Wake Up and Smell the Coffee!

“I want to change the way we think about mental health care so that any child, whether they have a mental illness or simply need support through a difficult time, can get the right help at the right time.” This was said by Care Minister Norman Lamb and quoted by the BBC on March 17^th 2015. Mr. Lamb is known to have a son who has suffered mental health difficulties and it may well have come from the heart as much as it did from the election fever which is beginning to infect British politicians. However it says something  worth picking up upon. I want to change the way we think about mental health care… and … simply need support through a difficult time. These are important shifts of language, and doubly important when they come from a government health minister. He is talking about “changing the way we think about mental health care” and “support through a difficult time.” How different these are from debates about which sorts of treatment to apply, how to improve the efficiency of services, of the cost benefits of different medicines or how to access psychological therapies. They reflect widespread dissatisfaction with what is generally available, particularly as NHS Child and Adolescent Mental Health Services (CAMHS), and hint at what might represent much needed change … support through a difficult time, rather than “treatment.”

Many of Mad in America’s contributors sing the same refrain and it is welcoming to hear it from the lips of a senior politician. I am not used to seeing psychiatrists in a white coat … indeed even our NHS physicians have discarded them because of the risks of spreading infection, which makes the spectacle of Jeffrey Lieberman pontificating about his new book particularly striking. Robert Whitaker has just posted a characteristically fluent and penetrating review of this and I look forward to his insights into how psychiatry can be understood as a self-defensive institution. I am sure he will give us much to chew upon. I’ve yet to read Lieberman’s … but if he were to ask his publishers to send me a copy I would be happy to do so.  Even without reading it I am interested in picking up Robert’s point about medical “heroes.”

Medicine, whether it be “shrinking,” cardiology, orthopaedic surgery, gynaecology or anything else is and always has been an enterprise located in the no man’s land between the world of human discourse and its institutions, and nature. Ailments are situations in which the natural world (as in human anatomy and physiology, physical or chemical assault upon them, or the lives of infectious micro-organisms) intrudes into the human, disturbing  the comfort and security of the individual and quite often, the comfort and security of their loved ones. The giants of medicine, those whose names we remember, are those who have altered our understanding of this territory; William Harvey for recognition of how blood circulates, Edward Jenner, Ignaz Semmelweis and Joseph Lister for their insights into the role of infecting organisms in so many of our afflictions, and as a result changes in the treatment of drinking water, sewage and food hygiene, Alexander Fleming for the discovery of penicillin, which can kill bacteria but leave other cells unharmed and others. What all of these had in common was a determination to learn from the evidence of their own eyes, rather than following the orthodoxies they had been taught. One of the fathers of modern medical education was William Osler, who is perhaps best remembered for insisting that students learn from their patients, rather than from lectures, books or instructors.

Lieberman’s book comes at the end of a grand experiment in which he has played a significant part. Unlike his colleague, Allen Frances, he doesn’t appear to have looked at the findings with very much thought or care. I have been researching a book as well. “Psychiatry Reconsidered: From Medical Treatment to Supportive Understanding” will be published in May. In essence it is an attempt to draw together the results of our fifty years’ experimental flirtation with medical psychiatry. This can be thought of as running from the introduction of psycho-pharmaceutical “treatments” in the 1950s, through the misappropriation of the term “diagnosis” by psychiatrists, and in particular by DSM and the growth of enthusiasm for randomised controlled trials of psychological therapy during the 1970s and 1980s, to our current state of knowledge. The findings are no different from the conclusions we (the UK Critical Psychiatry Network) articulated a couple of years ago and I repeated here in December 2012.

• There is no agreed and scientific understanding of how psychiatric medicines work … if and when they do.
• Claims of efficacy have to be tempered by respect for the idiosyncratic influences of expectancy and hope … what is clumsily referred to as “the placebo effect” is alive and kicking in every consultation.
• Repeated reviews stubbornly refuse to refute Rosenzweig’s 1936 Dodo Bird verdict: that it is common, non-specific features which make the greatest contribution to psychotherapy outcomes.

In other words, psychopharmacology is not a therapeutic science, and a good psychotherapy outcome is primarily the result of a healing relationship. What has been particularly interesting is that although these assertions were published in the British Journal of Psychiatry, which goes to most UK psychiatrists and a considerable number elsewhere on the planet, we have had barely a murmur of disagreement. When thoughtful people are invited to consider the evidence they find it hard to disagree with these conclusions, and I do hope Professor Lieberman has an opportunity to consider and reflect upon how we have come to them. If he is reading this and is interested I am sure my publishers will be happy to let him have a copy of Psychiatry Reconsidered as soon as it is available. I would welcome his comments, because my understanding of the evidence from our half century experimental flirtation with medical psychiatry appears to be different from his, and it would be helpful to discover whether or not he is among “heroes” who have acquired data that refutes our conclusions, or an institutional figure committed to defending a crumbling orthodoxy.

Whatever their other faults, politicians are good at waking up and smelling the coffee. It is what they do, and although Mr. Lamb might well have personal reasons for being critical of CAMHS he has undoubtedly picked up a resonant theme. 600 people attended a meeting in London on March 11th which was, effectively, a lobby encouraging the introduction of Peer-Supported Open Dialogue into NHS mental health services … and it provided another opportunity for a senior politician; Luciana Berger, Shadow Minister of State for Health. Open Dialogue is another story for another time, but that coffee smells good and if mainstream psychiatry can’t smell it, then it isn’t going to be mainstream for much longer.