Psychiatry is not neurology; it is not a medicine of the brain. Although mental health problems undoubtedly have a biological dimension, in their very nature they reach beyond the brain to involve social, cultural and psychological dimensions. These cannot always be grasped through the epistemology of biomedicine. The mental life of humans is discursive in nature.
Wow. I want to get in contact with a psychiatrist in the Pittsburgh area who believes and practices their profession consistent with this position. The article from which I took the opening quote, “Psychiatry beyond the current paradigm,” is reminiscent of Thomas Szasz, who presented his argument that mental illness was a myth in his seminal book, The Myth of Mental Illness. His original article of the same title, “The Myth of Mental Illness,” is available on the website, Classics in the History of Psychology.
Szasz said that the notion of mental illness assumed that there was some neurological defect, “perhaps a very subtle one,” behind all disorders of thinking and behavior. “The crux of the matter is that a disease of the brain, analogous to a disease of the skin or bone, is a neurological defect, and not a problem in living.” Pat Bracken et al., who wrote “Psychiatry beyond the current paradigm” for The British Journal of Psychiatry, were more nuanced. They acknowledged the undoubted biological dimension in mental health problems, but also admitted the reality of other dimensions beyond the grasp of “the epistemology of biomedicine.” They believe the biomedical dimension should be a secondary—not the primary—consideration in psychiatry.
A “biomedical idiom” has guided psychiatry’s understanding of mental health problems. Problems with feelings, thoughts, and behaviors were thought to be capable of exploration and understanding just like our livers and lungs. The scientific tools and methods used to investigate problems with biological life would help unlock the secrets of mental life. In recent decades, even models of cognitive psychology have been developed to work within this “technological paradigm.” Its main assumptions made are:
- The problem to be addressed is that of a faulty mechanism in the individual.
- The mechanism or process can be modeled in causal terms; it can be described in a universal way that works regardless of the context.
- Technological interventions are instrumental.
In the technological paradigm, mental health problems can be mapped and categorized with the same causal logic used in the rest of medicine, and our interventions can be understood as a series of discrete treatments targeted at specific syndromes or symptoms. Relationships, meanings, values, cultural beliefs and practices are not ignored but become secondary in importance. This order of priorities is reflected in our understanding of the training needs of future psychiatrists, what gets published in journals, what topics are selected for analysis at conferences, [and] the types of research that are promoted.
Bracken et al. said the overall evidence did not support the idea that mental health problems were best understood through this technical paradigm. While medical knowledge was relevant, “the problems we grapple with cry out for a more nuanced form of medical understanding and practice.” Psychiatrists need to develop an approach to mental health problems that is genuinely sensitive to the interplay of forces (biological, psychological, social and cultural) that underlie them.
Pat Bracken said in a lecture he gave at the University of Copenhagen in 2012, that: “The realm of mental health is one area of human life that cannot be grasped in a purely technical way.” He argued that psychiatry is very much a product of the cultural shift brought on by the Enlightenment. Without the Enlightenment, Bracken believes we would not have the discipline of psychiatry as it exists today. The attention to unreason, came as a byproduct of the Enlightenment emphasis on rationality or reason. It also gave rise to the isolation and confinement of the “mentally ill.”
As a result, they became the subject matter for the new discipline to study, theorize and treat. There could now be a “science” of madness and distress, with its own experts and authorities. The new medical specialty sought to frame all its problems within a modernist, scientific and technical idiom. This grew to become the technological paradigm of psychiatry. Now it’s the dominant paradigm of psychiatry and mental health. “It underscores not just the medical model in psychiatry, but many of the alternatives being argued for at present.”
This technological approach is the foundation of the medical model of psychiatric “disease,” some of the psychological approaches to mental health, and positivist forms of social science. The only questions asked by this approach are: does it work; is it efficient; and is it cost effective. The technological paradigm shapes the classification systems of mental health problems (the DSM-5 and the ICD-10), the research into mental health problems, and the delivery system of clinical care. This is particularly true in the concept of “evidence-based medicine,” which has become the standard for many aspects of clinical care. Looking for a specific technical “fix” for a condition pushes the less technical issues to the periphery. They are still acknowledged, but are seen as secondary issues or causes.
In an article published in the journal World Psychiatry, Bracken detailed how psychiatry is currently going through a crisis of confidence. He argued the need for a hermeneutical shift in psychiatry. And if it is to be truly “evidence-based,” psychiatry needs to radically rethink its guiding epistemology, namely that of the technological paradigm. “We need a radical rethinking of our guiding epistemology: a move from reductionism to hermeneutics.” He rejected the heralded Research Domain Criteria (RDoC) project (see “Psychiatry Has No Clothes;” or “Psychiatry’s Mythical Phoenix;” or “The Quest for the Holy Grail of Psychiatry”) as a “quintessentially technological view of the future” that conceptualizes mental illnesses as brain disorders. He believes such an approach is simply inadequate.
Good psychiatry, he contends, involves a “primary focus on meanings, values and relationships,” both in terms of how patients are helped and where their problems come from. When the word “mental” is put in front of the word “illness,” it demarks “a territory of human suffering that has issues of meaning at its core. This simply demands an interpretive [hermeneutical] response.”
I do not believe that we will ever be able to explain the meaningful world of human thought, emotion and behaviour reductively, using the “tools of clinical neuroscience”. This world is simply not located inside the brain. Neuroscience offers us powerful insights, but it will never be able to GROUND a psychiatry that is focused on interpretation and meaning. Indeed, it is clear that there is a major hermeneutic dimension to neuroscience itself. A mature psychiatry will embrace neuroscience but it will also accept that “the neurobiological project in psychiatry finds its limit in the simple and often repeated fact: mental disorders are problems of persons, not of brains. Mental disorders are not problems of brains in labs, but of human beings in time, space, culture, and history.”
Pat Bracken has an intriguing background. Not only is he a clinical psychiatrist, he also has a Ph.D. in philosophy. His thoughts can be found in various places online. Here is a link for “Bracken” on Mad in America. He helped found the UK division of the International Critical Psychiatry Network (ICPN). He’s co-written Postpsychiatry: A New Direction for Mental Health. Currently he is the Clinical Director of the Mental Health Service in West Cork, Ireland. Sadly he lives too far away to consult on cases in the Pittsburgh area.