Mental health doesn't need psychiatry

October 17, 2005

As a medical discipline psychiatry's purpose is neither to provide psychological or practical help nor human support, argue Phil Barker and Poppy Buchanan-Barker. So if people with brain disorders and learning disabilities can be supported without psychiatrists, why not people with mental health problems?

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Recently, on BBC radio, Raj Persaud, arguably the country's most famous psychiatrist described schizophrenia as a 'mental health difficulty'. This showed how far we have come with the linguistic revolution in mental health. Schizophrenia - long established as the scariest, most complex and disturbing form of human experience - now sits comfortably alongside 'public speaking anxiety' or 'low self-esteem'. We couldn't imagine a prominent physician describing 'breast cancer' or 'motor neurone disease' as a 'physical health difficulty'?

Political correctness drains most of the meaning from what we once called 'mental illness'. No one can lay claim to full mental health, so we all must have some kind of 'mental health difficulty'. It is not surprising that activists and consumer groups have reclaimed expressions like 'crazy' and 'madness' as a defiant act of subversion - hence the success of 'Crazy Folks' in the US and 'Mad Pride' in the UK.

Physicians - and other health care workers - never talk about 'physical illness' - far less physical health difficulties'. They deal with specific diseases or disorders, which they examine clinically, and measure reliably. Some show manifest lesions of the body - like the various cancers; others indicate a dangerous disturbance of bodily functioning - like high blood pressure. All are, however, identifiable and measurable, making physical medicine a genuine scientific enterprise.

By comparison, psychiatric 'medicine' is almost a contradiction in terms. The psychologist, Richard Bentall, has pointed out that psychiatric diagnoses are no better predictors of what will happen in a person's future, than horoscopes: A sobering, if obvious, judgement. When we become seriously ill, we expect blood tests, urinalysis, X-rays, biopsies, MRI scans and so on. These will, hopefully, identify what is wrong with us. The person suspected of having a 'serious mental illness' will have a conversation with a psychiatrist, who then makes a judgement based on what has been seen and heard. Despite the absence of the crystal ball the parallels with astrology are certainly apparent.

Psychiatry's attempt to collapse the huge catalogue of human misery into one rag-bag classification of 'mental illness', makes no logical sense, but it makes perfect historical sense. Psychiatry may not have invented 'mental illness' but by attributing our various personal and interpersonal problems to some 'disturbance of the mind', the myth of 'mental illness' was born.

Some psychiatrists are trying to redeem themselves by reviving old ideas like the 'biopsychosocial' model. They hope this will counter the reductionism of the 'medical model', without altogether abandoning scientific psychiatry. The best-known advocates of a new psychiatric paradigm are Pat Bracken and Phil Thomas . Their idea of 'post-psychiatry' is, however, not as attractive as it first sounds. They wonder what psychiatry would be like if it could accommodate certain contemporary philosophical ideas - regarding the self, lived experience, community, race, power etc?

Their work has gone some considerable way to answering such questions. However, by trying to revise psychiatry, they avoid challenging the powerful forces that sustain psychiatric medicine. In particular, they avoid asking what would a world without psychiatry be like? Lets talk 'post-psychiatry' proper.

Post-psychiatry
Imagining a world without the wise counsel and intimate comfort of a humane, insightful, scientific, 'healer of the mind', is difficult only for those with a psychiatric dependency. For everyone else, this is romantic fiction, spawned by Hollywood - and especially the films of Alfred Hitchcock. Instead, many ask: "what, exactly, do psychiatrists offer us today?"

* Psychological help? No! If we need or want psychotherapy or counselling we see a psychologist or some other 'therapist'.
* Practical help? No! If we need to sort out our everyday problems, we see a social worker, or some other 'mental health worker'
* Human support? No! If we need someone to comfort us, during a crisis- we look to nurses, support workers, members of a mutual support group, if not our family and friends.

Currently, the delivery of a psychiatric diagnosis and the prescription of psychiatric drugs is what we expect from a psychiatrist, but for how much longer? Nurses in the UK are being prepared to become 'prescribers', following the lead of their American cousins, where nurses have been prescribing for over a decade. Given that US nurses have also been prepared to deliver psychiatric diagnoses, this seems likely to happen here too. After all, one can hardly prescribe drugs without knowing what is wrong with someone - and that requires the delivery of a diagnosis.

All of which raises the big question: what, exactly, do people need psychiatrists for? If not for psychotherapy or counselling, or practical help, or ordinary human comfort, or medication or the delivery of diagnosis - or at least, not for long - then what?

Psychiatrists like Pat Bracken and Phil Thomas recognise that few of the core concepts of psychiatry make any scientific sense, and even have asked for ideas like 'schizophrenia' to be scrapped. As psychiatrists themselves, they stop short of suggesting that psychiatry itself might be scrapped, and who can blame them. However, what would a 'post-psychiatric' society be like?

Two hundred years ago - when modern psychiatry began - the abolition of slavery had not yet started. Who would have thought then, that 'post-slavery' was possible? In the early 1900s, as Freud began to shape many of our current ideas about the mind and brain, women had yet to gain the vote. Who would have thought that a 'post-women's suffrage' world would now be so easily taken for granted. In 1960, when Thomas Szasz first laid down his challenge to the orthodox logic of psychiatry, the American civil rights movement was just beginning. Who would have thought, then, that we would talk 'post-civil rights' so easily? In 1990 as Ronald Reagan announced funding for the infamous 'decade of the brain', the Soviet Union began to implode. Who would have thought that 15 years on, we would talk so casually about 'post communist societies'? These historical timelines remind us that all institutions and ideas have a limited lifespan. Nothing endures - and that includes psychiatry.

These events also remind us that the key issues in contemporary mental health are about personhood (slavery) equality (suffrage) humanity (rights) and power (scientism or communism - take your pick).

Problems of living
There is no doubt that some people experience very serious problems of living. However, even if 'mental health difficulties' are shown to have associated biological, genetic or biochemical factors - a very big 'if' - would this mean that psychiatry should still be the core of the help such people need?

Twenty years ago many people with so-called 'learning disabilities' were still in the 'care' of psychiatrists. There is plenty of evidence that the cognitive, emotional, intellectual and other 'mental' difficulties of such people arise from brain injury or organic defect, chromosomal abnormality or other genetic influence. However, despite the obvious 'medical' nature of many of their problems, people with learning difficulties have almost completely escaped the dead hand of psychiatry. Such people may experience complex problems of living, with themselves and others. They may need a variety of forms of human helping -from special education to special housing. What they do not need - despite many of them having obvious brain pathology - is a psychiatrist. Indeed, the success of contemporary learning disability services has involved reclaiming the personhood of the people with the so-called learning disabilities and ditching psychiatric paternalism in the process.

Dyslexia, which affects about 10% of the population, regardless of intelligence, race or social class, may offer a more striking example. The problems associated with dyslexia focus mainly on difficulties with reading, writing and spelling, but other 'mental problems' such as short-term memory, concentration and personal organisation can also be affected. It is well accepted that dyslexia is biological in origin and runs in families, suggesting some genetic influence. However, no one would dream of calling dyslexia a mental illness. Like 'learning disability' dyslexia can be, and often is, a complex problem of human living

People with experience of dyslexia need understanding, support and practical help in learning to live with or overcome their problem. They do not need to see a psychiatrist. Although having serious problems in reading, understanding and concentrating could potentially be lethal - the person with dyslexia is not a candidate for detention under the mental health act and forcible psychiatric 'treatment'.

Getting over psychiatry
However, having invented itself two centuries ago, psychiatry is not simply going to walk away from the action. Despite unremitting criticism over the past 30 years, psychiatry still reigns supreme. There is no doubt that some psychiatrists are sophisticated communicators, warm and compassionate individuals, with an encyclopaedic knowledge of both the physical and social sciences. However, one might ask, is it necessary to spend a decade training as a doctor to acquire such qualities? More importantly, do people with 'mental health difficulties' - like schizophrenia - need such a brilliant mind, to be supervising their everyday 'care and treatment'. Clearly people with learning disabilities or dyslexia don't. So, what - apart from history - is different about 'mental health'?

* Phil Barker is a psychotherapist in private practice and honorary professor at the University of Dundee. He was a mental health nurse for more than 35 years and the UK's first professor of psychiatric nursing practice. He is also professor of health science, Trinity College, Dublin, Ireland

* Poppy Buchanan-Barker is a counsellor, advocate and director of Clan Unity International, Scotland.

They have, between them, authored a number of books, including The Tidal Model: A guide for mental health professionals and Spirituality and Mental Health: Breakthrough

* Get comment direct to your inbox by joining the Psychminded Members Forum

See also:
Mental health nursing comment
May 16, 2005: It's time the giant of mental health nursing woke up - Input from mental health nurses is markedly absent from clinical guidelines produced by The National Institute for Clinical Excellence, say Phil Barker and Poppy Buchanan-Barker. It's time, they argue, that mental health nurses had their own representative body to stand up for them.
Aug 16, 2003: Pushing for compassionate and ethical psychiatric nursing - Name an eminent thinker from 20th century psychiatry and mental health, and a psychologist, psychiatrist or philosopher might spring to mind. It's unlikely to be a psychiatric nurse. But if it was, it might be Phil Barker

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12 years of hospital care without once seeing a consultant psychiatrist

Comment from: Trudy Hirst, activist, Acceptance, a self help support/campaign group meeting weekly at Pontefract Family Centre, Pontefract, West Yorkshire

Date: May 12, 2006

I wholeheartedly agree. I have suffered 'mental illness' since childhood. I am now 49. This 'mental illness' has taken the form of bouts of severe depression coupled with a history of serious self harm, which through cognitive therapy (and not drugs) I have now almost conquered altogether.

At my worst I was eventually referred to my local psychiatrist.
I remained under the hospital's care for about twelve years, only being discharged two years ago. Throughout all this time I I never actually saw the consultant psychiatrist in whose care my mental wellbeing had been placed, not even once.

I was merely shifted from one junior doctor doing their pysch rotation to the next, most of the time never seeing the same doctor twice, whilst the consultant who I had never even spoken to was passing judgement on my condition and instructing my GP to give me medication.

From being involved with other survivors of our local mental health system, I came to realise my experience was not unique.

Having quite a few physical health problems that have required hospital treatment over the years, I know that it is normal practice elsewhere in the NHS to be seen by the consultant, at the very least on your first visit.

In view of all this I have come to view psychiatrists as legalised drug pushers. When I was discharged from their care I was left on medication which I feel I do not need.

The only reason I am still taking these drugs is because my GP cannot come up with a safe way to wean me off the lowest dose. (I take slow release medication because other forms cause me to have severe migraines).

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