Understanding Mental Health

A critical realist exploration

David Pilgrim

• Publisher: Taylor & Francis
• Year: 2014
• eBook ISBN: 9781317630630
• Edition: 1
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

David Pilgrim PhD is Professor of Health & Social Policy in the Department of Sociology, Social Policy and Criminology at the University of Liverpool.

1
Psychiatric crises and the crisis of psychiatry

Introduction

Most of this book attempts to prioritise ontology in discussions about mental health. So many of these have been concerned with knowing, not being, and so epistemological arguments have been centre stage. Critical realism is not unconcerned with epistemology (not at all), but the reality of the actions of those who for now are diagnosed as being mentally disordered and the relevant real antecedents of those actions can get lost when epistemic matters dominate research. This analytical shortcoming has been evident even amongst political critics of orthodox psychiatry, not just its defenders.

Many critics have tended to focus on people surviving psychiatric oppression and public prejudice, which are legitimate concerns, but they have evaded difficult challenges around the reality of the impact of the incipient or identified patient’s behaviour contingently on a moral order in a particular time and place. Sometimes even the reality of childhood adversity, to which I return emphatically later in the book, can be played down in arguments about a patient surviving professional oppression and public rejection post-diagnosis.

Synchronic discursive arguments about the here and now or those overly focused on stigmatisation may risk ignoring the diachronic matter of causal antecedents to account for what the labelling theorists have called ‘primary deviance’. Some of us some of the time really are distressed or unintelligible or incorrigible. Other people get upset about these forms of conduct. Social consequences have to be dealt with. This messy reality needs a fair exploration. And that messy reality includes real oppressive relations from the past impacting on the present, which are discerned or might be shrouded in mystery.

In the light of this imbalance in the field, I will start with the crisis of psychiatry. The profession has struggled to cope with external critics and particularly its internal dissenters for the past fifty years. And, as I will demonstrate later in the book, the more that psychiatric theory and practice have been promoted, the worse the mental health of humanity seems to have become. It has failed monumentally as a medical project, but, like lemmings, the defenders of its orthodoxy seem to plough on towards the cliff edge (Craddock et al., 2008; cf. Pilgrim and Rogers, 2009).

And crisis is a word certainly relevant to the role of psychiatry in another way. All psychiatric crises are social crises (Bean, 1980). When the latter emerge because the conduct of incipient patients has become contingently unacceptable or frightening to others, then the power of those significant others and of the professionals they entreat will be enacted to ensure social control. The role will be imposed, maybe invoking fear or anger in the identified patient, not embraced in gratitude by them.

In the British context of today that process is called being ‘sectioned’, reflecting the use of a section of the current ‘Mental Health Act’. Under Victorian legislation all patients were ‘certified’ as being insane by the courts (a position that changed after 1930 in Britain). We have a recent cultural tradition of the state, its agents, and those sane by common consent regularly working in unison to control those who they deem require that control. Any of us will go beyond the normative pale at our peril. That is why the fear of ‘unfair detention’ in our current culture is almost as great as the fear of madness itself and why we have invented legal rules to manage that anxiety in the public imagination.

Because all psychiatric crises are social crises, what happens in particular situations depends on this interplay between the meanings attributed by those involved and the relative powers they hold and might deploy in action. Their meaning-saturated actions in turn have consequences, which create a contingent feedback loop for those actors. This loop contributes to and might alter or reinforce the impact of pre-existing generative mechanisms. If the voluntary patient gains succour and new meaning from their help seeking, then their expressed need will have been satisfied and a mutually negotiated and agreed improvement in mental health might emerge. On the other hand, if the power held and expressed by those who are sane by common consent is distressing to the identified patient, then the latter may resent and so resist current and future engagement with ‘mental health professionals’. At this point psychiatric oppression emerges as an aspect of reality in the social relations of modern societies.

And following from these actual and everyday scenarios, which are to various degrees empirically codified and recorded for clinical and social administrative purposes, hares are then set running about the morality and evidential justification of psychiatric theory and practice. The profession, quite understandably, has been attacked by its critics for being casually ignorant and arrogant, in equal measure, in relation to the dubious generative mechanisms it posits and the civil liberties it tramples on with seeming impunity. The latter occurs under the cloak of respectable legalism during taken-for-granted daily practice. The argument goes that the mentally ill must be treated. The professional ‘right to treat’ from medicine routinely justifies the deprivation of liberty without trial and the imposition of treatments on patients.

Mental illness: Myth or reality?

The very existence of mental illness was queried by Thomas Szasz, a Hungarian émigré in the United States, prodded into a form of rightist and anti-statist libertarianism by his early life under the authoritarian yoke of the Eastern European bloc. He demonstrated that the political left has no monopoly on righteous indignation about personal oppression (Szasz, 1961, 1963). Szasz was a trained psychiatrist and psychoanalyst, and he proposed that mental illness was a metaphor, not a fact, and that coercive psychiatric practice was the modern legacy of witch-finding.

Another psychiatrist and psychoanalyst, the Scot Ronald Laing, and from a different political stable than Szasz, with a penchant for Sartrean existential philosophy, wanted to defy the premise that madness was merely the meaningless chaotic outcome of skin-encapsulated pathology (Laing, 1961, 1968). His aspiration to make the unintelligible intelligible by listening carefully to patients and their families offered us a form of enlightened, if somewhat esoteric, hermeneutics. What has happened to this person in this particular family system and what is their madness signalling?

In the wake of the native fascist love of strong order and hatred of weakness in his defeated warring country, the Italian psychiatrist Franco Basaglia defended the right to liberty and citizenship of his patients, who were very evidently both weak and disorderly and had paid the personal price of institutionalised misery. The French philosopher and historian of ideas Michel Foucault also endorsed the need to re-discover means of respectful dialogue between sanity and madness within his emerging wider critique of the modern episteme. American labelling theorists like the sociologists Erving Goffman and Thomas Scheff were interested in the particular contingencies under which some rule transgressions and role failures were medicalised, such that deviance was publicly identified and consequently amplified because of stigmatisation and social rejection.

These attacks upon the moral worthiness and epistemological credibility of orthodox psychiatry provoked strong conservative defenders of the professional faith (Hamilton, 1973; Wing, 1978). These reactive and reactionary ripostes argued that a global anti-medical and anti-scientific conspiracy was afoot. Although there was certainly an international dimension to this criticism, it certainly was not coordinated. The protagonists operated separately and did not always concur on their views and reasons for them (when and if they were aware of one another).

And as for these critiques being ‘anti-scientific’, it was for the orthodox defenders to explain their own science credibly rather than complaining that they were being attacked. To this day the same pattern is evident. Orthodox psychiatry cannot shake off its image as a pseudo-science, but any criticism of this blatant problem is seen as an unfair attack driven by unworthy or sinister motives.

All of this unresolved bad feeling about modern psychiatry tells us little or nothing of other times and places. The latter too are part of reality. For example, modern psychiatric theory and practice are defended or attacked only where they exist. And in some parts of the world now they still do not exist. Moreover, it did not exist in modern developed society properly until the late nineteenth century. For example, earlier in that century in England, humane reforms of ‘moral treatment’ in asylums (the forerunner of later ‘therapeutic communities’) were promoted by religiously motivated lay administrators, not by medical men.

Ideological implications of ‘psychiatry and its critics’

In the light of these exchanges, three underlying ideological aspirations or positions are now evident in debates about psychiatry and its role in contemporary societies. The first is conservative and celebratory: modern psychiatry is simply part of the triumph of scientific incrementalism, which displaced religious superstition after the Enlightenment. In this view, we need more of the same: more resources to offer more psychiatry, its preferred diagnoses, legal apparatus, and pharmaceutical and psychological technologies to more and more people. Poorer developed countries need to be resourced to the same level as richer countries, and under-developed countries need the expansive introduction of the assumed benefits of modern psychiatry. Pity the poor African town without an ECT machine, psychotropic drugs in its pharmacy or the benefits of a ‘mental health law’. This position of self-assured medical expansionism flows from psychiatric positivism, which is a form of naïve realism.

The second position I see is one of open-ended cultural relativism. Maybe we should abandon any criteria of universal understanding of mental abnormality or programmes for its amelioration. By implication, maybe we should totally abandon psychiatry and its labels, infrastructure, legalistic trappings, and therapeutic technologies. To complement this political aspiration, we could now seek new societal arrangements, which would generate a yet-to-be-fully-specified tolerance for psychological difference.

We might protect and ensure only forms of support for people in mental distress that are benign and always voluntary in form and sentiment (this was the Szaszian argument as well as that of leftist libertarians). The human need for succour and remediation would then be expressed by the self-defined sufferer and never defined and imposed by others. This position flows from critics associated with the postmodern turn and its libertarian and identity politics in the mental health campaigns of variegated New Social Movements, such as the ‘Campaign for the Abolition of Psychiatry’, ‘Survivors Speak Out’, or ‘Mad Pride’ (Haafkens et al., 1986; Rogers and Pilgrim, 1991; Crossley, 2006).

The third position, which I favour and try to adopt in this book, is to challenge the first position but avoid the potential impotent nihilism or vague aspirational utopianism of the second, while recognising the political challenge it legitimately poses for any of us. The postmodern turn has left us with libertarian identity politics and no confident anchor points in reality about mental disorder. And yet, we still face an unavoidable reality that postmodernists themselves complain of: current psychiatric orthodoxy has no scientific justification for most of its theory and practice, which are focused erroneously on the assumed validity of its diagnoses. Highly iatrogenic forms of intervention are barely effective at acute ‘symptom reduction’, let alone ‘curative’ in the long term. As psychiatric jurisdiction within countries and globally has expanded, so too has the prevalence of the very mental diseases it is claiming to treat, when the reverse should be expected if it was a credible form of effective applied science. These aspects of reality cannot be dealt with persuasively if we limit our methodological attention to ‘deconstruction’ alone. The anti-realist premise it works from undermines the pressing intellectual task now required.

Moreover, the enduring political, social, and personal need for ‘something to be done’ in complex modern societies about misery, madness, and incorrigibility provides an over-arching but rarely reflected upon rationale for the mental health industry. But that mandate, from politicians and those who are sane by common consent, is strongly present to individualise and over-simplify the way we understand mental health problems. Indeed this convenient and putative strength is the probable reason that the diagnostic absurdities and unwarranted therapeutic claims of psychiatry are glossed over so readily and so often by so many.

Psychiatry has been a palpable failure as a therapeutic enterprise, and when attacked for its scientific and humanistic failures it has tended to shoot the messenger. And yet it has survived another day to complain that others do not value and appreciate its own preferred version of self-promoting scientific humanism (Pilgrim and Rogers, 2009). From a critical realist perspective, I start then with an immanent critique of this vulnerable theory and practice on the one hand and the current robust and undeniable societal mandate on the other.

An immanent critique of modern psychiatry and those it serves

Earlier I noted that some ontological and epistemological matters were raised during the phase associated with ‘anti-psychiatry’. Both Szasz and Goffman noted that the legitimacy of psychiatric diagnosis is undermined by its overwhelming emphasis on symptoms (what the patient says and does), whereas physical medicine also can point to and privilege measurable bodily signs.

This ontological point still recurs in criticisms of psychiatry because it has no blood test for ‘schizophrenia’ or ‘depression’. Because psychiatry’s clinical mandate about ‘functional mental disorders’ is based upon symptoms, not signs (valid measures of somatic changes), it has been a particularly vulnerable specialty within medicine and so has become both irritably defensive and riven with internal dissent.

Symptoms as complaints or presenting problems in society

Symptoms are what the patient says and does, and they necessarily require normative judgements. When it comes to mental abnormality, the latter do not require any medical training; they are what the majority learn to express simply and automatically, what Aristotle called ‘doxa’. However, when and if those normative judgements are codified as medical phenomena, then it becomes tricky logically and scientifically to defend de-contextualised criteria of assessment during a psychiatric diagnosis.

Symptoms are interpersonal communications and are problematic to measure, for the very reason that they are negotiated inter-subjectively in a culturally context-bound situation in flux. For this reason, they ought to be treated tentatively as transitive phenomena at all times. Humble exploration, not authoritative declamation, is implied from those offering some sort of plausible healing trade. By contrast, true signs are far less ambiguous and open to interpretation, and so their invariant or intransitive status is easier to defend scientifically. For this reason, Szasz and others noted that the ‘organic mental illnesses’, such as dementia, were better understood as neurological diseases with psychological consequences. And true signs may be identified only postmortem (it is current psychosocial (in) competence that tends to concern significant others and professionals).

In physical medicine confidence in signs is greater. For example, the rise and fall of a virus in the body of a person or other mammal can be measured in real time, and that observation can be repeated again and again, from case to case. Similarly an adolescent diagnosed with Type I diabetes will weaken and soon die in any context if he is not offered injected insulin for the rest of his life (unless a cure emerges after the time of this writing). No such diagnostic and therapeutic certainties exist about the adolescent diagnosed with a ‘first episode of psychosis’. Not only will her proneness to future episodes be a matter of curious speculation, but also she may or may not respond to ‘anti-psychotic medication’.

In psychiatric medicine, currently the two dominant classificatory systems (‘nosologies’) used are from the American Psychiatric Association (2013) and the World Health Organization (1992). The first, now in its fifth edition, is the Diagnostic and Statistical Manual (DSM), and the second is the International Classification of Diseases (ICD), in its tenth edition but being revised at the time of writing. Both attribute the same ontological status to signs and symptoms.

Thus, from the outset, we have a fundamental problem with psychiatric diagnosis. It reifies symptoms as signs, turning transitive phenomena into intransitive phenomena, and consequently that process of reification becomes an example of the epistemic fallacy (psychiatrists confuse reality with what they call reality). What should be a tentative exploration about the meaning of actions in a specific social context becomes a dubious assertion of traditional medical diagnosis. The doctor looks on with false confidence, using specious logic for embodied evidence of an objectively agreed disease process in the patient sitting before them. Put simply, diagnosing schizophrenia really is not like diagnosing Type I diabetes. Orthodox psychiatry mimics that process in an implausible and pale imitation.

The micro-politics of this wrong-headed process are then important to track in practice and relate to the type of conversation that occurs during psychiatric diagnosis. A diagnosis reflects the judgement of the doctor; he or she discerns what is wrong with the patient. It is a medical monologue predicated upon a limited and doctor-centred dialogue. The rules of that limited dialogue are codified in strictures used in psychiatry such as the ‘Present Mental State Examination’.

What these protocols of psychiatric examination pre-empt is a truly open-minded an...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of illustrations
• Acknowledgements
• Preface
• 1 Psychiatric crises and the crisis of psychiatry
• 2 Misery in context
• 3 Madness in context
• 4 Incorrigible egocentricity in context
• 5 People, pharmaceuticals, and politicians
• 6 Wellbeing
• 7 Overview and implications
• Bibliography
• Index