Tuesday, 9 July 2013

Improving Mental Health Care: 3 Myths to Avoid

The Struggle of Good vs. Evil:

No Grey Areas Here

Howard Zinn’s massive book on American history is a gripping account of the ways in which the poor and dispossessed of the country have been oppressed and undermined by the financial interests of the financial and political elite. It has one major flaw; a tendency toward painting those elites as a coherent unit of baddies, explicitly motivated to work against the interests of the common man and actively choosing to do so at every turn. For this it was voted one of the least credible books by a poll on the History News Network. The charge is not that Zinn misrepresents the social consequences of financial injustice, but that he falls into the easy trap of inventing a coherent group of people whose malign intent is the cause of those consequences. In fact history is messier; events are caused by isolated individuals, subject to circumstance and acting in what seem to be their best interests at the time.

People on both sides of the debate about psychiatry persistently fall into the same trap and the Manichean narrative erupts all the time in unexpected ways. Jeffrey Lieberman does it here, drawing an unfortunate parallel between anti-psychiatry (which undoubtedly contains some ill thought through positions) and "racism, sexism and homophobia". His piece contains a reasonable point about the nature of debate over DSM; some people seem opposed to diagnosis and psychiatry as a matter of principle, but he can't resist his own anger at the way psychiatry is being criticised.

As if to make Lieberman's point for him, the psychologist and blogger Phil Hickey maintains a fairly constant stream of angry diatribes at his site Behaviorism and Mental Health. His posts (here's one about Lieberman himself) are characterised by an uncompromising rejection of any argument that gets made in psychiatry's favour, assuming it is necessarily being made cynically. Hickey's position is to start from the premise that psychiatry, drugs and diagnosis can never be a good thing and it is surprisingly influential. In debates with qualified clinical psychologists on Twitter I have been called a "pseudo psychiatrist" (as though that in itself were an insult) and seen genetic research into mental health baldly equated with "Nazism".

There is certainly a corrupting influence of big pharma on psychiatry. For my money this was described rather well in Richard Bentall’s Doctoring The Mind: Psychiatrists are treated to glamourous and all expenses paid international conferences; some people make hundreds of thousands of dollars, calling themselves "educators" to promote these drugs. However, this is not the result of some grand concocted scheme by a unified overarching "Psychiatry", it emerges through the collected actions of more or less well intentioned individuals, many of whom fall prey to cognitive biases and self-deception. There is an evil in such a state of affairs, but unfortunately it does not lie where it would be easiest to see and avert.

The notion of the Sacred:

Beware Sacred Cows!

One consequence of thinking in terms of an almost cosmological good and evil is that some ideas come to be seen as inherently unspeakable; a breach of the sacred (or at the very least, of simple common sense and decency). The result over time is that ideas are received, left unchallenged and assume the level of a received truth. This habit is evident among just as many of those who associate the "medical model" with all that is evil as among those that defend it.

Witness the final sentence of the fourth paragraph in this article by Susan Inman, the author of a book about having a child with mental health problems: "Books linking schizophrenia to capitalism have become bestsellers" she sighs. Inman may very well feel this line of sociological inquiry is a waste of everyone's time, but it is never enough to register it in a taken-for-granted tone of indignation. Why not link Schizophrenia to capitalism? If it turns out to be a crappy idea, explain why and show your workings. 

On the other side, all manner of sacred truths abound; diagnosis is "one of the worst things one human can do to another", "bio-genetic explanations" cause stigma and medical treatments do more harm than good. There are important facts that underlie these positions (diagnosis can cause social harms; certain bio-genetic explanations are overly simple and chemical/brain interventions often have damaging effects) but that they too easily become sacred cows which stop us from hearing evidence which contradicts our position. Become too attached to a position and you are vulnerable to the confirmation bias, our tendency to seek out evidence which affirms a position we have already decided is correct. 

Revolutionary Promise:

The Revolution Will Not be Tranquilised

There is no getting away from the fact that psychiatry and clinical psychology offer little consolation of a complete resolution of the problems they take on. We may talk of “treatments” in our field but any mention of “cures” prompts justifiable cynical laughter from practitioners and service users alike. Mental health problems are sufficiently complex (and involve a sufficient mixture of the bio-psycho and social in their cause) that any suggestion that we have discovered that miraculous silver bullet should be taken with a healthy dose of scepticism.

This fact is regularly rehearsed in relation to new biological treatments; anti-psychotics and anti-depressants are debunked as mere dampeners of experience and the internet genre of neuro-criticism (as exemplified by bloggers Neuroskeptic, Neurobollocks and Neurocritic). It is less often raised in response to the utopian claims of social constructivists. In blithely asserting that “we would halve the amount of emotional distress in this country if we had the more equal, relatively cohesive, less debt-ridden political economics of our European neighbours”, Oliver James all but torpedoed his own case by making it implausible. Any talk of revolutions or "paradigm shifts" in clinical psychology should be met with suspicion, not because revolutions are necessarily unwelcome (although it is true that their dangers are easily overlooked) but because they often represent a promise that is then dismally betrayed.

The best possible response to mental health problems probably doesn't lie just over some ever receding social horizon, it is an ongoing process of improvement and research, integrating more kindness and better understanding into our services. 

1 comment:

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