Psychiatrists can have understanding too: Recent advances in psychological understanding of psychotic experiences
D B Double
I am unusual professionally in being both a member of the Royal College of Psychiatrists and the British Psychological Society. It was during the time that I had an 8 year gap in my medical training that I obtained a psychology degree. I even applied for clinical psychology training, and at one appointments interview was advised that I would have more influence as a psychiatrist than a clinical psychologist and that I should go back and complete my medical training - which I did.
I have never regretted the decision financially! However, I have found my medical professionalisation difficult. It was part of the reason I gave up my medical training for a while. On being congratulated after my first consultant appointment I was told that I had now joined the "medical club". I am not sure if I now seem like a doctor or not.
Relations between the Royal College of Psychiatrists and the British Psychological Society have not always been good. For example, in 1973 the newly founded Royal College of Psychiatrists submitted a memorandum to the Department of Health expressing their views on the possible role of the psychological services. In an infamous passage it stated:-
It is recognised that there is a school of thought which denies the concept of mental illness and considers that the symptoms hitherto classified as mental illness, mental disorder, tensions, psychosis, personality disorder etc. should be regarded as psychological behavioural maladjustments and should be treated outside the medical ambit. These views are not acceptable to the College.
This statement was taken by some as an unequivocal defence of the medical model. Even if there has not been overt hostility between clinical psychology and psychiatry, there has been a history of 'unspoken confrontation'. The implementation of the Trethowan report gave clinical psychology more independence as the profession expanded in numbers. With the rise of a managerialism in the NHS, professional conflicts have become less prominent. There used to be a Joint Standing Committee between the two official bodies, which I understand has fallen into abeyance. As it is no longer required this must confirm that relationships have been better recently.
Not that I am suggesting that the BPS Report "Recent advances in psychological understanding of psychotic experiences" should lead to renewed ructions between psychiatrists and psychologists. It has been supported by eminent psychiatrists such as Graham Thornicroft and Paul Bebbington. Many psychiatrists are now interested in cognitive approaches, which is the stock-in-trade of clinical psychology.
Now I do not want to get into an ideological battle about the nature of psychotic experiences. The fact is, though, that most psychiatrists take what I call a biomedical view of psychosis, whereas the report takes what I will call a biopsychological view. Now my position has always been that psychiatry need not be tied to a biomedical view - there has been a minority biopsychological approach in psychiatry, represented particularly by Adolf Meyer, who was the foremost American psychiatrist of the first half of the last century. His approach was called Psychobiology. However, his views are not well known in the current biomedical dominance of psychiatry. Meyer concentrated on understanding the patient as a person - hence the reference to understanding in the title of my presentation.
Adopting a biopsychological approach to practice has led me into conflict with my medical colleagues. I am a member of the Critical Psychiatry Network which some of my colleagues find threatening. Not that I want to threaten their position. I think the Critical Psychiatry Network is only arguing for more self-awareness in psychiatric practice.
There are two particular ways in which my practice has been criticised. Firstly, I am said not to use psychiatric diagnosis enough. Secondly, I am told I do not prescribe enough medication. I want to look at each of these two accusations in turn. In the third part of my talk I want to say a little more about power relations in mental health work, in particular in relation to the BPS report on psychosis.
So, to recap, the three parts of my talk are:-
(1) The importance of psychiatric diagnosis
(2) The efficacy of psychiatric medication
(3) The control of mental health services
The importance of psychiatric diagnosis
As a psychiatrist, do I not place enough emphasis on psychiatric diagnosis? As a doctor, am I not expected to produce a clear diagnosis, if only to be able to apply the appropriate management plan which is laid out for each diagnosis?
My basic answers to these two questions are that, firstly, there is a current overemphasis on diagnosis in practice and that, secondly, practice is not as simple and certain as the biomedical model would suggest. And this is not just my view. It does have the authority of Adolf Meyer and I want to say a little more about his ideas on diagnosis.
Meyer argued with Kraepelin about the diagnosis of dementia praecox, which of course came to be known as schizophrenia. Although Kraepelin thought he had identified a single, morbid process, Meyer argued that it was no help in understanding a person's problems to hypothesise a biological process behind the presentation. As far as Meyer was concerned, even psychotic processes, which can be very difficult to understand, need to be seen in the context of the patient's personal and social situation to be able to make sense of their symptoms and behaviour. In fact, producing a diagnosis avoids the effort required to produce that understanding.
Meyer's advice in psychiatric assessment was to concentrate on what he called the facts of the case, which are the personal and social details in the history. It may well not be possible to come to a diagnosis - but then the patient's problems still need to be managed. So, in a way, diagnosis is unimportant. And anyway, reducing the complexity of a presentation to a single-word diagnosis does not do justice to an understanding of why the patient has reacted in the way that they have to the situation in which they have found themselves.
All of this is too vague for my medical colleagues. And these were the kind of remarks made of Adolf Meyer. For example, in the Mayer-Gross textbook, which was a standard textbook for a previous generation of psychiatrists, Meyer's approach was regarded as "almost entirely sterile".
Yet the reality of psychiatric diagnosis is that it is not just a description of facts, it is also about values. One need only to attend any psychiatric case conference to realise this. Many different opinions will be expressed about diagnosis. Making a judgement about another person inevitably is ideological. There is a reciprocal relationship between the psychiatrist making the diagnosis and the diagnosed patient.
The difficulty in diagnosis is facing up to this uncertainty. This is why we are tempted by the certainty of biological processes. But diagnosis is primarily a statement about psychological functioning, not biological functioning. In fact, although diagnosis has been monopolised by biomedical psychiatry, it is not even tied to specific biological functioning in the way that the word is used. This should not be seen as a dualistic statement. It recognises the integration of mind and brain. Of course psychological functioning has its basis in the brain. This is why I have used the term bio-psychological.
A restatement of the biopsychological model of psychosis is required in a new mental health service. In relation to diagnosis, this involves replacement of the dominant biomedical model. This is why I welcome the BPS report.
The efficacy of psychiatric medication
Do I underprescribe as a psychiatrist? Do I as a doctor fail to prescribe the required treatment for different psychiatric conditions?
Again, my basic answer is no. In everyday practice, there is considerable evidence of overprescribing, and irrational prescribing, in the sense that more than one drug is prescribed when it is not needed. I think these anomalies would be found to occur less commonly in my practice. I would argue that my practice is evidenced-based.
So why is the medical evidence base biased? After all, should science not be about taking a sceptical approach to the data? Is a scientific hypothesis not about providing evidence against the null hypothesis? If so, why do most psychiatrists say that the efficacy of psychiatric medication has been proven?
I suppose it is too threatening for psychiatrists themselves to challenge their own stock-in-trade. Those that have, like Peter Breggin, have had to survive outside the psychiatric system. Non-medical professions, like clinical psychology, may find it easier to get a clearer perspective. For example, the work of Fisher and Greenberg in their most recent book From Placebo to Panacea: Putting Psychiatric Drugs to the Test has been particularly pertinent.
The main point Fisher and Greenberg make is about the biasing of randomised controlled trials through unblinding. The benefits of randomisation need to be preserved by ensuring that allocation is blind to both subjects and experimenter. Reflective triallists generally accept that double-blinding is not infallible - yet, because there is a sense that nothing can be done about it, there is no serious attempt to accommodate the implications. Randomised controlled trials are not as objective or unbiased as we might like - even the best designed and well executed studies.
If bias is introduced through unblinding, does this matter? The evidence seems to be that it does. Few trials measure whether the blind has been maintained. Those that do, generally confirm that there has been significant unblinding and that the degree of unblinding correlates positively with efficacy ratings.
The power of the placebo effect has been acknowledged at least since the classic paper by Beecher in 1955. One of the best recent summaries of the evidence about the placebo effect is that by Arthur and Elaine Shapiro, in a book entitled The Powerful Placebo. The role of expectations in the doctor-patient relationship is well described in Jerome Franks' book Persuasion and Healing, now in its third edition. Both these sets of evidence have only reinforced the recognition of the powerful influence of expectations on outcome.
If these expectations can be powerful in treatment, they can also be powerful in discontinuing treatment. People may form attachments to their medications more because of what they mean to them than what they do. Psychiatric patients often stay on medications, maybe several at once, even though their actual benefit is questionable. Any change threatens an equilibrium related to a complex set of meanings that their medications have acquired. These issues of dependence should not be minimised, yet commonly treatment compliance is reinforced by emphasising that it is not addictive.
Yet my medical colleagues look at me with askance if I raise issues about the psychological and social context of the taking of medication, and suggest that people can become psychologically dependent on psychotropic medication. They think my views need to be challenged. I can understand them not wanting to complicate matters or to recognise the need to justify their practice. To be an effective healer, they might think they should have as much faith in their medications as their patients. Yet one history of medicine is of doctors prescribing medication which is subsequently regarded as useless and often dangerous. Prescribing trends follow fashions rather that necessarily objective data.
People find it surprising that as a psychiatrist I am not preoccupied with medication in my management of patients. I again appeal for my authority to Adolf Meyer. Although trained as a neuroanatomist, and maintaining an interest in the subject, biological considerations hardly ever arose in his consideration of mental conditions. In management what prevailed was a humane psychological interest. For example, he was sceptical about the enthusiasms of his time for insulin coma therapy. Although we have moved on from this fad, it is important to see the history of psychiatric treatment in perspective. It is vital that we do not repeat the exploitation of the mentally ill, which has always been the historical tendency.
The control of mental health services
So should I become a clinical psychologist - should I never have returned to medicine, having given it up in my training? If I think that there is too much emphasis on diagnosis and medication in current mental health practice, should I give up being a doctor?
I must admit that some of the professional pressures I have experienced have made me feel like caving in. It has not always helped emotionally to remind myself that I am caught in the power relationship of psychiatry. Nonetheless, this is what it is and I think we do need to make a judgement about who is in control of mental health services.
Not that I am saying that mental health services should not be about social control. As we are aware, the government is currently revising the Mental Health Act. I am not advising abolition of the Mental Health Act - I am sure that some powers for controlling psychosis may be beneficial in society. I may have concerns about the motivation for change being primarily about public safety without adequate safeguards for the rights of patients, but that is another matter. Psychiatry's origins in the asylums was about social control. Although voluntary treatment both inside and outside hospital expanded considerably in the last century, psychiatry has not and cannot manage completely to separate itself from these roots.
If I had wanted to I could have avoided the elements of social control in psychiatry by becoming a psychotherapist. Of course many clinical psychologist practise in this way, these days particularly as cognitive behavioural therapists.
Now I am not wanting to undermine the value of CBT for psychosis, although I think there are indications in the BPS report that there is too much of a bias in favour of this approach. Certainly I understand there was a split on this issue in the committee that produced the report.
I think the danger is that the BPS report will just be seen as a profession defending its own view of psychosis. This is particularly likely if it has an unnecessary bias in favour of CBT. This will mean that the challenge to the biomedical view of psychiatry will be undermined - which in my view will be a great pity for the report in terms of its impact.
After all, the dominant biomedical view has been very good at marginalising any critique. I think this is particularly obvious in the way that it has undermined any criticism by suggesting that it is an attack on the seriousness of mental distress itself. Critics of psychiatry have all been lumped together as anti-psychiatrists, despite the considerable differences, for example, between Thomas Szasz and R D Laing.
Personally I am more in sympathy with RD Laing than Thomas Szasz. Indeed, I would argue that we should not allow these views to be confused. Laing's essential view of mental illness is biopsychological, like Adolf Meyer. His main predicament in psychiatry, which he made clear in his autobiography, Wisdom, Madness and Folly, was that he found that he could make more sense of what psychotic people were telling him he was being told he should be able to do by his psychiatric training. Psychiatrists at least should have more understanding about psychosis, like Laing.
The Critical Psychiatry Network is keen to reduce the current biomedical dominance of psychiatry. We have a conference in Sheffield at the end of April with this title. This is an open conference - although the Critical Psychiatry Network is a group of psychiatrists, and of course there are particular issues within the psychiatric profession, we do recognise that any reform of mental health services has got to be interdisciplinary, including users and carers. For this reason, we have supported the development of the Critical Mental Health Group, or whatever it is going to be called, which has now met twice in London.
The issue is about accountability and the direction of mental health services needs to be user-led. This is not intended to be a token statement. The Critical Psychiatry Network does have good links with user groups, which it is developing. The aim is a radical shift in power towards users.
So, in summary, I have looked at why I am accused of not using psychiatric diagnosis and medication enough. In the current biomedical dominance of psychiatry, the positive strengths of avoiding unnecessary labelling and overmedication of people are attacked as too risky. Yet users need to direct the development of a new mental health service. Their concerns about the inhumanity of services do need to be taken seriously. In thinking about psychosis, I welcome the BPS report which should help to improve this understanding.
Psychiatrists can have understanding too:
Recent advances in psychological understanding of psychotic experiences
(1) The importance of psychiatric diagnosis
(2) The efficacy of psychiatric medication
(3) The control of mental health services