Two cheers for
psychiatry Robert Fergusson tion occupied. The ethos of the Mental Health Ac of 1959 was an acknowledgement of the unchallei# ability of the authority of psychiatry. But the early days had seen the emergence of'
crusading spirit,
By being so eager to prove itself, has psychiatry bitten off more than it can chew ? As
more
and
more
people
need of treatment' the
are seen as
quality
'in
of the treat-
become debased. Stimulating the growth of non-medical therapeutic groups plus widespread mental health education could ease a mounting crisis in psychiatry. ment can
the 1930s, I remember reading a phrase in the old literary weekly John O'London, 'If Paul of Tarsus were to return to London today, he would say "Ye people of London, I perceive that of all things ye are too psychological".' Presumably this had something to do with the fears of some literati that psychoanalysis would engulf literary inspiration. But it seems to me the warning might still have timely application to medical, and especially psychiatric,
Many thinking.
years ago, in
After its early struggles for recognition, the advance of psychiatry has been quite spectacular? witness its major holding in the medical services both in terms of personnel employed and bed accommoda2
a
resentment at
being ignored,
a
ze3,
for the cause so to speak, that led the prophets a11,* their followers to carry the arguments and the clai*11 altogether too far. One effect of this was to ac^f' the fact that treatment was always desirable and g?? could only be benevolent and beneficial and, in ^ it became sacrosanct under the title 'therapy'. this may be regarded, though wrongly in my vieW,5 harmless. Another effect of the crusade was to try to ob^1 the benefits of treatment for groups of people 11 hitherto regarded as 'ill.' Treatment was an questioned desideratum and to achieve it the medicf model had to be used. There was excellent precede of course because, in a way, Charcot himself had exactly this with one of his own inimitable 'tours Maitre\ So a more obvious effect of the crusade was to blur the dividing lines between 'illfleS"
psychi^1.*
on the one hand, and unhappiness, nonconformism, delinquency and numerous
eccentric*^ form5"
life failures and inadequacies on the other. have said the advance of psychi^. had much in common with a relig'0 u movement?it
r
represented
a
new
view
C'
human behaviour, a new vision as it ^ Any movement with emotional drive resists cha^ particularly if it is called revisionism. We are see'11! now
communism, which has
drive of
much of the
emoti0^
religion, dealing with its revisionists j classing them as mentally sick?a demonstration the kind of social change envisaged here, but ^ exactly the opposite direction, i.e. as a punishmc.. a
In matters of faith it is
no doubt true that he vvh? for us is against us. If the milieu in which the psychotropic drug5 V given is as important as the drugs themselves, if[
not
i
Placebo'
effect
accounts for
erapeutic
something
like 33 3% of
success, then the sceptic is to be feared ecause he represents a threat to treatment. But
Psychiatry
claims to be scientific or at least claims to be scientific (one of the most reassuring things e Royal Medico-Psychological Association ever did to change the arrogant title of its journal from he Journal of Mental Science' to 'The British Journal of Psychiatry'). As an aspiring scientific lscipline, therefore, it ought to welcome controversy, ontroversy is essential to development. It may often ei^and a re-examination of the foundations on lch a subject is built. If controversy is suppressed, ? doubt growth may be fast and impressive, but 0 aPse may be equally spectacular. Awareness of the need for some revision or condefence has become, or at least ought to have come, inescapable in the face of some powerful Cent criticism. The criticisms of Eysenck against Vchotherapy have been known for a long time, have Host become institutionalised, and are essentially He is really 'One of Us', we feel. robably the most puzzling of the recent critics has Henry Miller?whose writings are a fearsome arrM ^am academic excellence, humour and conharshness. What is Miller really saying ?ut psychiatrists? At the risk of oversimplification, are rather Poor -^e Sa^ t^iat ?rS t^le sensc and their scientific positivists) onl ?ther source of y sciences is social the authority vv. arC of short 'n^ant^e' imprecise, desperately basi !c ^ata3 still groping for first principles'. nat*ve critic?this time from outside ?aroness Wooton who is much troubled by 6 ^?^ca^ inconsistencies of psychiatry. She can find S?^ f?undation, objective data on which to definitions of mental health?and, by con' n.? definition of mental illness other than an ex tastes anc* vaiue_iucigements of ?r t^le cu^tura^ norms of a particular
tTy
t0
kjfdng
Cp
'
si_,a
a^erable
doc?U^
Ps7chiatrists
med-101^^ th"105?^ b.00
trastaSe
PsychSSl?n
s?cietyatriStS
A
*
merican critics include Schofield who is uneasy on the score of the implications of
psychiatry for moral philosophy. Psychiatry ls
hapD-
an
d0mlness^das lhable -^?r^ st&
imply
illness
dim,v
myth
of
and apathy are illness. But an important social t^le term 'illness' is absolution from res^e most enobling human experience is t0 make the journey to self knowledge
meanP?nsihv the cu
The
offshoot of the Western
Under this banner, all discontent, bore-
weariness, jealousy
as
*s
&t
^
minishes
always painful. Psychiatry
lt *s
man.
nnwise
to
seems to
evidence of 'go it alone.' Such a view
Pa'ns are unnecessary,
are
another American critic from within itself is Szasz, who rejects the medical model as very often inapplicable to these new categories of neo-illness, or 'illness behaviour', to use David Mechanic's term. Such a model of doctorpatient-cure implies that some kind of superman exists and his name is psychiatrist. Szasz believes that the situation is more realistically dealt with in terms of the world of ethics, social psychology, games, game goals and games rules, that is to say a sociological model of roles, expectations, rights, duties, sanctions and controls. What we now call illness would be better reclassified as role conflicts, role refusals. This is no place to counter such criticisms. Perhaps there are powerful counters. One merely seeks here, however, to draw attention to the force of the dissent. Most professional workers inside psychiatry now fully realise the limitation of the subject. They are clearly aware of the quite modest influence they can hope to exert in terms of changing the personality, reducing vulnerability to further breakdowns, etc.; while, at the same time, society at large (especially interested and involved lay organisations) still has unrealistically high expectations. The picture that emerges then is that of social organisations and institutions?such as the Regional Hospital Board, Hospital Management Committee, large associations like the National Association for Mental Health, Leagues of Hospital Friends and government departments?looking benevolently and encouragingly, even deferentially, towards professional organisations of doctors, psychiatrists, nurses, and social workers for these expectations to be fulfilled?and being mildly puzzled, but courteously and discreetly silent, over the contrast between the predictions and the outcome. The professional workers themselves are defensive and sensitive, often presenting an image of confidence they do not feel or displacing their anxieties in aggressive criticism of financing arrangements, time allocation, or material conditions which may or may not be relevant. But no one can say how often the professional worker experiences or admits despair at the magnitude of the tasks with which he finds he is saddled. It should be clear from the argument that 'magnitude of task' refers to the task of influencing human behaviour and specifically does not refer to case loads or any material consideration of a similar
Lastly, psychiatry
kind. The main line of argument has to be that, over the last thirty to forty years, we have progressively widened the boundaries of psychiatric territory, in order to achieve the maximum amount of treatment for as many people as possible who might be classed as 'sufferers' and the basis for doing so has been an 3
belief in the value of treatment. More, come into treatment and, as Kingsley Amis might well argue?transferring his argument from the educational to the psychiatric field ?More means Worse, i.e. the more you treat, the poorer the quality of treatment, the less satisfactory the outcome achieved. Worse still, we now have on our hands the Scheff sociological finding that once a behavioural idiosyncracy or disability or life failure of some kind is labelled 'illness', it becomes quite difficult for the individual concerned ever to shake off the illness label; and, since psychiatric illness is statistically more likely to occur in people who have previously already had psychiatric illness, the more instances in which behaviour is classified as 'illness', the more likely further illnesses become?a simple snowballing
unquestioned
many more,
therefore, have
process. As always of course, destructive social criticism of this kind is easy. Positive social theorizing and engneering is not so easy. The sharp invective and brilliant intellectualism of Brave New World, Animal Farm and Nineteen Eighty Four is somehow regarded as a more significant achievement than Utopia and The Island which, by their very nature, are easy targets for further negative criticism. But, unless we have models at which to aim, it is hard to see how any progress can be achieved and even if we turn out to be wrong, then arguably it is better to be wrong than to be confused?at least the situation is clarified and the direction for further actions is more plainly seen.
two major ways in which the social problem of psychopathology can be tackled other than by endless extension or expansion of therapeutic services on a medical and paramedical basis. But first, two disclaimers. On the one hand, I use the term psychopathology as descriptive of the areas of human behavioural discrepancies and dissatisfactions, are
There
current
upheavals?in a word, unhappiness. Psychopathology has come to encompass all this in its meaning, but the medical content of the word is specifically rejected here. On the other hand, one takes the simplistic view, shared it seems to me by emotional
members of the National Association for Mental Health, that religion is not applicable in any very direct way in this field. Billy Graham, and perhaps any fundamentalist, is no doubt justified in claiming a formula that solves all human problems, but it seems that this can only ever be applicable to a tiny
minority.
So then, in the first place one would want to encourage the growth of non-medical therapeutic agencies. The obvious example of success here is the 4
Samaritan organisation. From the published figulj it seems clear that where this organisation is function ing efficiently the suicide figures are lowered. This in line with one of Schofield's main hypotheses tW psychotherapy is merely a form of friendsM intimate friendships have largely disappeared in tfl highly mobile, industrialised, mass society. And sud friendships do not demand expertise. The Cult' the Expert is an overblown myth, he says. In the second place, when one looks at the histo' of medicine, it is clear that environmental and pf' ventive approaches are far more significant thf therapeutics when dealing with pandemics (diseaS* prevalent over the whole country or world)?and case could be made for asserting that we are dealt1 now with a psychiatric, or pseudo-psychiatric, demic. In this context assistance on a very large s& might be expected from the emergence of the Hea'1 Education Council, but it may have to be courageo11 > pioneering and unclassical in what it tries to teachas the statistics now read, one third of all our nation 1 ill-health consists either of psychiatric entities physical complaints compounded with psychia11 attitudes, then it would seem that here is an import area for concern by the Council. The VD post* attack is on a miniature scale compared with M challenge. The Council might well experiment collaboration with the Department of Education devising humanistic-type courses, now that the schc 1 leaving age is raised and there are spaces on timetable for which to compete. We educate in cognitive skills, but we shrink the emotional sphere. Ought we not to lend 0 support to the teaching of psychology and socioM at a simple level at school? The message would e through to some (hopefully) that it is possible to reasonably objective about one's feelings, at ^ sufficiently so that one is not destroyed by them. *j effect of this could only be productive of support $ enhanced self-reliance as one inexorably goes thro11 life's rougher experiences. The acquisition of some kind of Weltansch
psychiatry Robert Fergusson tion occupied. The ethos of the Mental Health Ac of 1959 was an acknowledgement of the unchallei# ability of the authority of psychiatry. But the early days had seen the emergence of'
crusading spirit,
By being so eager to prove itself, has psychiatry bitten off more than it can chew ? As
more
and
more
people
need of treatment' the
are seen as
quality
'in
of the treat-
become debased. Stimulating the growth of non-medical therapeutic groups plus widespread mental health education could ease a mounting crisis in psychiatry. ment can
the 1930s, I remember reading a phrase in the old literary weekly John O'London, 'If Paul of Tarsus were to return to London today, he would say "Ye people of London, I perceive that of all things ye are too psychological".' Presumably this had something to do with the fears of some literati that psychoanalysis would engulf literary inspiration. But it seems to me the warning might still have timely application to medical, and especially psychiatric,
Many thinking.
years ago, in
After its early struggles for recognition, the advance of psychiatry has been quite spectacular? witness its major holding in the medical services both in terms of personnel employed and bed accommoda2
a
resentment at
being ignored,
a
ze3,
for the cause so to speak, that led the prophets a11,* their followers to carry the arguments and the clai*11 altogether too far. One effect of this was to ac^f' the fact that treatment was always desirable and g?? could only be benevolent and beneficial and, in ^ it became sacrosanct under the title 'therapy'. this may be regarded, though wrongly in my vieW,5 harmless. Another effect of the crusade was to try to ob^1 the benefits of treatment for groups of people 11 hitherto regarded as 'ill.' Treatment was an questioned desideratum and to achieve it the medicf model had to be used. There was excellent precede of course because, in a way, Charcot himself had exactly this with one of his own inimitable 'tours Maitre\ So a more obvious effect of the crusade was to blur the dividing lines between 'illfleS"
psychi^1.*
on the one hand, and unhappiness, nonconformism, delinquency and numerous
eccentric*^ form5"
life failures and inadequacies on the other. have said the advance of psychi^. had much in common with a relig'0 u movement?it
r
represented
a
new
view
C'
human behaviour, a new vision as it ^ Any movement with emotional drive resists cha^ particularly if it is called revisionism. We are see'11! now
communism, which has
drive of
much of the
emoti0^
religion, dealing with its revisionists j classing them as mentally sick?a demonstration the kind of social change envisaged here, but ^ exactly the opposite direction, i.e. as a punishmc.. a
In matters of faith it is
no doubt true that he vvh? for us is against us. If the milieu in which the psychotropic drug5 V given is as important as the drugs themselves, if[
not
i
Placebo'
effect
accounts for
erapeutic
something
like 33 3% of
success, then the sceptic is to be feared ecause he represents a threat to treatment. But
Psychiatry
claims to be scientific or at least claims to be scientific (one of the most reassuring things e Royal Medico-Psychological Association ever did to change the arrogant title of its journal from he Journal of Mental Science' to 'The British Journal of Psychiatry'). As an aspiring scientific lscipline, therefore, it ought to welcome controversy, ontroversy is essential to development. It may often ei^and a re-examination of the foundations on lch a subject is built. If controversy is suppressed, ? doubt growth may be fast and impressive, but 0 aPse may be equally spectacular. Awareness of the need for some revision or condefence has become, or at least ought to have come, inescapable in the face of some powerful Cent criticism. The criticisms of Eysenck against Vchotherapy have been known for a long time, have Host become institutionalised, and are essentially He is really 'One of Us', we feel. robably the most puzzling of the recent critics has Henry Miller?whose writings are a fearsome arrM ^am academic excellence, humour and conharshness. What is Miller really saying ?ut psychiatrists? At the risk of oversimplification, are rather Poor -^e Sa^ t^iat ?rS t^le sensc and their scientific positivists) onl ?ther source of y sciences is social the authority vv. arC of short 'n^ant^e' imprecise, desperately basi !c ^ata3 still groping for first principles'. nat*ve critic?this time from outside ?aroness Wooton who is much troubled by 6 ^?^ca^ inconsistencies of psychiatry. She can find S?^ f?undation, objective data on which to definitions of mental health?and, by con' n.? definition of mental illness other than an ex tastes anc* vaiue_iucigements of ?r t^le cu^tura^ norms of a particular
tTy
t0
kjfdng
Cp
'
si_,a
a^erable
doc?U^
Ps7chiatrists
med-101^^ th"105?^ b.00
trastaSe
PsychSSl?n
s?cietyatriStS
A
*
merican critics include Schofield who is uneasy on the score of the implications of
psychiatry for moral philosophy. Psychiatry ls
hapD-
an
d0mlness^das lhable -^?r^ st&
imply
illness
dim,v
myth
of
and apathy are illness. But an important social t^le term 'illness' is absolution from res^e most enobling human experience is t0 make the journey to self knowledge
meanP?nsihv the cu
The
offshoot of the Western
Under this banner, all discontent, bore-
weariness, jealousy
as
*s
&t
^
minishes
always painful. Psychiatry
lt *s
man.
nnwise
to
seems to
evidence of 'go it alone.' Such a view
Pa'ns are unnecessary,
are
another American critic from within itself is Szasz, who rejects the medical model as very often inapplicable to these new categories of neo-illness, or 'illness behaviour', to use David Mechanic's term. Such a model of doctorpatient-cure implies that some kind of superman exists and his name is psychiatrist. Szasz believes that the situation is more realistically dealt with in terms of the world of ethics, social psychology, games, game goals and games rules, that is to say a sociological model of roles, expectations, rights, duties, sanctions and controls. What we now call illness would be better reclassified as role conflicts, role refusals. This is no place to counter such criticisms. Perhaps there are powerful counters. One merely seeks here, however, to draw attention to the force of the dissent. Most professional workers inside psychiatry now fully realise the limitation of the subject. They are clearly aware of the quite modest influence they can hope to exert in terms of changing the personality, reducing vulnerability to further breakdowns, etc.; while, at the same time, society at large (especially interested and involved lay organisations) still has unrealistically high expectations. The picture that emerges then is that of social organisations and institutions?such as the Regional Hospital Board, Hospital Management Committee, large associations like the National Association for Mental Health, Leagues of Hospital Friends and government departments?looking benevolently and encouragingly, even deferentially, towards professional organisations of doctors, psychiatrists, nurses, and social workers for these expectations to be fulfilled?and being mildly puzzled, but courteously and discreetly silent, over the contrast between the predictions and the outcome. The professional workers themselves are defensive and sensitive, often presenting an image of confidence they do not feel or displacing their anxieties in aggressive criticism of financing arrangements, time allocation, or material conditions which may or may not be relevant. But no one can say how often the professional worker experiences or admits despair at the magnitude of the tasks with which he finds he is saddled. It should be clear from the argument that 'magnitude of task' refers to the task of influencing human behaviour and specifically does not refer to case loads or any material consideration of a similar
Lastly, psychiatry
kind. The main line of argument has to be that, over the last thirty to forty years, we have progressively widened the boundaries of psychiatric territory, in order to achieve the maximum amount of treatment for as many people as possible who might be classed as 'sufferers' and the basis for doing so has been an 3
belief in the value of treatment. More, come into treatment and, as Kingsley Amis might well argue?transferring his argument from the educational to the psychiatric field ?More means Worse, i.e. the more you treat, the poorer the quality of treatment, the less satisfactory the outcome achieved. Worse still, we now have on our hands the Scheff sociological finding that once a behavioural idiosyncracy or disability or life failure of some kind is labelled 'illness', it becomes quite difficult for the individual concerned ever to shake off the illness label; and, since psychiatric illness is statistically more likely to occur in people who have previously already had psychiatric illness, the more instances in which behaviour is classified as 'illness', the more likely further illnesses become?a simple snowballing
unquestioned
many more,
therefore, have
process. As always of course, destructive social criticism of this kind is easy. Positive social theorizing and engneering is not so easy. The sharp invective and brilliant intellectualism of Brave New World, Animal Farm and Nineteen Eighty Four is somehow regarded as a more significant achievement than Utopia and The Island which, by their very nature, are easy targets for further negative criticism. But, unless we have models at which to aim, it is hard to see how any progress can be achieved and even if we turn out to be wrong, then arguably it is better to be wrong than to be confused?at least the situation is clarified and the direction for further actions is more plainly seen.
two major ways in which the social problem of psychopathology can be tackled other than by endless extension or expansion of therapeutic services on a medical and paramedical basis. But first, two disclaimers. On the one hand, I use the term psychopathology as descriptive of the areas of human behavioural discrepancies and dissatisfactions, are
There
current
upheavals?in a word, unhappiness. Psychopathology has come to encompass all this in its meaning, but the medical content of the word is specifically rejected here. On the other hand, one takes the simplistic view, shared it seems to me by emotional
members of the National Association for Mental Health, that religion is not applicable in any very direct way in this field. Billy Graham, and perhaps any fundamentalist, is no doubt justified in claiming a formula that solves all human problems, but it seems that this can only ever be applicable to a tiny
minority.
So then, in the first place one would want to encourage the growth of non-medical therapeutic agencies. The obvious example of success here is the 4
Samaritan organisation. From the published figulj it seems clear that where this organisation is function ing efficiently the suicide figures are lowered. This in line with one of Schofield's main hypotheses tW psychotherapy is merely a form of friendsM intimate friendships have largely disappeared in tfl highly mobile, industrialised, mass society. And sud friendships do not demand expertise. The Cult' the Expert is an overblown myth, he says. In the second place, when one looks at the histo' of medicine, it is clear that environmental and pf' ventive approaches are far more significant thf therapeutics when dealing with pandemics (diseaS* prevalent over the whole country or world)?and case could be made for asserting that we are dealt1 now with a psychiatric, or pseudo-psychiatric, demic. In this context assistance on a very large s& might be expected from the emergence of the Hea'1 Education Council, but it may have to be courageo11 > pioneering and unclassical in what it tries to teachas the statistics now read, one third of all our nation 1 ill-health consists either of psychiatric entities physical complaints compounded with psychia11 attitudes, then it would seem that here is an import area for concern by the Council. The VD post* attack is on a miniature scale compared with M challenge. The Council might well experiment collaboration with the Department of Education devising humanistic-type courses, now that the schc 1 leaving age is raised and there are spaces on timetable for which to compete. We educate in cognitive skills, but we shrink the emotional sphere. Ought we not to lend 0 support to the teaching of psychology and socioM at a simple level at school? The message would e through to some (hopefully) that it is possible to reasonably objective about one's feelings, at ^ sufficiently so that one is not destroyed by them. *j effect of this could only be productive of support $ enhanced self-reliance as one inexorably goes thro11 life's rougher experiences. The acquisition of some kind of Weltansch
