Old dilemmas in new forms

  Despite all this we enter the 21st century with remarkably similar dilemmas with which we entered the 20th. Compulsion in psychiatry has not gone away – rather increased somewhat. Similarly the fear that psychiatry may trivialize individual differences and treat people as objects remains just as strong. This conflict may now be played out between ‘evidence based medicine’ versus ‘post-modern individualism’, where once it was the crushing uniformity of large asylums versus the dignity of the patient. Society and psychiatry will always have (and probably should always have) an uneasy relationship balancing duty to the patients and duty to society in the social control of a small number of potentially dangerous individuals. The very durability of these debates reveals them as not simply technical problems. They reflect the tensions and paradoxes that are inherent to psychiatry as a discipline and with which we started this book.

Will psychiatry survive the 21st century?

  The imminent demise of psychiatry has been predicted for most of its history. Optimists (particularly those engaged in medical and biological research) anticipate dramatic breakthroughs that will tame mental illnesses in the way that antibiotics defeated tuberculosis or vaccination eradicated small pox. The mental hygiene movement also hoped that rational child care, reduced alcohol consumption, and improved social conditions would make the analyst and psychotherapist redundant. It hasn’t happened so far. The very success of modern medicine has brought with it the challenges of an ageing population with increased depression and Alzheimer’s disease. Greater openness and respect for individual feelings has resulted in an enormous increase in the demand for counselling and psychotherapy. The numbers of psychiatrists and mental health professionals has risen inexorably across the world. On a simple head-count of staff and the mounting demand for its service, yes it should continue to flourish.

  But will it survive as it is now? Certainly things are changing. Might the psychological and psychotherapeutic treatments separate from the more traditionally medical treatment of the psychoses? In many parts of the world psychiatry has only recently gained its independence from neurology but we now hear strong calls for reuniting them as a logical development of a more powerful medical psychiatry for the future. Many psychiatrists already call themselves ‘neuropsychiatrists’. This is the case in many Germanic systems. There are several health care systems where the psychiatrists deal with diagnosis and inpatient care, emphasizing a highly scientific medical model. Long-term outpatient care of disabled patients is managed by social workers and psychologists/psychotherapists using a more interpersonal approach. These pressures are not new. What is new is the wide availability of highly trained clinical psychologists, nurses, and social workers with the necessary skills. Responsibilities and power structures are shifting and radically different practices evolving.

  There is a logic to such developments. Increased knowledge drives specialization, so some fragmentation of psychiatry is inevitable. Despite this, psychiatry is entrenching as a discipline. Establishing departments of psychiatry independent of neurology or internal medicine is still seen as a marker of progress. Similarly when people can choose they still seem to want that mixture of medical expertise (or is it authority?) combined with psychological and emotional sensitivity traditional to psychiatry. Psychiatry’s medical pedigree gives reassurance yet few of us believe that it is really just a branch of medicine.

  The mind is not the same as the brain. The defining characteristic of mental illnesses (and consequently psychiatry) remains their impact on our sense of self and on our closest relationships. Working with these is the hallmark of psychiatry and there is no evidence of society losing interest in it. There probably will be a Very Short Introduction to Psychiatry in a hundred years’ time.