Cracked (27 page)

Rather than diagnosing and medicating his behavior, the psychiatrist focused on helping the mother and son gain insight into why the boy was struggling. In one session, for instance, while the psychiatrist was reflecting on the mother's feelings of guilt and lack of confidence, the mother began to cry. Straight away the boy started rebuking the psychiatrist; he saw the psychiatrist as yet another man hurting his mother. This event opened up a conversation about how hypervigilant the boy had needed to become, and how this was hampering his life. By talking and working things through, together they developed an explanatory framework that began to make sense of why the boy might be struggling with authorities and with being angry generally. As this work continued, the boy, without drugs or a diagnosis, gradually began to improve.

In the second example, the same psychiatrist met the family of a boy who had many learning difficulties but who had worked out how to cover this up, usually by acting the class clown. Again, rather than using the common approach of assigning a diagnosis and prescribing meds, the psychiatrist centered on working with the boy's local school. In the end, the psychiatrist helped the boy move to another school where more classroom support could be offered and where the boy could enjoy a fresh start. Once again, this simple non-medical strategy worked to good effect.

The psychiatrist in both examples spent far more time with his patients than would have been required had he merely assigned a diagnosis and prescribed medication. But the results were worth the additional time, effort, and of course money. In fact, when Timimi assessed how well patients did in the non-diagnostic approach compared to those treated via the medical model, the differences were dramatic: Only 9 percent of patients treated by the non-diagnostic approach continued needing treatment after two years, compared with 34 percent of patients who were being treated via the medical model. Furthermore, only one person from the non-diagnostic approach ended up having to be hospitalized, whereas over fifteen people in the medical-model team were referred for in-patient hospital treatment. Finally, the non-diagnostic approach led to more people being discharged more quickly and to the lowest patient “no show” rate out of all the mental health teams in the county.

“So we know the non-diagnostic approach was effective because we measured the outcomes,” said Timmi. “It had the lowest use of medication, the lowest use of inpatient treatment, but the highest recovery rate. So research like this shows that a non-diagnostic approach can not only work, but it can work a lot better than the current medical one we have.”

This view was further confirmed for Timimi when, after his study, he became consultant to one of the lesser successful mental health teams in his county, where the medical model was firmly entrenched. What he found was that most patients had been in the service for many years and had become psychologically dependent upon their pills and thoroughly acculturated into thinking of their problems as related to diagnoses like ADHD, bipolar disorder, depression, and so on. The medical model seemed to be actually helping
create
patients who had chronic conditions, conditions that were products not of their biology but of how their problems were being medically managed. The medical model was, in effect, creating the circumstances in which patients were staying unwell for longer.

Timimi's approach is not unique. Many of the psychiatrists contributing to the editorial also embrace similar methods, but so too do increasing numbers of others. When I interviewed Dr. Peter Breggin, another internationally renowned critical psychiatrist located in the United States, it was clear he had long ago rejected the medical model, and to very good effect. “The model I prefer to use is a person-centered team approach,” said Breggin, “where the prescriber and the therapist work with the family and the patient. This approach is centered around the person, and what the patient really wants, feels, and needs.”

For Breggin, this did not mean simply diagnosing and medicating people outside their context, but sidestepping the medical model and focusing on the matrix of relationships in which the person habitually operates. “If I get a child who is labeled ADHD and is on stimulants, I just work with the family in the office. I take the kid off the drug and work with the family in an honest and caring atmosphere, which is something kids love, working out what went wrong. Even if the child is ‘psychotic,' I guarantee that in time these problems can be fixed if we all work together responsibly. And we are getting amazing results.”

For Breggin, most problems are created by the contexts in which people live, and therefore require contextual, not chemical, solutions. “People who are breaking down are often like canaries in a mineshaft,” explained Breggin. “They are a signal of a severe family issue. And sometimes the one who is breaking down is being scapegoated; sometimes they are the most sensitive, creative member of the family, or sometimes they are the one person in the family with a really different personality. You don't know what is going on, often, but with work you can see the dynamics that have developed in the family that are pulling things down.” For Breggin, because the medical model fails to take context seriously—whether the family or the wider social context—it overlooks the importance of understanding and managing contexts to help the person in distress.

Another consultant psychiatrist and contributor to the editorial, Dr. Pat Bracken, echoed the value of this more person-centered approach. “One of the reasons psychiatry is in crisis is that we are simply overprescribing meds. Lots of people say that the only thing they get from psychiatry is pills. But there are serious questions about whether this approach has delivered. Has it alleviated distress, has it helped people enduring states of madness or depression, has it helped them to move on in their lives? There are serious people standing back from psychiatry, looking at the evidence and saying, hang on a minute here, there is no evidence that this massive expansion of drugs is working. In fact, there is growing concern that this enormous tidal wave of prescribing is actually causing major problems, least of all by increasing mortality rates of people experiencing mental illness.” (For more information on this, please see the appendix.)

Bracken argues, in keeping with the editorial, that psychiatry must therefore readjust its relationship to the usefulness of psychopharmacology. “But this is not the same as being anti-drugs,” Bracken was keen to emphasize. “We are very clear in the editorial that there is a role for using medicine to ease human distress. Rather, we believe we need to get balance back into the situation again.”

For Bracken, the balance will return only by dethroning the medical model from the helm of psychiatry, where problems are simply understood as symptoms and signs of underlying illnesses. But he also recognizes this is a tall order. “The medical model was established in the asylums in the early twentieth century,” continued Bracken, “so it has been at the heart of psychiatry's identity for a long time. This could have changed in the 1970s–'80s when psychiatry moved out of the asylums. At this time the natural process would have been for psychiatry to have become more interested and involved with the social sciences, with efforts to look at what kind of environments are important for people to recover and flourish in.

“But instead, at that very moment, the pharmaceutical industry started to target psychiatry in a way that has allowed the dominance of the medical paradigm to continue. In fact, I think the influence of pharma has made the medical focus in psychiatry even narrower, largely because money speaks. When there is money to support academic departments, psychiatry departments, etc., that all promote this approach, well then, it is not surprising that is what continued.”

Bracken's message was clear: “We are not saying there is no valuable practice going on in psychiatry. Our point is that when you actually look at how people are helped, it is not all about medication and diagnosis; we are rather focusing on issues to do with negotiation of meaning and context, prioritizing relationships with people, working democratically with other agencies and service users. We are not abandoning our typologies in that move, but we are seeing the use of drugs, the use of therapies, the use of diagnosis, even, as secondary to something more primary. And when psychiatrists in their individual practices do that, I think that's what people say is a good psychiatrist. So we should start turning the paradigm round, start seeing the non-medical approach as the real work of psychiatry rather than as incidental to the main thrust of the job, which is about diagnosing people and then getting them on the right drugs.”

2

It was clear to me what the future of psychiatry would be if the critical psychiatrists had the power. But as this group was on the institutional outskirts, what I now wanted to know was how the future would look for those with power at the center. Would the future look anything like what the critical psychiatrists hope for, with their desire to relegate the medical model?

I put this question to Sue Bailey, who once again offered a strong response. “The risk [of challenging the medical model] is that we end up without a voice for mental health,” she said. “Despite the best efforts of some senior members of this college, mental disorder is still not recognized by the United Nations and World Health Organization as a non-communicable disease [i.e., as a serious medical illness like heart disease, diabetes, or cancer].”

Getting this recognition was crucial, Bailey believed, because it would finally force governments to take mental health issues seriously, which would in turn increase provision for mental health care. But so long as the profession remained internally divided, mental disorders were less likely to be granted this coveted disease status
.
“By having the neuroscientists and the critical psychiatrists fighting,” explained Bailey, “I would go as far as to say they are causing harm, because our argument about the importance of mental health is as strong as [the argument about the importance of] cancer. But cancer specialists have these polarized debates in a closed room, and yes, with a bit of blood spilt on the carpet. But when they come out, they speak about cancer in one voice. We do not speak about mental health in one voice, but until we do, with enough common ground, then mental health will not get the attention or service provision it deserves.”

The main problem with Bailey's quest for professional consensus is that the forces of disagreement are deeply entrenched. How can you get the brain-disease psychiatrists and the critical psychiatrists to agree on a common vision of mental distress when their understandings of suffering, of etiology, of treatment, of diagnosis are fundamentally at odds? It is like asking Buddhists and Christians to agree that their views of the afterlife are, at bottom, really the same.

Furthermore, Bailey's request for professional agreement is hobbled by her aim for those critical of the medical model to help form a consensus that would ultimately allow mental disorder to attain “disease status.” But why would the critical psychiatrists do that? Their whole point is that to think of suffering in “disease terms” is to fundamentally misunderstand what we are dealing with.

3

Once I had closed the door of the Royal College of Psychiatrists behind me and stood again outside on Belgrave Square, I felt a sudden and gloomy wave of certainty that Sue Bailey's position was an impossible one. In many ways, I could understand her exasperation—the reconciliation she sought was so improbable that her solution offered very little hope. I therefore would need to turn to others I had spoken to, unconstrained by having to juggle many competing interests, who had thought through alternative ways in which psychiatry could be reformed.

When summarizing the various views I had heard, they broadly boiled down to about four propositions. So let me briefly state them here:

• • Psychiatry needs to develop greater modesty and humility about what it can actually hope to achieve.
  
• • There needs to be more thorough regulation and transparency regarding psychiatry's financial ties to the pharmaceutical industry
  .
  
• • The training of future psychiatrists must include instilling greater critical awareness of psychiatry's scientific failings and current excesses, as well as better awareness of how to manage patients outside of the medical model.
  
• • The public needs to become better informed about the current crisis psychiatry is in. And if the industry does not reform, be prepared to vote with their feet.
  

I realize that an entire book could be written for each of these propositions. But I have nothing like that kind of time. So allow me to just give you a very brief summary of each of these propositions in turn.

This first proposition I heard again and again. For example, I interviewed Professor Thomas Szasz, perhaps one of the most influential critical psychiatrists of the twentieth century and author of the now classic
The Myth of Mental Illness
. He had always argued that the biological philosophy of suffering underpinning psychiatry was causing more problems than it solved, so I asked him what his philosophy looked like.

“My understanding of emotional suffering,” answered Szasz in considered tones, “and I hope I won't be misunderstood, is no different from the traditional understanding of the Jews, Christians, or Muslims of emotional suffering. Suffering is life. God didn't put us on this earth, assuming that he did, to be happy. Life, as I put it humorously, is not a picnic. It makes no difference if you are a king or a pope or a tyrant.”

I asked Szasz what is it about our period that makes it normal for everyone to be medicated when misery strikes. Why do we believe as a culture that suffering must be removed chemically, rather than understood in many cases as a natural human phenomenon and possibly something from which we can learn and grow if worked through productively?