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What do Psychiatrists Actually Believe?

August 6, 2011

I’ve just had a read of the introduction of the Oxford Handbook of Psychiatry.  Here are some thoughts.

It is certainly true that the level of knowledge about causation and treatment of mental disorders is less advanced than for other branches of medicine. In some ways, however, this is an attraction.  In other specialities much of what was formerly mysterious is now understood, and interventions and diagnostic methods once fantastic are now quotidian. Psychiatry offers a final frontier of diagnostic uncertainty and an undiscovered country of aetiology to explore. Perhaps the lack of progress made in psychiatry, compared with the other specialities, is not because of lack of will or intelligence of the practitioners but due to the inherent toughness of the problems. To put this another way, all scientists `stand on the shoulders of giants’: in psychiatry we have no fewer and no shorter giants, just a higher wall to peer over.

To `peer over’ the `wall’, you need more than scientific shoulders to stand on: you need a philosophy beyond that of science. Science is only a few hundred years old and is greatly limited in many respects compared with the ancient philosophies of India, China, Greece and the Jews. In treating another’s mind there is one fundamental question: are they sane? If they are sane, then signs and symptoms observed are reflections of problems elsewhere in society; if insane, they need to be taught to know sanity.  This is the first thing which must be ascertained, and the solution in the case of insanity is to find stability in their mental processes and build a knowledge of sanity upon this. If necessary, temporary
stability may be induced by another stable mind, but this is not without difficulty: the other must prod and probe with explorative behaviours until stable feedback loops emerge, and then these must be used as the initial basis for building stability. None of this requires the use of toxic substances, but it does require a stable logical mind on the part of the practitioner, and a solid background in ancient philosophy is not optional.

Most mental diagnoses have had their validity questioned at several points in their history. Diagnosed by doctors on the basis of symptoms alone, some people find their presence difficult to accept in a field which has been almost universally successful in finding demonstrable physical pathology or infection.

We are right to have questioned their validity, and we are right to still question it. It has not been proved or soundly justified, just assumed by current mental health professions and the fundamental questions ignored.  It is unlikely to be the case that mental diseases can ever be diagnosed by a doctor based on symptoms alone, since the doctor fundamentally cannot `see’ what he is trying to diagnose: in the case of a broken leg or a bacterial infection, there is clear physical evidence. So far attempts to tie mental problems to physical causes have produced results that are wholly unsatisfactory to those who have to live with the consequences of judgements based upon them.

This model of disease has become synonymous in many peoples’ mind with a model based solely on demonstrably abnormal structure. Thomas Szasz has criticized psychiatry in general by suggesting that its diseases fail when this model is applied.

This argument that psychiatric diagnoses are invalid still strikes a chord with many doctors and non-medical academics.  When the BMJ conducted a survey of non-disease, many people thought depression to be a non-disease, although schizophrenia and alcoholism fared somewhat better. It is clear from the graph that many conditions rated as real diseases have a characteristic pathology, although some do not (alcoholism, epilepsy). Similarly, many people regard head injury and duodenal ulcer as non-disease, although their pathology is well described.

There is a profound lack of clarity here. It talks vaguely of what the average member of the public thinks, but is light on substance.

Models based on aetiology or pathology have been found to be the most useful, but the reality may be that `disease’ is a concept which will tend to change over time and has no real existence in itself.

This passage underlies the fundamental instability of the medical mindset. They have not found solid foundations for their opinions and are still exploring. How much longer must they be allowed to explore before we demand substance from them? Just because `Models based on aetiology or pathology have been found to be the most useful’ according to someone’s judgement of what is useful, there is no rational reason to use one as the foundation for assessing mental issues. What is needed is stability, clarity, reliability, certainty and above all, simplicity. Things need to be stable enough that they are not going to be fundamentally rewritten every five years or so, clear enough that all who need to know can agree on what’s what, reliable in the sense that the methods work in all cases except the most unusual, certain in the sense that applying them does not rely upon guesswork and simple in the sense that explanations are not more complicated than they need to be, and can be described fully in a few pages of clear writing. These properties are not optional, and a mental health profession which lacks them should not be tolerated.

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