The announcement by Dinesh Bhugra, president of the World Psychiatric Association, that an independent commission will investigate what psychiatrists of the future will look like signals what all mental health researchers have known for the past 50 years: that the profession is in crisis.
The challenges the profession faces are legion and can be divided into two types. The first relate to whether those in our midst who are miserable, unintelligible or egocentrically incorrigible should be met with a form of presumed pre-eminent medical expertise. This is a tribal issue – and some professionals, such as clinical psychologists and nurses, are making bids to legitimacy to compromise, share or even fully displace medical authority. In other words, non-medical professions are trying to undermine medical dominance in the field and assert their own autonomous theory and practice.
The second set of challenges relate to whether the mental health industry as a whole can respond in an effective and compassionate way to people who are deemed by their fellows (or themselves) to be psychologically abnormal.
The tribal challenges
Medical authority over psychological abnormality in society was only consolidated at the end of the 19th century in Western Europe and North America. Prior to that “lay managers” of asylums had implemented forms of “moral treatment,” mixing strict daily routines and compassionate fortitude, which brought lunacy back into the moral fold of society from an alienated state out of touch with shared expectations of daily life. As insanity defied a moral order, the insane had to be challenged to re-integrate into normal expectations of contemporary society.
Once psychiatrists won the battle and each asylum had its own “medical superintendent,” then an increasingly biological approach became evident. This biomedical emphasis went hand in glove with a dominant political philosophy of the time: eugenics. The eugenic consensus of the time assumed that a range of deviance, like lunacy, idiocy, epilepsy, prostitution, inebriation, was the product of a tainted gene pool of the fecund lower social orders.
In Britain, where eugenics started, the main focus was on social class, but this shifted to a racial emphasis elsewhere. Today’s psychiatry has strong eugenic roots in this 19th-century political philosophy. Its current obsession with genetics maintains that tradition.
However, during World War I this eugenic approach came into crisis in Britain, as officers and gentlemen and working-class volunteers broke down with predictable regularity in the trenches, with the first group actually having higher rates of “shell shock”. These were “England’s finest blood”, so eugenic claims about genetic inferiority were tantamount to treason. In 1926 when the Royal Commission on Lunacy and Mental Disorder was set up to review the organisation and content of services for the mentally ill, not a single asylum doctor was appointed to its inquiry team.
Suddenly non-biological theories and interventions were let into the trade. For example, prior to the war, psychoanalysis was derided and rejected in the medical profession, but by 1920 in Britain there emerged the Tavistock Clinic, the British Psychoanalytical Society and the Medical Section of the British Psychological Society (with the latter being dominated by psychotherapy-orientated “shell-shock doctors”). These two factions (biological psychiatrists and medical psychotherapists) were joined by another: social psychiatrists. And during the Great Depression, this inter-war period, like the war before it, made it very evident that mental stability was precarious in the face of environmental stressors.
The industrial challenges
The above three-way factionalism still remains today, with drug companies now a key player in shaping biomedical knowledge and offering corrective interventions with putative magic bullets for the conditions defined by diagnostic psychiatry. But this matter of internal fracturing in the psychiatric profession and the bids for legitimacy from nearby professions – like psychologists seeking to lead new forms of psychological therapy and be responsible for the discharge of detained patients – is only part of the picture.
Whoever runs the show, the central question remains: what is the point of the mental health industry? Is it to ameliorate distress? Is it to remove madness forcibly from society? Is it to contain those who others find offensive or chronically burdensome – those deemed to be “personality disordered”? In other words, is the industry in the business of healing or social control, or both?
If it is both then the crisis that Bhugra and his commission will struggle with will be about squaring a circle in society. Not only has the psychiatric profession not squared this circle but neither have its professional competitors. While we still retain “mental health law”, in the form of the Mental Health Act and other legislation, the tension between offering treatments – which are anxiously sought and gratefully received – and imposed and resented forms of control like sectioning, will be integral to the mental health industry.
Over the years various groups have kept reconsidering the same malaise: the “anti-psychiatrists” of the 1960s, the New Social Movement of user critics of the 1980s – such as Survivors Speak Out and the Campaign Against Psychiatric Oppression, which sought to abolish psychiatry or reform its oppressive aspects – and more recently, those attacking diagnostic psychiatry and failed medicinal solutions.
These matters of coercive social control, of the necessity or otherwise of “mental health law”, of ineffective and iatrogenic drug treatments (ones that actual cause illness or disease), of the shaping role of big pharma and of the choice between unique psycho-social formulations and creating categories of diagnosis, are unresolved and maybe irresolvable.
These incorrigible features of the mental health industry will be there for the foreseeable future, whether or not the psychiatric profession succeeds in retaining its medical dominance. Even if it loses the battle to its user and professional critics, the industrial challenges just noted will still haunt all parties new and old.
You can read Peter Woodruff’s response, Psychiatrists alleviate mental illness – don’t attack them, here.