefing and counselling, for example, may not be the
most appropriate focus of humanitarian relief operations in wars and other
disasters.16
Psychiatry is a branch of medicine
Psychiatry should use modern scientific methods and base its practice on
scientific knowledge
Psychiatry treats people who are sick and need treatment for mental illness
A boundary exists between normal and sick people
Mental illness is not a myth; there are many mental illnesses. It is the
task of scientific psychiatry to investigate the causes, diagnosis, and
treatment of these mental illnesses
The focus of psychiatric physicians should focus on the biological aspects
of mental illness
There should be an explicit and intentional concern with diagnosis and
classification
Diagnostic criteria should be codified, and a legitimate and valued area of
research should be to validate such criteria by various techniques.
Psychiatry departments in medical schools should teach these criteria and
not belittle them, as has been the case for many years
Statistical techniques should be used in research efforts directed at
improving the reliability and validity of diagnosis and classification
Box 2: Assumptions of Meyer's biopsychological model22
The boundary between mentally well and mentally ill people is fluid because
normal people can become ill if exposed to sufficiently severe trauma
Mental illness is conceived along a continuum of severity from neurosis
through borderline conditions to psychosis
An untoward mixture of noxious environment and psychic conflict causes
mental illness
The mechanisms by which mental illness emerges in an individual are
psychologically mediated
Postmodernity provides doctors with an opportunity to redefine their roles
and responsibilities
Diagnoses are not diseases
The number of diagnostic categories has increased in the Diagnostic and
Statistical Manual of Mental Disorders of the American Psychiatric
Association from 106 in DSM-I in 1952 to 357 in DSM-IV in 1994.17 This
increase has occurred in the context of attempts to make psychiatric
diagnosis more reliable by the introduction in 1980 of DSM-III.
DSM-III encouraged the reification of psychological conditions. Social
phobia and post-traumatic stress disorder, for example, were first included
in international classifications in DSM-III.
Box 3: Summary of "post-psychiatry" (from Bracken and Thomas23)
Faith in the ability of science and technology to resolve human and social
problems is diminishing
This creates challenges for medicine, particularly traditional psychiatry
Psychiatry must move beyond its "modernist" framework to engage with recent
government proposals and the growing power of service users
Post-psychiatry emphasises social and cultural contexts, places ethics
before technology, and works to minimise medical control of coercive
interventions
(Credit: NATIONAL PORTRAIT GALLERY)
R D Laing: "The experience and behaviour that gets labelled schizophrenic
is a special strategy that a person invents in order to live in an unlivable
situation"
Confidence in psychiatric classification was dampened by the classic study
of Rosenhan.18 In this, "pseudo-patients," who were accomplices of the
experimenter, gained admission to different hospitals, each presenting with
a single complainthearing a voice that said "empty," "hollow," or "thud." On
admission to the psychiatric ward, each pseudo-patient stopped simulating
any symptom of abnormality. All of them received a psychiatric diagnosis,
mainly schizophrenia. Rosenhan concluded from this experiment that
psychiatric diagnosis is subjective and does not reflect inherent patient
characteristics. As a follow up, staff of a research and teaching hospital
were informed that at some time during the following three months, one or
more pseudo-patients would attempt to be admitted. No such attempt was made.
Yet about 10% of 193 real patients were suspected by two or more staff
members to be pseudo-patients. After the publication of Rosenhan's study,
psychiatric diagnoses have become more rigidly defined by operational
criteria as in DSM-III.
(Credit: UPSTATE MEDICAL UNIVERSITY HEALTH SCIENCES LIBRARY)
Thomas Szasz: "Classifying thoughts, feelings, and behaviors as diseases is
a logical and semantic error"
(Credit: NATIONAL LIBRARY OF MEDICINE)
Alfred Meyer: "A diagnosis usually does justice to only one part of the
facts and is merely a convenience of nomenclature"
This attempt to make psychiatric diagnosis more reliable was associated with
a return to a biomedical model of mental illness. The approach has been
called neo-Kraepelinian, as it promotes many of the ideas associated with
the views of Emil Kraepelin, regarded as the founder of modern psychiatry
(box 1).19
Diagnosis does not need to be exclusively in terms of a biomedical model. It
can be about creating an understanding of the reasons for a patient's
presentation. Indeed, focusing on the somatic nature of a hypothetical
underlying disorder tends to deny the patient as a person and objectifies
patients so that they become merely bodies needing treatment. Although
biological explanations are importantas the brain is the substrate for
cognition, emotions, and behaviourunderstanding personal action is not
helped by eliminating the meaning of people's distress and the psychological
and social origins of their difficulties.
An adverse consequence of the biomedical model is that it encourages a
tendency to believe that people are powerless to do anything about their
condition. Such an implication may be obvious, for example, in the case of
alcoholism,20 but the same principle also applies to other mental health
problems, even psychosis, despite such symptoms and behaviour being more
difficult to understand.
(Credit: NATIONAL LIBRARY OF MEDICINE)
Emil Kraepelin: "Clinical observation must be supplemented by thorough
examination of healthy and diseased brains"
The somatic model has always tended to dominate psychiatric thinking, but
psychological and psychodynamic explanations were more widely accepted over
50 years ago. Adolf Meyer, the foremost American psychiatrist in the first
half of the 20th century, insisted on regarding his philosophical approach
to psychiatry, with its emphasis on the understanding of the person, as an
advance over the mechanistic philosophy of the 19th century.21 His work is
now largely neglected in the modern biological consensus in psychiatry. He
warned against going beyond statements about the person to wishful
"neurologising tautology" about the brain (box 2 summarises the assumptions
of his biopsychological view22).
Psychiatry needs to return to a biopsychological view to limit its
excessesin other words, it needs to temper and complement a biological view
with psychological and social understanding, thus recognising the
uncertainties of clinical practice. Such an approach conforms to the new
direction that has been called "post-psychiatry" (box 3).23
The Critical Psychiatry Network
The Critical Psychiatry Network has recently been formed to provide a
network to develop a critique of the current psychiatric system. Its aim is
to avoid the polarisation of psychiatry and anti-psychiatry. Anti-psychiatry
may have failed because its main proponents were ultimately more interested
in personal and spiritual growth. Moreover, its message became diluted and
confused by combining conflicting viewpoints. The Critical Psychiatry
Network is dedicated to establishing a constructive framework for renewing
mental health practice (www.criticalpsychiatry.co.uk).