Paper given at World Assembly for Mental Health 2001, Vancouver
What has happened to a biopsychological approach in psychiatry?
Objective: To place the views of Adolf Meyer in their broader cultural context and to see their continuities rather than discontinuities with the present state of psychiatry.
Design: Historical analysis of the increasing hegemony of neo-Kraepelinian and neurobiological approaches since the work of Adolf Meyer.
Materials and methods: Description and analysis of: developments in social psychiatry, including the formation of the World Federation for Mental Health; the process of dehospitalisation and the development of community care; the multi-professionalisation of mental health services; the development of "antipsychiatry"; the current denigration of socially critical perspectives; and the development of the user movement in psychiatry.
Results: The integrity of psychiatry has been difficult to maintain and the need for the personalist perspective of Adolf Meyer remains.
Conclusion: It is misleading to reduce the biopsychological ideas of Adolf Meyer to a set of largely depassé ideas and concepts and their force and freshness in western culture should not be underestimated.
Gene Brody, who who gave the Margaret Mead lecture at this Assembly, regarded the previous World Federation for Mental Health Conference held in Vancouver in 1977 as the largest and most influential meeting on mental health since the formation of the World Federation for Mental Health in 1948. There seems to have been an energy generated at that event. Part of the energy was created by the inspirational presence of Ivan Illich, well-known author of the book Limits to Medicine. Medical Nemesis: The Expropriation of Health. He debated the issue of whether there is a need for mental health professionals. I think it is less likely these days that we would raise such a fundamental question about the nature of psychiatry.
For, it seems to me that, at present, we want to avoid controversy in psychiatry. In the forward to the book of the 1977 conference, Rosenhan's famous experiment is mentioned. Rosenhan arranged for his research assistants to be admitted to psychiatric hospital by them pretending to be insane. His study led to a crisis at the time about the reliability of psychiatric diagnosis. Similarly, RD Laing and Thomas Szasz, who are commonly regarded as anti-psychiatrists, feature prominently in the forward. The challenge created by their views was recognised. The uncertainty and ethical dimensions which their views created were embraced.
Of course, Illich, Laing and Szasz have been regarded as extremists, even at the 1977 conference. When the conference was summarised and the themes highlighted, Illich's argument that there was no need for professional services, and that "do it yourself" care was preferable, was regarded as being out on a limb. What I want to suggest, however, is the need for debate within psychiatry. Our modern day neglect of criticisms of psychiatry means that we are not engaging with its central issues.
I want to do this by looking at the reception of the views of Adolf Meyer over the years. Meyer's approach to psychiatry was called Psychobiology. These days we have created an apparent consensus in psychiatry, in opposition to the Meyerian approach, which has been called neo-Kraepelinian, because it returns to many of the ideas promoted by Emil Kraepelin, regarded as the founder of modern psychiatry. This reaction was formed partly to answer attacks on psychiatry as a profession coming from the anti-psychiatrists.
I think Ivan Illich's argument about the role of professionals should still demand our attention today. What most concerned Illich, whether it was in health establishments, or in other institutions, such as education, was the legitimacy of professional power. This seemingly misled him into suggesting that psychiatry should not be imposed on anyone. Such a perspective goes against the history of a practice which has its origins in compulsory treatment. Indeed, it was only over the twentieth century that voluntary treatment became an option. However, Illich's standpoint does recognise that the exercise of psychiatric power may need to be restrained. Deprofessionalisation may not be the solution, but a critical perspective is required in the sense that it should be recognised that psychiatry can inadvertently exacerbate the problem rather than necessarily be the solution to mental illness. Although this may be unpalatable for psychiatry, it is an issue which does need to be addressed.
Ideas in psychiatry at the time of the founding of the World Federation for Mental Health
The outlook in psychiatry at the time of the formation of the World Federation for Mental Health in 1948 was very different from the present day. Modern day psychiatry could be seen as almost defined by neurobiology. In the first half of the last century psychoanalysis and Meyerian ideas were more influential than they are now.
Several reasons for this change over the last 50 years can be suggested. These would include the following: introduction onto the market of psychotropic medication, which is regarded as efficacious; increasing assumptions about the genetic basis for mental disorders; the introduction of operational diagnostic criteria, allowing a restatement of mental disorder as a biological entity; and, the impact of neuroimaging, both structural and functional methods. Although the primacy of these developments can be questioned, there is little doubt that they have reinforced a biomedical perspective.
In contrast the strands that can be detected in the original themes of the World Federation include the following: mental hygiene and mental health promotion; lay involvement in mental health promotion; recognition of the importance of the social in relation to health; and psychogenic explanations of mental illness. These ideas are all consistent with Meyer's psychobiology. I want to look at each of these notions briefly and to note some of the direct links with Adolf Meyer.
(1) Mental hygiene. The World Federation for Mental Health was founded at the third International Congress on Mental Hygiene in London in 1948 - it could be seen as part of the history of the mental hygiene movement. The purpose for which the Federation was formed was: "To promote among all peoples and nations the highest possible level of mental health." Adolf Meyer was very much associated with mental hygiene and in particular is remembered for his role in the promotion of social work in prevention.
(2) Lay involvement in mental health promotion. Clifford Beers has been regarded as the grandfather of the World Federation for Mental Health. Beers wrote his account of his own psychiatric hospitalisation in a book A Mind That Found Itself, published in 1908. One of the early supporters of Clifford Beers was Adolf Meyer. Although it was not until 1982 that survivors of mental health services were more formally involved with the Federation, there has always been non-clinical involvement in its work, with, for example, eminent social scientists such as Margaret Mead playing a central role in the International Preparatory Commission.
(3) Recognition of the social in relation to health. The Federation's interest in social context in relation to health contrasts with the current emphasis on mental disease as a biological entity. The social perspective was very much that of Adolf Meyer's psychobiology. Meyer was interested in understanding the conditions of reaction of people with mental health problems. He thought speculation about the biological basis of their disorder was "neurologising tautology". As far as he was concerned the person was the focus of medical intervention, particularly in psychiatry. In his view, personal and social dimensions were avoided by postulating mental disease as a biological entity.
Harry Stack Sullivan was a member of the World Federation for Mental Health's founding group and it was his suggestion that led to the International Preparatory Commission. It is evident that Sullivan before his death had a significant influence on the ideas which shaped the Federation's initial programme. Sullivan's approach was called interpersonal psychiatry. Adolf Meyer was an early influence on Sullivan. There is an obvious similarity between interpersonal psychiatry and psychobiology. Their consensus can be contrasted with the modern neo-Kraepelinian orthodoxy.
(4) Psychogenic explanations of mental illness. Although ultimately rejecting psychoanalysis, Meyer was open to psychotherapeutic ideas. Both Meyer and psychoanalysis agreed on a dynamic interpretation of mental illness based on an understanding of psychological factors. The first president of the World Federation for Mental Health was JR Rees, medical director of the Tavistock Clinic, which had been established to promote psychotherapy and child guidance clinics. The influence of Rees himself in the World Federation was seen in the interests in human relations and group dynamics. Such an emphasis on psychodynamics contrasts with the modern dominance of neurobiology in psychiatry.
Biomedical dominance of psychiatry
Whilst these biopsychological factors were central in the formation of the World Federation for Mental Health, the current dominant model in mental health is biomedical. It would be misleading to suggest that psychiatry has not always had a somatic bias. However, psychogenic explanations of mental illness were more likely to be considered at the time of the formation of the World Federation than is currently the case in psychiatry.
The interlude of the influence of psychotherapy and Meyerian ideas has been seen as brief in the overall history of psychiatry, covering no more than the period 1900-1970. Reassertion of the biomedical model took place not only to replace Meyerian ideas, but also as part of the reaction to what were seen to be far more threatening criticisms of psychiatry which have been collected together under the label "anti-psychiatry".
The essential point I want to make is that the perceived threat of anti-psychiatry eclipsed the views of Adolf Meyer. Opposition to the Meyerian position provided an argument for establishing the reality of mental illness in the biological sense. What this meant was that the validity of the Meyerian position was no longer promoted. In the efforts to re-establish the reputation of psychiatry in the face of the criticisms of anti-psychiatry, Meyerian ideas were neglected. If they are now restated they appear tainted with the unorthodoxy of anti-psychiatry. It was almost as though Meyerian ideas were held responsible for allowing the threat of anti-psychiatry to be taken so seriously. The underlying assumption seems to be that if psychiatry had not allowed itself to become so imbued with the vague and woolly ideas of Meyer, anti-psychiatry would not have been able to take such hold and to have had such credence.
As an illustration in Britain, the ideas of Adolf Meyer were brought from the USA by people like Aubrey Lewis and David Henderson. Henderson and Gillespie's Textbook of Psychiatry, which went through several editions, was based on the Meyerian approach and emphasised the importance of looking at the individual case and the settings in which symptoms arose. In contrast, a rival textbook by Slater and Roth in revising the Mayer-Gross textbook promoted the biological viewpoint and regarded Meyer's approach as "almost entirely sterile". One of the co-authors of the Mayer-Gross textbook, Martin Roth, was also involved in restating the authority of psychiatry by dismissing the arguments of anti-psychiatry in his book with Jerome Kroll called The Reality of Mental Illness.
Although the biomedical position now dominates psychiatry, there has been and continues to be considerably cultural interest in criticisms of psychiatry. The common view is that anti-psychiatry in particular was a passing phase in the history of psychiatry. However, it makes sense to note its connections with cultural factors and to recognise its continuities rather than discontinuities with the development of ideas in psychiatry.
Here it is significant that the conceptual approach of some so-called anti-psychiatrists such as RD Laing overlaps considerably with the model of mental illness used by Adolf Meyer. In several ways their views are similar, for example: the metaphorical meaning of the term mental illness, rather than it being understood as a biological disease entity; the psychological aetiology of mental illness; and, a non-positivistic view of human science.
The connections became clouded by the failure to recognise that the group of writers known as anti-psychiatrists do not have homogeneous views. In particular it is incorrect to conflate the views of Thomas Szasz and RD Laing. Szasz has been vehement in his criticism of RD Laing. Laing never denied the reality of mental illness, a position that Szasz regards as inconsistent and illogical. Essentially Laing said that mental illnesses are not diseases in the biological sense, but that they are reactions to unbearable stresses in life - very much the view of Adolf Meyer. In a more radical sense Szasz thinks mental illness is a myth.
There continues to be interest in RD Laing, and biographies of his life continue to be published more than 10 years after his death. The Philosophy Special Interest Group of the Royal College of Psychiatrists in the UK held its second annual RD Laing conference last year. Laing himself insisted that his primary motivation was that he found psychotic experience more understandable than acknowledged by his training. Again, this is consistent with the conceptual approach of Meyer that concentrates on understanding the patient as a person, including people experiencing psychosis.
I want to suggest that a re-evaluation of the views of Adolf Meyer will help provide direction in psychiatry. In my view, the force and direction of psychiatry has been lost for a number of reasons and psychiatry has not yet fully accommodated to several developments over recent years. These would include the following: the process of dehospitalisation and the development of community care, which has created confusion about the social role of psychiatry; the multi-professionalisation of mental health services, which has produced uncertainty about the authority of psychiatry; the current denigration of socially critical perspectives, which tend to be seen as naïve; and, the growth of the user movement.
In many respects it seems psychiatric practice is out of step with the political circumstances in which it operates. What is needed is a paradigm shift from a biomedical to a biopsychological model.
Perhaps the World Federation needs to return to its roots to be able to marshal a modern response to these developments. In my view, the danger is that if it does not, psychiatry will become increasingly irrelevant in its overmedicalisation of mental distress. The positive concept of mental health created an enthusiasm about the formation of the World Federation. We can now appreciate the overidealisation of the concept that this involved. Such realisation should not stultify the progress of psychiatry. We need to recreate the energy that was identified at the previous Vancouver conference.