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To provide a useful contextual backdrop to an exhibition at the Royal College of Psychiatrists this summer, we used a question and answer format to summarise the thoughts of its curator, Gavin Miller. Gavin has chosen 12 books published by Penguin between 1949 and 1975 to illuminate the relationship between psychiatrists, psychologists, psychotherapists and the British media. He reflects on the opportunities and pitfalls that come with the association, the motivations of previous writers and provides practical advice for any media psychiatrists considering such a role in the future. The exhibition is open to visitors to the College building in London.
History tells us that the broader values of society can be just as important as those of psychiatry itself in shaping the way people with mental illness are treated. Historical scholarship also alerts us to the need to be circumspect about taking society’s self-declared values at face value, an example being the humanitarian reform of the care system for the mentally ill during the Victorian era where harsh and discriminating morality and a growing intolerance of society towards the marginal have also been demonstrated. Historically, in the UK, doctors have repeatedly found themselves limited in their ability to build a person-centred, therapeutic relationship with their patients by circumstances that were beyond their control, for example the overcrowding and strict legalism of the asylum system.
From the twentieth century onwards, there have been periods when society turned to psychiatry for advice about normal life. Anti-psychiatry emerged during a period when the idea that psychiatry could be a tool for social adjustment was under growing criticism; individual freedom began to be prized over conformity; and the service user movement started. One important legacy of the anti-psychiatry criticism is that psychiatry has become much more cautious about taking a public role on values.
Developing a satisfactory explanation of the pathomechanism of mental illness, developing biomarkers to aid diagnosis, developing an aetiological classification system, and developing effective treatments to achieve both symptom elimination and functional recovery has so far remained the holy grail of psychiatry for most conditions. To make progress, psychiatric research needs to integrate the biological, psychological, sociocultural, and existential dimensions of mental illness and incorporate and work with values more efficiently. This chapter offers a methodology for this through first describing value-mapping and then elucidating the potential contribution of qualitative and mixed-method studies, phenomenological, hermeneutic, and other idiographic approaches, interpretative phenomenological analysis, analytic induction, quasi-judicial approaches, and the history of psychiatry.
An essential prerequisite of any breakthrough here would be going back to the person level. Research centres would need to become truly multidisciplinary to bring together researchers with expertise in the relevant natural and social sciences and the medical humanities as well as experts by experience for effective co-production.
Madness, as a form of suffering, has existed as long as humankind. Only in the nineteenth century did it come under the aegis of medicine, giving rise to the birth of psychiatry/alienism as a discipline. Prior to this, madness had attracted the attention of many agents, including the Church, medics, philosophers, and others. During the seventeenth century in the context of secularization, the scientific revolution, and other factors, it began to be viewed as a natural kind and thereby a medical object. In the nineteenth century, the medicalization of madness was further associated with a growth of mental asylums, enabling alienists to observe patients longitudinally, to classify their complaints, and to construct the language for the description/construction/capture of mental symptoms, namely, descriptive psychopathology. In contrast to the signs available to medical doctors, alienists had to develop different clinical criteria, and the emerging social sciences became the natural source for these. Thus, from the beginning, descriptive psychopathology was a hybrid construct, incorporating the frameworks of both the natural sciences and the social sciences. The tension resulting from this incongruent union has persisted ever since and contributed to the polarities in current conceptions of mental disorders as well as the challenges facing psychiatry today.
Published in 1913, General Psychopathology blends philosophy, rigorous conceptual analysis and detailed clinical examples. Jaspers makes the case that psychopathology requires two different methods (explaining and understanding) to address the predicament of the subjective nature of experience and what it was to be human. Key contributions from General Psychopathology to psychiatry include the conceptual framework for delusions, the issue of somatic prejudice, empathy as the key tool at our disposal in thinking about another person’s subjectivity, and the whole versus the part (gestalt). Jaspers was a proponent of the existential school of philosophy, which is evident throughout the work.
This fascinating book brings together a multidisciplinary team of authors from a variety of backgrounds and lived experience who offer insight into the historical roots and current reasons for the hybrid natural and social scientific conceptual platform of psychiatry. The role of values in the development and recovery from mental illness are covered as well as progressive developments, outlining a novel research methodology. Demonstrating the importance of the integration of each main dimension of psychiatry (such as biological, psychological, social, and existential), the book includes values in theory and research in working out the epistemological foundations of psychiatry as an academic discipline and in clinical practice. Covering the major directions from which the subject of mental ill health has been approached (neurobiology, psychoanalysis and the psychotherapies), the common conditions and the controversies surrounding them are explored. Highly relevant to academics, clinicians and students in psychiatry, psychology, primary and social care.
Experiences in Groups is a revolutionary text in the understanding and analysis of group dynamics which remains highly relevant to mental health practice today. This article considers its key themes as well as its development in the context of Wilfred Bion’s work as a doctor and a psychoanalyst.
As psychiatrists, we are hopefully especially attuned to the power of language, especially the words we use when discussing sensations, thoughts and bodies. This article explores some of the heritage of medical language of today, drawing on classical Latin and how this interfaces with our day-to-day practice, with special reference to eating disorders.
In this opinion article, we discuss the application of critical realism as an alternative model to the biopsychosocial model in the understanding of psychiatric disorders. Critical realism presents a stratified view of reality and recognises mental disorders as emergent phenomena; that is, their full explanation cannot be reduced to explanations at any lower level of biological processes alone. It thus underscores the significance of the depth of ontology, the interaction between agency and structure, and the context dependency and complex nature of causality. Critical realism provides the conceptual and epistemological basis for a more subtle understanding of the aetiology of psychiatric conditions, which is polyfactorial and includes biological, psychological and social dimensions. Through the realisation of the conceptual and applicative shortcomings in the biopsychosocial model, critical realism promises to advance the understanding of mental disorders and enable a more holistic approach to the problem of people with mental disorders.
Franco Basaglia (1924–1980) has a particular relevance to psychiatry today as he combined social critique with psychiatric reform. In the new ‘metacommunity’ era in psychiatry, his radical and critical thinking provides important tools, as does his enduring message that ‘freedom is (still today) therapeutic’.
Modern management has much to learn from ancient wisdoms. Management structures based on corporate trends were transferred from business to services such as healthcare to promote cost-efficiency and productivity. In this article, I argue that the short-term approach of corporate leaders being brought into healthcare for ‘transformation’ has led to a trail of service dismemberment with no discernible clinical gain for those we seek to serve. Bhagwad Gita, the ancient Hindu scripture on right conduct, is an exemplar of how the primary aim of leaders should be to provide better service rather than serve personal interests or those of the ‘business’ of healthcare.
To outline the life and work of Greek physician Asclepiades of Bithynia (124–40 BC), especially his contributions to thinking about mental illness.
Methods:
Review and discussion of relevant fragments of Asclepiades’ work that survive and review of secondary literature, supplemented by relevant systematic literature searches (e.g. PubMed).
Results:
Asclepiades challenged the long-standing Hippocratic doctrine of the four humours and developed an approach to physical and mental illness that was humane, reasoned, and a forerunner of later developments in psychiatry. Asclepiades argued that the human body, like everything in the universe, comprised tiny, imperceptible particles, which he called önkoi, seamless masses in perpetual motion. In consequence, Yapijakis describes Asclepiades as ‘the father of molecular medicine’. Asclepiades held that good health was maintained by free, balanced motion of önkoi through theoretical pores, while disease resulted from blockage or impaction of önkoi passing through pores in various body parts (e.g. brain). Based on this idea, Asclepiades recommended releasing people with apparent mental illness from confinement and using judicious combinations of diet, exercise, massage, bathing, and music to treat ‘phrenitis’ (delirium) and melancholia. He suggested that the physician act ‘safely, swiftly and pleasantly’ (‘cito, tutu, jucunde’) for both physical and mental illness.
Conclusions:
Asclepiades belongs to the historical tradition of progressive medical approaches to mental illness, not least because he applied his principles for the treatment of physical illness to mental illness. His ideas about psychiatry set the scene for further evolution of attitudes to mental illness and its treatment over subsequent centuries.
This article discusses sceptical arguments about measurement scales. Measurement scales are part of a promising agenda of openness, transparency and patient and public involvement (PPI) in medical research, but have received critical, sometimes hostile attention from anthropologists. This is because scales repackage localised cultural assumptions about distress as something universal and pan-human and have the capacity to reshape people's interior lives in unhelpful, possibly harmful ways. We take as an example the Patient Health Questionnaire-9 (PHQ-9). Use of the PHQ-9 is currently mandated by major funders. But its history suggests flawed PPI and a lack of openness. The article suggests a constructive role for anthropology in mental health research, using ethnographic evidence and theory to show how, although they have their uses, mental health scales should not be regarded as inert or harmless.
Twenty years ago, the British Journal of Psychiatry published an editorial regarding racism and psychiatry. Three decades ago, the journal published a lecture by Professor Michael Sheperd about Kraepelin's contributions to racist degeneration theories. A century ago, Albert Einstein visited the Brazilian Academy of Sciences, where he was hosted by Juliano Moreira [1872–1933], one of the most distinguished Brazilian scientists of that time. The only son of a former enslaved woman, he is regarded as one of the founding fathers of scientific psychiatry in Brazil. Moreira may have been a case of ‘exceptional racism’, the strategy of praising outstanding people from oppressed groups as a way of denying or covering up processes of structural racism.
In 1978, William Alwyn Lishman's Organic Psychiatry: The Psychological Consequences of Cerebral Disorder was published, fostering the development of neuropsychiatry and leading to the recognition of Lishman as the father of neuropsychiatry. This article is a narrative account of his personal struggles, as well as conceptual dilemmas he dealt with while writing this book, and how through its four editions it has evolved to become an anchor for psychiatrists as they seek to develop understanding of the workings of the brain, and a beacon for them when they discuss clinical implications of diagnosis with patients and families.
Lunatic Asylums, published 130 years ago, is a fascinating insight into how these institutions were managed in the late Victorian era. This brief article considers what it reveals about the zeitgeist of the time and the book's author, the remarkable Charles Mercier.
This paper reflects on a special edition of the journal History of Psychiatry and a related symposium held at Somerville College, Oxford, exploring the innovations in mental healthcare in Oxfordshire led by Dr Bertram Mandelbrote between 1959 and 1988. I draw on clinical culture, biography, mental health policy and my lived experience to understand Mandelbrote's life and work, and his legacy and lessons for contemporary psychiatrists. I explore the ecological niche that Mandelbrote created and conclude with the probable importance of his relationship with Professor Michael Gelder, who led the University of Oxford Department of Psychiatry at the time.
To address some challenges facing psychiatrists today we discuss issues of happenstance and fulfilment in psychiatric careers through some of the record and reflections of four psychiatrists since the 1950s. We trace the changes in psychiatry attendant to the transition from the welfare to the neoliberal state and=its contemporary postmodern culture. We highlight the crucial importance of political-cultural as well as technological developments in determining psychiatric service management and provision, and clinical practice and career outcomes. In the light of this impact, in a global era that some highly respected authorities consider in apocalyptic terms, we advocate for the incorporation of training in political awareness and activism in the psychiatric curriculum and practice. We suggest that this is necessary for social justice and patient welfare and that it will help safeguard psychiatric professionalism, conscience and self-esteem.
The history of the Grange Annual Conference is traced to its roots in the work of Sir William Norwood East, the Royal Medico-Psychological Association and Waddiloves Hospital in Bradford, UK.