CAN PSYCHIATRY ABANDON THE "MEDICAL MODEL"?
Based on talk given at The Leeds Mental Health and Crisis Service Conference, Leeds, 6 December 2000
There are several parallels that can be drawn between the chaos on the train services in this country in the period following the Hatfield crash in October 2000 and the current state of mental health services. The train journey from London to Leeds to this conference took me a very long five hours. My train was at a standstill for an hour and a quarter at one stage, because it took this length of time for the train staff to work out that somebody had pulled the communication chord. Initially we had been told that the wheels of the train had jammed - then that the driver had managed to fix the problem. A few minutes later it was announced that we would after all have to wait for an engineer to come to lend assistance. Eventually the train started moving and we were informed that the real reason for the wait had been that someone had pulled the communication chord. Even though there had been no apparent need for such a long delay, the train company thought it could ameliorate any damage by keeping us informed. I am sure the company thought it was fulfilling its responsibilities.
Glad to be on the move again, I started thinking about what would have happened if there had been a real emergency and if someone had pulled the communication chord in extremis, only for it to have taken an hour and a quarter to find out. I even went to look for where the communication chord had been pulled and discovered from one of the conductors that it was apparently in a toilet in one of the carriages. I asked why the staff had not detected the signal from the communication chord. His answer was that the chord was broken. A few minutes later it was announced over the public address system that the toilet should not be used because of a faulty communication chord!
Again, I am sure the company thought it was protecting its interests against a complaining public by making such an announcement. A moment's reflection will conclude, however, that the best action may not have been taken in the interests of passenger safety. Surely it would have made sense to lock the toilet and put it out of action if there was a genuine faulty communication chord. Despite having made the announcement to the current passengers, who may have been able to take heed and remember the warning if they were listening, people getting on at the next station would not have had this information. They may have used the toilet in ignorance of the fact that they could not have called for help by pulling the communication chord.
I mention this episode to emphasise that we live in a risk society (Beck 1992). It may have made sense for train speeds to be restricted because of the poor state of the railtrack. An overemphasis and obsession with risk however may not necessarily make matters safer overall. Commonsense may be abandoned in the interest of defensive actions.
In the same way, we can ask whether the current emphasis on risk assessment in mental health will really improve public safety. Many mental health professionals will recognise a similar sense of confusion in their everyday mental health practice to that I described on the train that day.
David Clark (1995) was the medical superintendent of Fulbourn Hospital in Cambridge at its heyday of social therapy, therapeutic communities and rehabilitation. He regrets the recent emphasis on risk prevention and defensive practice, which he sees as a return to institutionalisation. He compares such bureaucratic behaviour to the worst days of the traditional mental asylums -
issuing memoranda, forbidding activities, putting up warning notices, setting up disciplinary enquiries and penalising staff who take risks or show initiative. Staff have learned to be cautious, to get everything in writing, to avoid initiative.
This issue of risk relates to my question of whether psychiatry can abandon the "medical model". My argument is that adopting the "medical model" gives a kind of reassurance to mental health practice. I think this sense of security will only be given up with difficulty.
To take my own situation, as an example, I have been considered "dangerous" by my colleagues because, according to their view, I do not give enough authoritative direction to patients in my medical practice. I do not follow the conventional biomedical model of treatment of mental illness, which provides a clearcut approach of medical diagnosis and management.
Life has not been easy for me as a consultant, because I have been regarded as "too radical". But I have not left the system of psychiatry. I have stayed within it. I have not dropped out like so-called anti-psychiatrists such as, most notably, Ronnie Laing. In fact, it seems more to me that psychiatry does not want me rather than that I do not want to be part of it. After all, anti-psychiatry is a term that is generally used by mainstream psychiatry, not the so-called anti-psychiatrists themselves (Double 2001). I think that a psychiatry which is able to be critical about itself is surely part of psychiatry. Maybe the problem is that psychiatry is too conservative in the sense of being risk-averse rather than me being too radical. But is it really too radical to suggest that psychiatry should be open minded and at least answerable to criticism?
The latest accusation seems to be that I am too extreme and take too much risk. The emphasis in psychiatry over recent years has been on making services safer. The government is now reforming the Mental Health Act, and its motivation is presented as improving public safety (Department of Health and Home Office 2000). Thus if I do not seem to go along with the direction towards more safety in standard psychiatric practice then I must be considered as 'unsafe'. But why is the Royal College of Psychiatrists not part of the Mental Health Alliance which was formed to express concern about the government's reforms? It is a very wide alliance. It is led by MIND, the Mental Health Foundation and the National Schizophrenia Fellowship. In other words the user movement has concerns about the government's emphasis on social control. The only group of psychiatrists which is a member of the Mental Health Alliance, alongside users, is the Critical Psychiatry Network. This gives me a chance to say a little about the Critical Psychiatry Network.
The Critical Psychiatry Network
The Critical Psychiatry Network is a group of senior psychiatrists formed in Bradford in January 1999. Whilst not all taking the same views, we do have mutual concerns about the nature of psychiatry. We are prepared to be critical of our own profession and to recognise that sometimes psychiatry can be part of the problem rather than necessarily the solution to mental illness. We have concentrated initially on the government's reform of the Mental Health Act which has allowed us to develop links with user and advocacy groups. Other professional groups outside psychiatry are generally more in tune with our views than psychiatry itself, in that they are looking for ways in which psychiatry can be more therapeutic and less coercive and abusive - psychiatry should be open, challenging and empowering, not the reverse.
The Network organised a Conference in Sheffield in April 2001, entitled 'Reducing the biomedical dominance of psychiatry'. Our keynote speaker, Jan Foudraine from Holland, was, if you like, the Dutch equivalent of Ronnie Laing for critical psychiatry. He wrote a bestseller in the 1970s which was translated in English as Not made of Wood (Foudraine 1974), in which he expressed his disappointment with the lack of human dignity that he found in traditional psychiatric practice. He was also frustrated with psychotherapeutic approaches when he went to America and worked there for a few years, trying to transform his psychotherapy based ward there into what he called a school for life. Even though this book had popular appeal, he could not make sense of the professional hostility he received and he became the personal ambassador in Holland of Bhagwan Rashish.
Another of our conference speakers, Lucy Johnstone, has recently published a second edition of her excellent book Users and abusers of psychiatry (Johnstone 2000). Lucy had to leave clinical work as a clinical psychologist to become an academic because of the hostility she experienced. A few years ago in a Clinical Psychology Forum she described how she was once harangued for forty five minutes after a clinical presentation by three medically minded psychiatrists trying to get her to change her views (Johnstone 1997). She only managed to stop being pestered by getting into her car and driving away!
Biomedicine, Psychology and Patient experiences
This brings us back to the question with which I started of whether psychiatry can abandon its biomedical emphasis. It has always had this bias. Over the last fifty years the bias has been reinforced by the plethora of drugs brought onto the market by the pharmaceutical companies. Nonetheless, the essential philosophy underlying the biomedical approach remains the same. Haslam concluded in his treatise in 1817 that "insanity is a corporal disease". The nature of mental illness is simplified by regarding it as originating in the body, or to be more specific, in the brain. Haslam was honest enough to recognise the power relations which such a philosophy creates. He regarded mental illness as the 'peculiar and exclusive province of the medical practitioner' (Haslam 1817). Doctors are in charge - why should they want to give up that influence?
However, the way that the term mental illness is used is as a psychological concept, not a medical concept. I am not wanting to separate the body from the mind - it does not make sense to have a dualistic notion of the mind/brain relationship. Of course mental illness has something to do with the brain. All behaviour, feeling and thought derive ultimately from the brain.
I would call my approach a bio-psychological approach contrasting it with a bio-medical approach. The prefix of "bio" is used deliberately to emphasise mind-brain integration. My critics may think I should become a clinical psychologist, and that I should not have the status and authority of a doctor if I am not prepared to accept the bio-medical model.
To go back to Haslam again, he stated that "From the limited nature of my powers, I have never been able to conceive a disease of the mind". At least, in saying this, he admits he does not understand. It does not make sense to him that mental illness may be a statement about psychological functioning.
Adolf Meyer (1951/2), who was the foremost American psychiatrist in the first half of the last century, was fond of calling the biological hypothesis a neurologising tautology. What he meant was that postulating a biological abnormality does not help personal understanding of mental illness. It is interesting how his views have been eclipsed in the last half of the last century and maybe they need to come back as part of a critical psychiatry renaissance. The problem with the bio-medical model is that it takes us away from understanding the patient as a person. In other words it reduces the person to the brain. A single word diagnosis does not do justice to the complexities of understanding a person's problems.
Rufus May is a Clinical Psychologist in Tower Hamlets in the East End of London. When he was eighteen years old, he was told he was a paranoid schizophrenic and that he should take medication for the rest of his life. He was compulsorily treated in hospital and in an article in the Guardian, he described his experience. He wrote as follows:
When I was a patient I felt misunderstood and written off. . . . I thought I was treated cruelly. When I was forcibly treated and injected, it felt like rape. . . . [I]t was believed that talking about psychosis made it worse. . . . But now [as a clinical psychologist] I prefer making sense with a person about their experience (James 2000).
Mind and the Big Issue (2000) (the weekly magazine produced and sold by the homeless) recently published a survey of people who have used in-patient mental health services. Forty seven per cent of the people in the survey said that the ward conditions made them worse, compared to twenty seven per cent who found that they helped them. Fifty six per cent, i.e. the majority, said that the ward was untherapeutic, as compared to twenty five per cent who found it therapeutic. Mental health services, such surveys surely confirm, are not the panaceas for people's mental health problems that the service providers often like to feel that they are.
Innovation in Services: Home Treatment and Critical Psychiatry
This takes me on to the subject of the changing nature of services and particularly crisis and emergency response services, or what has been called centrally by the National Service Framework (Department of Health 1999), "crisis resolution" services.
Psychiatrists generally are not good at being innovative about services. In practice, they often have too much to lose in terms of status. The Government has not apologised for its emphasis on public safety and for its view that community care has failed (Department of Health 1999). At least this stance may mean that we move on from the sterile debate about institutional versus community care.
Campaigning organisations such as SANE (Schizophrenia a National Emergency) have deliberately exploited public anxieties Initially this was the concern that homelessness is being increased among the mentally ill. They changed their tack when evidence accumulated against this view (Leff 1999), to concern about public safety due to homicides by psychiatric patients. More recently this latter argument has also been shown to be stigmatising, as it has been ratified that the proportion of homicides due to mentally disordered people has actually decreased over the period of deinstitutionalisation (Taylor & Gunn 1999). For a long time some psychiatrists did not want to give up their power base in the asylum. Even now most psychiatrists would prefer to be based in the in-patient unit. I am in a minority, having always based myself as a consultant in a community mental health centre.
This is not to say that I do not consider in-patient work to be important - it needs to be integrated with community work - perhaps not dissimilar to how I was saying there needs to be mind-brain integration. The professional barriers are not just in medicine and psychiatry. Nursing, as an example, has always been split into community and in-patient work. There is a resistance to looking at ways of providing an alternative residential setting, other than in a hospital.
Of course there are psychiatrists who support innovation - I do not wish to generalise. However, I think it is more likely that a critical psychiatrist will support innovation. To give an example, Marcellino Smyth, who is a member of our group, wrote an article with John Hoult on home treatment (Smyth & Hoult 1999). They commented on the resistance to implementing home treatment services and asked why home treatment for acute psychiatric services is generally ignored as an alternative to conventional admission to hospital. As does not seem to be unusual for members of our group, Marcellino's article was only published with an accompanying commentary article. This has happened several times to Joanna Moncrieff, who should have been here giving this talk today, but was unable to attend because of the train delays. For example, she has done some useful work on lithium, but each of her two main articles on this subject were only published by the British Journal of Psychiatry with an accompanying commentary (Moncrieff 1995, 1997).
It is as though critical psychiatrists can only have their say, as long as it is balanced by the so-called more even handed view. Now I am not saying there are not some errors and excesses in what critical psychiatrists say. But I am also sure that there are excesses and errors in what biomedical psychiatrists say and they seem to have a freer reign in the literature.
Smyth & Hoult (2000) point out that research evidence shows that home treatment is safe, effective and feasible for up to 80% of patients presenting for admission to hospital. They emphasise the addressing of social issues surrounding the crisis right from the beginning and the provision of practical, problem-solving help. Crisis resolution clearly has a role within an integrated comprehensive strategy.
I think it is important to note how resistance to home treatment is tied to conceptual issues about mental illness. Home treatment challenges the "medical model". Its mode of intervention emphasises flexibility and social networks. There is less stress on individual disease presentations. The Bradford Home Treatment services, for example, specifically identifies its philosophy as influenced by the social model of mental illness and patient directed care (Bracken & Thomas 1999).
What is to be done ?
What can be done about the current situation in psychiatry? I think we actually need to be sensitive to psychiatry's defensiveness. Not that I am excusing poor practice, but I do not think that poor practice is always deliberately and consciously motivated. Fundamental training is required to make services personal and humane. Biomedical psychiatrists think I need retraining. Maybe I do, we all need to continue learning and developing personally but I also think there is a need for psychiatry itself to retrain and re-educate itself, and this is not going to be an easy process.
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