Psychiatry under pressure: reflections on psychiatry's drift towards a reductionist biomedical conception of mental illness

'Effective' at What? On Effective Intervention in Serious Mental Illness

The term "effective," on its own, is honorific but vague. Interventions against serious mental illness may be "effective" at goals as diverse as reducing "apparent sadness" or providing housing. Underexamined use of "effective" and other success terms often obfuscates differences and incompatibilities in interventions, degrees of effectiveness, key omissions in effectiveness standards, and values involved in determining what counts as "effective." Yet vague use of such success terms is common in the research, clinical, and policy realms, with consequences that negatively affect the care offered to individuals experiencing serious mental illness. A pragmatist-oriented solution to these problems suggests that when people use success terms, they need to explain and defend the goals and supporting values embedded in the terms, asking and answering the questions, "Effective at what? For whom? How effective? And why that goal?" Practical and epistemic standards for effectiveness will likely remain plural for good reasons, but each standard should be well explained and well justified.

The Task before Psychiatry Today Redux: STSPIR*

This paper outlines six important tasks for psychiatry today, which can be put in short as:

Spread and scale up services;

Talk;

Science,

Psychotherapy;

Integrate; and

Research excellence.

As an acronym, STSPIR.

Spread and scale up services: Spreading mental health services to uncovered areas, and increasing facilities in covered areas:

Mental disorders are leading cause of ill health but bottom of health agenda;

Patients face widespread discrimination, human rights violations and lack of facilities;

Need to stem the brain drain from developing countries;

At any given point, 10% of the adult population report having some mental or behavioural disorder;

In India, serious mental disorders affect nearly 80 million people, i.e. combined population of the northern top of India, including Punjab, Haryana, Jammu and Kashmir, Uttarakhand and Himachal Pradesh;

Combating imbalance between burden of demand and supply of efficient psychiatric services in all countries, especially in developing ones like India, is the first task before psychiatry today. If ever a greater role for activism were needed, this is the field;

The need is to scale up effective and cost-effective treatments and preventive interventions for mental disorders.

Talk: Speaking to a wider audience about positive contributions of psychiatry:

Being aware of, understanding, and countering, the massive anti-psychiatry propaganda online and elsewhere;

Giving a firm answer to anti-psychiatry even while understanding its transformation into mental health consumerism and opposition to reckless medicalisation;

Defining normality and abnormality;

Bringing about greater precision in diagnosis and care;

Motivating those helped by psychiatry to speak up;

Setting up informative websites and organising programmes to reduce stigma and spread mental health awareness;

Setting up regular columns in psychiatry journals around the globe, called ‘Patients Speak’, or something similar, wherein those who have been helped get a chance to voice their stories.

Science: Shrugging ambivalence and disagreement and searching for commonalities in psychiatric phenomena;

An idiographic orientation which stresses individuality cannot, and should not, preclude the nomothetic or norm laying thrust that is the crux of scientific progress.

The major contribution of science has been to recognize such commonalities so they can be researched, categorized and used for human welfare.

It is a mistake to stress individuality so much that commonalities are obliterated.

While the purpose and approach of psychiatry, as of all medicine, has to be humane and caring, therapeutic advancements and aetiologic understandings are going to result only from a scientific methodology.

Just caring is not enough, if you have not mastered the methods of care, which only science can supply.

Psychotherapy: Psychiatrists continuing to do psychotherapy:

Psychotherapy must be clearly defined, its parameters and methods firmly delineated, its proof of effectiveness convincingly demonstrated by evidence based and controlled trials;

Psychotherapy research suffers from neglect by the mainstream at present, because of the ascendancy of biological psychiatry;

It suffers resource constraints as major sponsors like pharma not interested;

Needs funding from some sincere researcher organisations and altruistic sponsors, as also professional societies and governments;

Psychotherapy research will have to provide enough irrefutable evidence that it works, with replicable studies that prove it across geographical areas;

It will not do for psychiatrists to hand over psychotherapy to clinical psychologists and others.

Integrate approaches: Welcoming biological breakthroughs, while supplying psychosocial insights:

Experimental breakthroughs, both in aetiology and therapeutics, will come mainly from biology, but the insights and leads can hopefully come from many other fields, especially the psychosocial and philosophical;

The biological and the psychological are not exclusive but complementary approaches;

Both integration and reductionism are valid. Integration is necessary as an attitude, reductionism is necessary as an approach. Both the biological and the psychosocial must co-exist in the individual psychiatrist, as much as the branch itself.

Research excellence: Promoting genuine research alone, and working towards an Indian Nobel Laureate in psychiatry by 2020:

To stop promoting poor quality research and researchers, and to stop encouraging sycophants and ladder climbers. To pick up and hone genuine research talent from among faculty and students;

Developing consistent quality environs in departments and having Heads of Units who recognize, hone and nurture talent. And who never give in to pessimism and cynicism;

Stop being satisfied with the money, power and prestige that comes by wheeling-dealing, groupism and politicking;

Infinite vistas of opportunity wait in the wings to unfold and offer opportunities for unravelling the mysteries of the ‘mind’ to the earnest seeker. Provided he is ready to seek the valuable. Provided he stops holding on to the artificial and the superfluous.

[Biologism controversy: ethical implications for psychiatry]

Current biological psychiatry, it is frequently claimed by its opponents, is "biologistic" and unduly narrows psychological disorders to neurobiology and molecular biology. They deem a complete neuroscientific reduction of the mental phenomena to be impossible because of the impossibility of reducing certain phenomena, such as the individual subjective experience. If such a reduction is nevertheless undertaken it is ultimately to the disadvantage of the patients. We argue in this article that the very term "biologism" has to be put under scrutiny in the first place. As a result it becomes obvious that "biologism", as a subclass of "philosophical naturalism", is ultimately quite unproblematic. Biologism is dangerous only if it implies an eliminative rejection or an inappropriate underestimation of the relevance of the psyche. On closer examination it gets evident that such implications do not follow necessarily from biologism but cannot be precluded either. To better identify and possibly prevent such dangers, a more differentiated terminology seems helpful.