Psychiatry in Britain

Meaning and Policy

Shulamit Ramon

• Publisher: Taylor & Francis
• Year: 2018
• Print ISBN: 9781138317284
• eBook ISBN: 9780429848292
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Originally published in 1985, this book focuses on British psychiatric policies, particularly in the 1920s, and 1950s when the main legislation concerning mental illness was passed. It approaches policy primarily as the outcome of the relationship between politicians' attitudes and those of professional groups in a specific social context. It examines the beliefs and theories of psychiatrists, nurses, psychologists and social workers, as well as the attitudes of government and MPs to mental illness, related services and its role in society.

It is argued that the adherence to a medical-somatic view of mental illness by psychiatrists and politicians alike has led to the exclusion of viable alternatives, despite lip service being paid to some of them. It is shown that the issues of recent decades have important messages today, particularly in view of the 1982 amendments to the Mental Health Act and the debate about community services.

1 Introduction

The introduction will outline the framework and dimensions of the study. It will also spell out what this project does not attempt to do.

The book is concerned with the interface of meanings given to psychiatric phenomena and their translation into policy decisions.

It is written from the perspective of a social scientist interested in the theory and practice of psychiatry and their relationships to the social context in which they develop.

Throughout the book “psychiatry” or the “psy complex” are used in the wider sense, i.e. to cover not only psychiatrists but also allied professionals and all mental distress experiences. When a particular profession or mental distress category is focused on, it will be specified.

In the following exposition of approaches to the subject matter of psychiatry and throughout the book no attempt will be made to assess the truthfulness of any school of thought. Approaches are treated here as social products, which are a given in a particular moment in time but which have been and will continue to be modified by processes of cultural construction. Consequently, no attempt will be made here to present the evidence for and against an approach because the study is concerned primarily with meaning and policy.

The term “scientific” will be used only to denote the type of science employed within a specific approach or when a claim to scientific status is made by its protagonists.

Instead, a set of criteria by which to evaluate the contribution of each model will be outlined, based on what the author considers to be the essence of mental distress and its social significance.

Mental distress is perceived as a phenomenon which incorporates elements of our social and natural worlds. By virtue of being a human condition it is likely to be affected by and to have an effect on our minds and bodies.

Our understanding of reality is mediated by the social context in global and specific ways. Our attempt to change this reality is even more sharply dominated by that context. Therefore the presentation of approaches to psychiatric phenomena is divided into two sections, paradigms of understanding and paradigms of intervention. The second set is derived directly from the first but is also always mediated by the dimension of social policy on psychiatry, or the translation into directives of social action.

The presentation of approaches to understanding and intervention is a necessary background on which to delineate the particular direction taken up in the book. Of necessity the description of a perspective will be brief. It will focus on the differences among the three models rather than within each of them.

1.a.The State of the Art of Understanding Mental Distress from Three Perspectives: The Somatic, the Psychological and the Social.

The description of psychiatric phenomena expands over a range of human expression so wide that often a justification is called for including it all under the same heading. The justification is provided via the approaches to understanding such experiences.

The phenomenon of mental distress usually hits the outsider and often the involved person too by its apparent unintelligibility, by being self-defeating and hence seen as irrational and motiveless. A lower level of functioning, especially at the psychosocial facet, is frequently noticeable. Thus a high degree of inter and intra cultural interpretation in rendering this experience intelligible is called for.

The main other feature to impress observers and those involved is the extent of suffering that accompanies it. Suffering is an uncomfortable concept for any model to account for; it is highly subjective, changeable and not easily given to generalization or quantification.

Criteria for judging the value of a theoretical approach to understanding mental distress should therefore include:

a.Definitions and descriptions of deviation from the ordinary which are viewed by the lay culture and the professionals as mental distress and disturbances. The parameters of the definitions and the dimensions for the descriptions have to be spelled out to allow an evaluation of the degree of comprehensiveness and systematization of an approach.

b.Rendering intelligible the unexpected behaviour and experience, including suffering and the lower level of functioning. Factors at work, or reasons, or causes, should follow as the next stage with an explanation of the links between them and the description.

The literature on approaches to mental distress is divided between those who ascribe causes and those who refrain from doing so. For an overview of the issues involved in each stand see Ingleby(1).

The following issues interact implicitly with the broad areas just outlined.
a.View about human nature.

b.Definition of and the relationships between rational and irrational behaviour and the experience of individuals and groups.
c.Relationships between individuals; their primary groups and society, in their impact on psychiatric issues.

d.The place of professional and non-professional activity in the field under discussion.

The disagreement among the three broad perspectives to be discussed below starts with the concepts of disease, distress and illness. The decision to use or not to use each one of these terms as a central concept denotes the inclination of the user towards a particular perspective.

Disease(2).

The existence of a disease implies a somatic cause for an apparent inability to function ordinarily, mainly at the psychosocial level. For it to be a disease it has to manifest a cluster of extraordinary behaviour (syndrome), follow a specific pattern of development, lead to a predicted level of deterioration or arrested functioning if left without suitable intervention and have a specific cause. It clearly takes the view of psychiatric phenomena as a branch of physical disability.

Mental distress(3).

This concept focuses on the subjective experience of being considerably discontent with oneself and the world. It may or may not be accompanied by behavioural expressions and inability to function as before. Invariably, it will be reflected in an inability to take a definite course of action to change the state of discontent and with a continuous feeling of being such, at times without knowing why.

Mental illness(4).

The concept of illness stands in between disease and distress, containing features of both: illness comes to mean the experience of ill at ease, of discomfort with or without a specified cause. It is usually accompanied by change from ordinary to extraordinary behaviour, though such a change is likely to be limited to specific dimensions of one’s life.

In contrast to the notion of disease, both distress and illness do not carry with them a firm convinction as to the causes of the difficulties. They are also less prescriptive in regard to course and outcome. Distress and illness will be the terms used in this text. In all three concepts the actor is not ascribed conscious responsibility for having psychiatric symptoms.

The somatic perspective(5).

Historically this approach was located firmly within medicine. It applies knowledge of physical illness, accumulated practice wisdom and natural science methodology to the subject matter of psychiatry. Neurology, physiology and biochemistry have been the main background disciplines to be utilized.

The disease concept became its core concept, directing the understanding of psychiatrists towards biological causes and their assumed manifestations. Most of the methodological effort went into observation, classification and interpretations of behaviour. The adherents of this approach see psychiatric illness as a variation of physical diseases. Therefore they claim for it a universal existence, free of normative biases. As the behavioural and experiential components are seen as the manifestation of an underlying biological disturbance they are given only secondary importance at the conceptual level. Instead prime place is given to the method of classification. Proper diagnosis is believed to be the key to correct intervention and a lead to the underlying cause.

The fact that no specific biological factors have been identified for most psychiatric phenomena is put down to the short duration of the scientific pursuit of psychiatry. Likewise the indication of a minimal change in biological functioning – compared to greater changes in psychosocial functioning – is dismissed as due either to a narrow view of body-mind interaction or as the task of future research.

In some versions of this perspective psychological factors are perceived as indistinguishable from the biological dimension because an interaction between these factors is assumed(6). The mistaken notion of reducing an interaction back to the one-sided impact of a factor does not cause concern to the protagonists of this way of thinking.

Within this approach the social context is viewed either as irrelevant or as secondary to the impact of the biological dimension. Deterioration in functioning is firstly due to biological reasons, but may be made worse or improved by societal reactions.

It is clear from this brief exposition that the somatic approach opts for a narrow, economical definition and explanation of mental distress. It omits giving equal place to the subjective and intersubjective experience and has no conceptual place for the notion of suffering. It excludes the psychological and social dimensions from being primary factors.

One offshoot of the somatic perspective merits attention in this study because of the insight it offers into the twin concepts of cause and explanation(7). The current biochemical strand of the somatic perspective is very fashionable among natural scientists, doctors and the media. Thus it constitutes the latest cultural construction, though it is an approach that has been with us for some time.

Its innovative contribution is in locating the cause where the effect of chemical intervention seems to be. It argues that if drug A has influenced a particular structure/process of our body, then the fault/cause for mental disturbance must lie there. A unilinear, highly specific relationship is thus postulated between the synthetic drug and the totality of the person.

The somatic approach has an undisputable social attraction in locating the causes for mental distress outside the range of personal and social responsibility. It makes it possible to view psychiatric phenomena as an issue unrelated to value preferences but which is instead wholly dependent on objectively verified knowledge of our biological make up. As such it appeals to both rulers and ruled, professionals and lay people, sufferers and the uninvolved alike in offering a clear-cut view which has a seemingly clear direction for research and intervention. It also gives a monopoly on interpretation to medically qualified people.

The psychological perspective(8).

The emphasis in this approach is on the psychological processes of the individual who is identified as mentally distressed. These processes (in particular learning, problem-solving and identity formation) are viewed as influenced by relationships with significant others. Therefore most models are also interested in the psychological processess of relevant interpersonal interaction.

In the majority of psychological approaches it is assumed that mental distress is the outcome of an internal, unresolved conflict between contradictory tendencies. Often the clash is between socially desirable and undesirable activity. The person is aware of the likely price of opting for either one of these two possibilities, though the awareness is not necessarily at the level of consciousness. Given that the clash is experienced as unresolved the next assumption is that “being stuck” is a sensation which individuals cannot tolerate for long and therefore will resort to action. The activity selected at the end of such a process would not necessarily be either one of the two options which were at the core of the conflict. Instead a third course might be taken up which will allow relief from the tension created by the conflict and which may also lead to interpersonal rewards (e.g. special attention, opting out of previously held responsibilities) . Psychiatric symptoms fall into this category.

A third assumption, shared by all theorists, is that such a choice is unlikely to be made at the level of fully rational and conscious thought. Some schools are relatively clear as to the level at which the decision is taken while others are not. H...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Acknowledgements
• List of Abbreviations
• 1. INTRODUCTION
• 2. MENTAL DISTRESS IN THE SOCIAL CONTEXT OF THE 20s
• 3. PROFESSIONALS’ THEORIES AND VALUE PREFERENCES IN THE 20s
• 4. POLITICIANS’ CONCERNS AND ATTITUDES IN THE 20s
• 5. MENTAL DISTRESS IN THE SOCIAL CONTEXT OF THE 50s
• 6. PROFESSIONALS’ THEORIES AND VALUE PREFERENCES IN THE 50s
• 7. POLITICIANS ’ CONCERNS AND ATTITUDES IN THE 50s
• 8. IMPLICATIONS OF THIS STUDY
• Appendix
• Index