Self-help

  It may not be psychiatry, but the self-help movement has grown out of the psychotherapy tradition. Alcoholics Anonymous, Weight Watchers, The Depression Alliance, have all begun to apply what they have learnt, and more. Accurate empathy and unconditional regard – who better than someone who has been through it? Who less likely to condemn than someone with the same problems? Non-possessive warmth – what better source than shared suffering and real fellow-feeling? Self-help groups constitute a folk movement of our times which relieves distress and isolation and reduces stigma. Self-help books and computer programmes are increasingly available for common disorders like anxiety and depression. It is too early to judge their impact but they certainly get the popular vote.

  After 200 years of psychiatry it seems strange for psychotherapy to be restricted to its own short chapter. Can it really be considered independent from psychiatry or psychiatry independent from it? Psychotherapy has been a defining characteristic of the psychiatric craft – just as a surgeon operates, a radiographer reads x-rays, an obstetrician delivers a baby. Asylum doctors of 150 years ago spent time talking with distressed patients to bring understanding, comfort, and relief. In the second half of the 20th century this personal relationship was why most staff came into the profession. Yet as we start the 21st century psychiatry and psychotherapy are increasingly considered as parallel activities. Is psychiatry changing fundamentally? Time will tell if they are to grow together again or to continue to pursue increasingly independent paths. Some of the forces driving these changes will occupy us in succeeding chapters.

 

Chapter 5 Psychiatry under attack – inside and out

  Psychiatry has always been controversial – there never was an extended ‘Golden Age’ of peace and tranquillity when everyone was in agreement. You probably bought this book after some heated discussion about the rights and wrongs of something psychiatrists do. Because it deals with the mind, and because psychiatrists can act against our wishes, it will always generate a degree of suspicion and fear. And it isn’t good enough simply to put this down to ignorance and say that if people knew more they wouldn’t have such concerns. There are very real questions to be asked about psychiatry – both about its legitimacy, its status as ‘just another medical specialty’, and also about how it is practised. The power of modern medicine invariably brings ethical challenges and controversies and psychiatry has its fair share. These will be taken up more in Chapter 6. This chapter will focus on the contradictions and tensions which are inherent in psychiatry, that stem from its very nature, rather than problems with practice.

Mind–body dualism

  The French philosopher René Descartes (1596–1650) is often blamed for how we distinguish between the mind and the body in Western thought (often referred to as ‘Cartesian dualism’). His ‘cogito ergo sum’ (‘I think therefore I am’) is snappy and memorable; it expresses his scepticism about certainty in knowing about the material world. It is hard to understand why he has been singled out for all the ‘blame’ for an issue which exercised most of his empiricist philosopher contemporaries. He didn’t invent the problem of the mind; he simply put some of the issues better and they remain essentially unresolved 350 years later. What the mind is, and how it interacts with the material world, still remain mysteries. Most of us do think there is a difference and most of us accept that there is an interaction. We have to live our lives believing we can directly influence the material world (e.g. I decide to stretch out my arm and expect to turn on the computer). We also need to believe that we can know the minds of others (e.g. I’m sure that you will go to the library or hand in your essay). Without these beliefs we would effectively be paralysed.

  The mind–body question is unavoidable in psychiatry. The relationship between the mind and the brain is the big issue. It would be simple if psychiatry were just about ‘brain diseases’ in the way that nephrology is about kidney diseases or cardiology is about heart diseases. Psychiatry, however, is concerned with ‘mental’ illnesses. We know that many mental illnesses involve disorders of the brain (e.g. disturbances in transmitter chemicals between cells in depression and schizophrenia) but not all brain diseases are mental illnesses or the responsibility of psychiatrists. Multiple sclerosis and Parkinson’s disease are both undeniably brain diseases but it is neurologists, not psychiatrists, who deal with them. These neurological disorders often cause psychiatric problems, just as a wide range of physical disorders can. Many psychiatric disorders include physical symptoms (e.g. tiredness and pain), just as physical disorders include psychiatric symptoms (e.g. depression, anxiety, and even hallucinations).

  Psychiatric disorders are those where the main disturbances are in thoughts, feelings, and behaviour (Chapter 1). Physical diseases don’t just have physical causes and cures and mental diseases have mental causes and cures. Illnesses can have physical causes and even physical cures (e.g. a depression caused entirely by Parkinson’s disease which is effectively treated by antidepressant tablets) and still be ‘mental illnesses’. The division is based on the main disturbance and on the skills needed to help the patient. ‘Mental disorders are brain disorders’ has been a popular slogan with some psychiatrists and patient groups. Its purpose is to emphasize the similarity between mental and physical illnesses, reducing stigma and blame. These are admirable goals but it is an oversimplification. Psychiatry has to struggle with an ambiguity fought out on two main battlegrounds.