There’s an interesting article in the May 2013 issue of the British Journal of Psychiatry. It’s called “The future of academic psychiatry may be social” by Stefan Priebe, Tom Burns, and Tom K. J. Craig. You can see it here.
The abstract states:
“The past 30 years have produced no discoveries leading to major changes in psychiatric practice. The rules regulating research and a dominant neurobiological paradigm may both have stifled creativity. Embracing a social paradigm could generate real progress and, simultaneously, make the profession more attractive.”
This sounds very positive, but there are aspects of the article that I felt warranted closer scrutiny.
QUALITY OF CARE
The authors begin by stating that the quality of psychiatric care has clearly improved over the past 30 years. The “evidence” they cite for this position is that funding has increased, buildings are better, staffing levels are higher, more patients are treated, and quality management ensures that clinicians do what they are contracted to do.
In my view the most important criterion for quality of care is outcome. If quality of care is really improving, we would expect to see more positive outcomes and less iatrogenic damage. I would argue that from this perspective, quality of care has been deteriorating steadily for the past 30 years, but the authors don’t address this issue.
The authors state that there has been a great deal of “increasingly well-funded and high quality psychiatric research” in the recent decades, but they lament the fact that this has produced no breakthrough in the form of better treatments.
The authors attribute this failure to: firstly, an emphasis in research circles on getting published; and secondly, an over-reliance on a neurobiological paradigm.
“Adopted enthusiastically by the pharmaceutical industry, this paradigm has resulted in a criteria-based diagnostic system generating an ever increasing number of disorders.”
I certainly wouldn’t argue with that, but note the first phrase: “Adopted enthusiastically by the pharmaceutical industry.” This almost gives the impression that the whole thing is pharma’s fault. There is no mention of the fact that it was psychiatry who invented, developed, and promoted this paradigm. It was psychiatry who denigrated other paradigms and created and promoted the fiction that their inventions were “real illnesses, just like diabetes.” It was psychiatry who willingly collaborated with pharma to corrupt research. And it was psychiatry who stuck stubbornly to their guns through edition after edition of the DSM.
The authors are clearly and understandably anxious to distance themselves from these kinds of considerations. They state:
“There are good historical reasons for the current paradigm and for operationalised diagnostic systems. But surely the recent lack of progress is reason to pause and consider alternative paradigms rather than simply pressing on with ‘more of the same’.”
The only historical reasons for the current paradigm are the expansion of psychiatric turf and pharma profits. Whether one considers these reasons “good” depends on one’s perspective.
A SOCIAL PERSPECTIVE
The authors suggest the adoption of a social paradigm as an alternative to the neurobiological one discussed earlier.
Neurobiological phenomena are “…ultimately meaningless unless they are linked to the real lives of people in their social reality.”
Again, this is valid and important, but since neurobiological phenomena have been all that psychiatry has focused on for the past 30 years, shouldn’t we conclude that its diagnoses and treatments are “meaningless”? Perhaps this is what the authors are saying, but didn’t want to offend their fellow psychiatrists by being too direct.
The authors discuss this social paradigm as if it were something new. In fact, Harry Stack Sullivan, a psychiatrist writing in the 1940’s, stated explicitly that interpersonal relationships is the proper subject matter of psychiatry, and that treatment consisted of helping people improve the quality of their relationships. Eric Berne, also a psychiatrist, writing in the 60’s, developed a sophisticated social paradigm and a treatment philosophy that emphasized human interaction. He called it transactional analysis.
These paradigms didn’t just accidently fall by the wayside. They were systematically undermined and rejected by psychiatry in order to promote a biological approach which shored up their turf and increased their earnings. In addition, they systematically and routinely relegated to ancillary status the efforts of other professionals to inject into the treatment milieu anything other than a biological model.
The authors continue:
“A social paradigm requires research to study what happens between people rather than what is wrong with an individual wholly detached from a social context.”
But they don’t mention that the APA’s definition of a mental disorder includes the specific requirement that the problem “…occurs in an individual…” This wording has been in use since DSM III, and is clearly designed to head off any suggestion that a non-medical paradigm might have some validity. The phrase has caused a great deal of difficulty for psychologists, counselors, family therapist, etc., who conceptualize their work along social lines, but are required by APA-inspired regulations to shoe-horn their work into a medical paradigm.
A shift to a social paradigm, we are told “… may lead to a focus on treatment factors that are commonly regarded as non-specific without, in any way, diluting the core medical responsibilities.” This strikes me as trying to have your cake and eat it too. Psychiatry can’t shift its efforts towards a social paradigm without diluting its core medical responsibility. To shift towards a social paradigm one must stop thinking of human problems as illnesses to be treated with drugs. And this will inevitably reduce the significance of biological factors.
In addition, the term “core medical responsibilities” is ambiguous. Does it mean screening clients for that very small fraction of behavioral/emotional problems that stem from a genuine biological cause? Or does it mean pushing drugs as at present? Or does it simply mean that psychiatrists will still be in charge? If the latter, then the question needs to be asked: What would qualify psychiatrists to take the lead role in activity that was driven and directed by a social paradigm? Wouldn’t it make more sense for social workers to take the lead?
In their final paragraph the authors state that tension between the neurobiological and social models has been characteristic of psychiatry since the mid-1800’s. Then they state:
“This tension has been productive and moved psychiatry forward.”
This assertion seems extraordinary. Are the authors actually suggesting that psychiatry in recent decades has been productive and forward-moving? And are they suggesting that the social paradigm, crudely, and systematically, suppressed by psychiatry, has had some role in this process?
For the past 30 years, psychiatry has conceptualized human problems as illnesses and has promoted drugs as the only viable “treatment” for these pseudo-illnesses. They have ruthlessly expanded their spurious, disempowering, and stigmatizing “diagnoses.” They have developed corrupt and corrupting relationships with pharma. They have collaborated in the hijacking of research. They have legitimized the widespread prescription of dangerous drugs, and have stood by complacently as clients succumbed to the most devastating side effects.
Meanwhile, other helping professionals, working with social and psychological paradigms, have tried to provide positive help to clients despite the tyrannous and stifling hand of biological psychiatry.
Now, with their reputation in tatters, and the survivors of their “treatments” in open revolt, they seek to rehabilitate themselves. But there’s no apology. Not even an oops, sorry. Just “We’ve messed up our own patch. Can we come over to yours? And by the way, we’ll still be in charge.”
Perhaps I’m over-reacting to this paper. I don’t know much about the authors, but their publications history suggests that they might be on our side of the debate, at least to some extent. It’s likely that they conceptualized their paper as a step towards bringing psychiatry out of the dark ages. And as psychiatrists they perhaps feel constrained to keep a foot in both camps.
This paper could be viewed as a step in the right direction; an attempt to nudge psychiatry towards a more helpful paradigm, and that was probably the authors’ intent.
But psychiatry’s spurious conceptual framework, with its ever-expanding arsenal of destructive practices and its corrupting links to pharma is a deeply entrenched force in modern society.
It will take a great deal more than a nudge to realize a significant paradigm shift. I hope that Drs. Priebe, Burns, and Craig will continue to speak out, and perhaps with a little more force.