Social consensus and the post-modern society

  Concern with risk and its avoidance have been suggested as core features of a post-modern society. As common core values recede, protecting our individual survival and well-being becomes a dominant preoccupation. Whether or not one finds this argument convincing it is undeniable that Western societies are increasingly individualistic with less social consensus and greater riskconsciousness. The emphasis of the 1940s and 1950s on shared social capital such as public schooling and health care has given way in varying degrees to a consumerist approach with an emphasis on personalized care. This has reflected, and in turn been driven by, massively increased social mobility both locally and internationally. Families have also become less central to how we function as adults and less stable in themselves.

  Modern industrial societies are rarely ‘homogeneous’ – there are large sections of society with quite differing origins, religions, values, and ethnicity. Despite its obvious benefits this can make psychiatry very difficult. Differing lifestyles and behaviour are accepted as choices and tolerated as long as they do not infringe the next person’s liberties. Most of us value these freedoms very highly. An increasing tolerance of varied lifestyle choices however can mean a reduced sensitivity to mental illness. When you can choose to dress and behave almost any way you want, it is harder to realize when somebody’s strange dress and behaviour are not simply selfexpression but part of an illness. The over-active, disinhibited behaviour of manic patients is regularly misinterpreted as simply irresponsible or exhibitionist.

  Increasing uncertainty about social norms has been complicated by a vast increase in alcohol and recreational drug consumption in Western societies. Intoxication usually makes mental illnesses worse and their treatment more difficult. It also significantly complicates the recognition of mental illness – it is tragically common to assess a young student who has been unwell for months but whose room-mates attributed it all to drug use and so delayed getting help.

  Stigma, an exaggerated sense of risk from the mentally ill, family break-up, high social mobility, and increasing levels of drug and alcohol use all combine to make community care of the mentally ill much more difficult than it was when the process started. This is reflected in a small but widespread rise in compulsory treatment and a modest increase in ‘reinstitutionalization’. This is balanced by a much more sophisticated and embedded respect for individual rights than would have been conceivable a generation ago. We are likely to experience continued soul-searching about community care and probably some rebalancing of the institution/community emphasis. A large-scale return to long-stay institutions is fairly unlikely in the coming years. Community care in one form or another is with us for the foreseeable future.

 

Chapter 4 Psychoanalysis and psychotherapy

  Psychotherapy means different things to different people. Literally it means ‘treatment of the mind’, though it can be read as ‘treatment by the mind’. I will use this second understanding (otherwise all psychiatric activity would be psychotherapy and we would be no further forward). In this chapter psychotherapy will include any deliberate, structured use of the relationship between a therapist and patient to help that patient to change or better understand his or herself. Psychotherapy is usually conducted by talking, hence the current expression ‘talking treatments’, but in some therapies words are not the crucial element and in some the ‘dialogue’ is internal.