For the past few years, I’ve been trying to put words on my multiple dissatisfactions with mainstream psychiatry and its shameful lack of rigour, compassion, reflection and ethical practice: hence my enjoyment of Bonnie Burstow’s percussive, hard-hitting MIA article in September. (I have not read her new book, and am almost afraid to do so, since it may well make irrelevant the final draft of my own critical monograph on psychiatry!)
It struck me recently that many of those who really pushed the boundaries here were people who came from outside the field of psychiatry, like Richard Bentall, Bonnie Burstow, David Cohen, Peter Gotzsche, Iona Heath, James Hillman, John Read, David Smail, Bob Whitaker and Irvin Yalom; or some other remarkable people within psychiatry, like Pat Bracken, Ben Goldacre, David Healy, Jo Moncrieff, Phil Thomas and R.D. Laing, who all had significant expertise in other domains, like psychology, philosophy, anthropology and Classics.
I believe that if psychiatry is to survive it needs to become a rigorously self-critical profession, widen its horizons and bring together insights from French post-structuralist theory, from anthropology, philosophy, psychology, sociology and literature. It needs to elaborate a therapeutic credo that transcends the confines of the Western Ego, dispenses with traditional diagnoses, and focusses on key affective territories in so-called disorders like depression, BPD and PTSD. I should point out here that I employ terms like BPD, depression and PTSD because they are still so widely used, even by relatively enlightened researchers and practitioners. I do not consider them as states or diseases, but as disabling strategies for dealing with deep psychic pain, especially trauma, loss and mourning: my opposition to diagnosis, and all the trappings of the biomedical model, is absolute.
I believe, also, that music should be brought into the picture here, in the wake of Novalis’s pithy remark that illness is a musical problem so music must therefore be part of any solution. I think it might be well worth while trying to develop this idea and see where it might take psychiatry, drawing on the work of Colwyn Trevarthen, Oliver Sacks and the neuroscientists. A musical approach to therapy might help resuscitate a dying profession, making it more sensitive, soulful and compassionate.
Modern culture is highly dissociative, so I suggest that meditation and mindfulness training could fruitfully be built into psychiatric and therapeutic practice. This might prove to be especially important in work with so-called personality disorders and PTSD where patients often need help with fully experiencing the present moment in all its depth, freshness and novelty. (The trauma work of van der Kolk and Rothschild are my gold standards here.) In tandem with the memory reconsolidation work of Phelps et al., such a practice could prepare the ground for a quantum leap beyond early trauma and knee-jerk autonomic hyper-arousal which imprison victims in past images, visceral reactions and beliefs, destroying themselves and all those unfortunate enough to become trapped in their relational orbit.
Sophocles wrote: “For mortals, greatly to live is greatly to suffer.” This is fundamental to the tragic vision of the Ancient Greeks who knew just how important for the psyche was the journey into the depths of suffering and darkness. (See Parmenides’ great poem and Peter Kingsley’s brilliant exploration of it in his book on the “Dark Places of Wisdom”.) Sophocles’ line is not, of course, a call to self-flagellation before breakfast, but a bracing reminder that when suffering arrives we should let it inhabit us fully, make use of it and mine it for its potential gifts. Psychotropic medication shoots this messenger on sight, no questions asked.
In more recent times, Paul Brand wrote that because his leprosy patients very often reported a complete lack of any sense of bodily integrity, what he’d most like to give them is the gift of pain, insisting on the vital importance of a vibrant pain system for physical health, survival and a sense of being whole. For him, this is a necessary condition for achieving wholeness; without it we become dissociated, fragmented, less real. (It’s more than interesting that the words “whole,” “hale,” and “health” are cognate.) I think his reflections open up very important vistas for the treatment of psychic pain, as the relational cost of psychological dissociation is so crippling: to rewrite Dante’s warning at the gates of Hell, “Abandon hope, love and sanity all ye who dissociate from your pain.”
I believe that if psychiatry has any future it needs to attend fully to an individual patient’s story, breathing and body language, within an Attachment Theory perspective. It needs to take narrative medicine seriously, paying special attention to the detailed images, patterns and nuances of a patient’s often fragmented, enigmatic, even embryonic life-narrative, which must remain sovereign, and to which every diagnosis must remain subordinate: this is an approach that seems to me more “soulful”, subtle, complex and useful than Lucy Johnstone’s practice of formulation.
Physical and psychological suffering may be traced to fear, often terror, and to the varied maladaptive modalities, especially dissociation, that we use to deal with abuse, pain, loss, betrayal, separation, non-validation, abandonment and loss of love. A focus on individual narrative, on the specificity of maladaptive, regressive, creative or liberating modalities, combined with mindfulness training, a meditative practice and certain arts/body therapies would help psychiatrists to reframe the story of their patients’ lives, get in touch with what they really want, who they really are, and who they are called to be.
But here’s the rub. Here lies the hare, as the French so piquantly say. Finding a new, more enabling story and becoming more deeply aware of the obstacles that bar access to a life worth living may not be enough to overcome the elephant lurking in the shadows that biomedical psychiatry dares not look at: the external conditions over which a person may have little control. The druggy doxa fuelling the biomedical model of psychiatry blatantly side-steps the socio-political infrastructure by locating the problem IN the isolated individual and proposing medical solutions to socio-economic or existential problems. However, psychiatry is not the sole profession in the dock here: lest we become too complacent about our own preferred therapeutic practices and model(s), we should all bear in mind the fragility of any therapy which treats mental distress as a problem located solely within the monad: fundamental, even revolutionary changes in how our society is organized may be required to give any therapy the best chance of helping patients to lead a life worth living, and furnish an environment in which their children’s primary needs are met.
We all need, then, to be aware, with Bonnie Burstow, Karen Horney and David Smail, of the extent to which the socio-economic context sets harsh limits to the alleviation of psychological pain. In other words, we must all interrogate every individual therapy, asking if it confronts the real infrastructural context which so often renders humans helpless and, ideally, SHOULD generate depression as a perfectly appropriate, non-dissociative response to, say, homelessness or other unbearable living conditions. And, further, we might fruitfully consider the proposition that we may be asking the “mentally ill” to carry disavowed double binds, cultural contradictions and toxic social conditions that make life unliveable for many people, but in which we are all complicit. Should we not now start foregrounding the crucial importance of community, interrogating the politics subtending all therapies and looking to more radical social treatments as opposed to, or in addition to, individualized ones?
I’d like to suggest that the various horrors being perpetrated by modern psychiatry have their roots in a desperate attempt to survive at all costs. People eat or kill their friends and neighbours when survival is at stake. And recent surveys clearly show that very few turkeys now vote for Christmas, unless they are terminally ill or weary of life here-below. Psychiatrists are unlikely to vote themselves out of existence either, so it needs myriad Bonnie Burstows to help them on their way.
The wider cultural druggy doxa, rampant neo-liberalism and psychiatrists’ technical, pharmacological training enable, indeed encourage “research” like Study 329 and widespread academic corruption, so perhaps my Utopian hopes might be realized only in a brave new world where both individual blossoming and community support really matter. If some of my suggestions here were taken on board by psychiatry they might, just might, enrich, rejuvenate and possibly save its bacon, IF, AND ONLY IF psychiatric training and society itself were completely revolutionized. There are many economic and cultural forces working against my little Utopian fantasy, but what’s really at stake here is a wider, deeper vision of what a person is, what healing is all about, and what sort of world we want to fashion.
To conclude, I wonder why more ink is not spilt on debating this question: Is psychiatry a science? Or an art? Or both? For most of its critics, psychiatry is merely pseudo-science, but its hubristic scientific pretensions have not only castrated itself, impoverished the “discipline” – but, more tragically, have killed innocent patients beyond number. Only if psychiatry enlists the humanities might it once again become what it was under Hippocrates, and avoid becoming irrelevant. Or extinct.