The Short History of Psychiatry

The theory and practice of psychiatry has already been many things to many people, and let us not forget that debating the differences between notions of brain and mind is something philosophers have done for millennia.  

Because of this, our new-age friend in psychiatry might need some help if it's to keep up with the sheer weight of information that it needs to compute.  Of course, separating psychiatry as a discipline with some sort of life of its own from living psychiatrists who practice their trade, is a deliberate misnomer, or an artificial separation that we will just have to use for now.


The discipline or general study of psychiatry raises seemingly impossible questions of boundaries in knowledge as it's held to be now and as it's remade each day.  A simple idea of psychiatry as medical biology with a specialism in neurology (the human nervous system to you and I) would grossly simplify the work that existing psychiatrists do now and put pressure on their craft to live up to potentially impossible future goals such as linking internal human biology with external events as they unfold.

These events, no matter how personal or how general in scope, will occur sometimes in new ways unknown to both observer and observed, or historical participant and.. historical participant. 

The Royal College of Psychiatrists have produced a short introductory video which contains the phrase that psychiatry crosses both science and art.  'It' does more than this to most of the rest of us - 'it' plays a critical role in the real lives of countless millions amongst the living, the dead and the still to be born. 

From the academic British Journal of Psychiatry Andreas Marneros marked the passing of 200 years of formal use of the term 'psychiatry' in 2008, after Johann Christian Reil's considrered introduction of the new word aimed to draw in only the best physicians, who like he, were to have studied medicine.

The view commences formal discussion of the concept of 'mental illness' as the main domain of psychiatry, which for Reil was very different to other arguments rooted in philosophical psychology.  Where the recent author Marneros summarises, it's in saying that advances in biology, genetics and psychology are highly important.  Whether for us they can outweigh real world events in history, or as measured by sociology and explored by linguistics is not something we can conclude just yet.

The onset of psychiatry seems heavily linked with the establishment and development of institutions within which 'patients' can reside.  Not only were German universities a place where new doctors trained and educated but their role, as in other areas of the continent, was also in admitting people to asylums.

There are still of course historical debates surrounding the nature of the altered processes by which circumstances dramatically changed for most people as modernity took hold.  It seems also fair to say that the simultaneous developments (both elsewhere and in the UK) of the; American Civil War, French Revolution, industrial revolution and expansive quests overseas beyond mercantile venture, are hotly debated too.

When the 19th century dawned, records from 1801 indicate less than a thousand asylum inhabitants in Britain and France combined.  By 1900, this figure reaches over 100,000. 

We know that families and 'poorhouses' were able to care less and less for those who were deemed 'unwell'.  Asylums were often built away from centres of population and Rogers & Pilgrim note a move towards segregation between the able-bodied poor in workhouses and those unable to labour being put elsewhere.

The view of Michel Foucault from his seminal work 'Madness and Civilization' is along the lines of a challenge to conventional narrative tales of nineteenth century treatments liberating the 'mad' from brutal circumstance in previous times which  in turn was seen as being based on the ignorance of backward ages.  For Foucault, certain moral hyprocrises play a role, as he views the movement towards the modern era's confinement of people as congruent, or intimately linked with, the theoretical viewing of those confined subjects in a place where new generations of medical doctor begin to treat them as belonging.


Michel Foucault

For institutions to be the only place where therapy might occur is contextualised by the following quote from Madness and Civilization's preface:

 "The constitution of madness as mental illness... bears witness to a rupture in dialogue, gives the separation as already enacted, and expels from the memory all those imperfect worlds, of no fixed syntax, spoken falteringly, in which the exchange between madness and reason was carried out."

This is where psychiatry develops for Foucault, in the space left when perhaps what we may view as smaller communities of close communicative dependence are transformed. 

From the historical canon too, the view of Eric Hobsbawm in his work Industry and Empire,  sees old ways of life as being majorly transformed from the late eighteenth century onwards.  The stark differences between the majority who engage in pre-industrial labour based around peasant holdings (and perhaps craft workshops) and the new rigidly monotonous routines of factory, clock and wage- increasingly within cities, take hold.  

When previous ways of life are toppled, the quandry that  "pre-industrial experience, tradition, wisdom and morality provided no adequate guide for the kind of behaviour which a capitalist economy required"  is central to Hobsbawm's view, and of use to us here.  Where previously people may have viewed for themselves either the right to earn a living or be assisted within a community, the dictates of market practice and taking 'whatever one can get' raise new uncertainties in matters of life and death.

Simultaneoulsy as some would see it, mood-instabilities enter the psychiatric vocabulary as new conditions to be incorporated and to diagnose.  Joan Busfield notes in her work 'Men, Women and Madness', that the mid-nineteenth century is a form of golden era for psychiatry, with encroachment by neurology and the on-going establishement of three types of institution: private madhouses, voluntary or charitably run asylums and public asylums, providing real locations where practice could flourish.

When the twentieth century dawned, positivist approaches such as those of Emil Kraeplin are worth a mention.  Disease classification was important to him and this view is also said to have later influenced the 1980 Diagnostic and Statistical Manual III.  Kraeplin's view of genetic and biological problems also led into the theory and practice of eugenics, whereby the security of the German people or Volk was seen as being under threat from  "idiots, epileptics, psychopaths, criminals, prostitutes, and tramps who descend from alcoholic and syphilitc parents and who transfer their inferiority to their offspring."

Nazi commentators worried over the collapse of the whole social and moral system, and Hitler himself, spoke of the economic costs of illness as justification for mass sterilisation and extermination (not confined to Germany alone).

Notions of historical narrative also need to include the popularity of psychoanalysis for some time after Sigmund Freud's work and formulations in part sustained by a reaction against Nazi ideology after the second world war.  Despite this, the purely biological based views of those such as Kraeplin are said to dominate certain circles once more. 

Elsewhere, Joanna Moncrieff has informed us of the physical treatments used in asylums from around 1920 onwards.  Examples such as neurological syphillis and malarial treatments moved onto insulin coma treatment and electroconvulsive therapy after the 1930s. 

If ecclecticism is present in twentieth century psychiatry, psychiatrists own preference for physical treatments is cited by several commentators.  The development of powerful sedatives and stimulants as viewed just before 1950 give way for Moncrieff to the new views that the same substances are somehow able to pinpoint and treat exact causes of assorted malaise in what she refers to as a 'disease centred' model.  Her view is that a 'drug centred' model is more accurate to proceed from.

Knowing that the medications are drugs and knowing about the effects seem very sound principles to incorporate.  Of the main school of thought which adopts this view the 1960s current of 'anti-psychiatry' has been described by current Exeter Ph-D candidate Sarah Smith (paper available by request) as:

"A radical view of psychiatry [that] might be described as a movement which challenges conventional modern approaches to defining 'mental illness', the role of  psychiatric staff in treatment, and traditional ideas about the most appropriate site for psychaitric intervention, opposing the methods of coercion and compulsory hosptial treatment of traditional psychiatry." 

Looking at thinkers such as Gregory Bateson and R D Laing, Smith points out the relative merits of both, raising Bateson's emphasis on the symmetry that should be aimed for between sufferer and psychiatrist.  With double-binds of contradictory interactions leaving no room for any suitable response, family and micro-sociologcial circumstance are acknowledged as vital.

And of Glaswegian R D Laing, his view is that remaining 'normal' is a less healthy and human response to certain life circumstances than behaving in ways that may attract a dianosis of mental 'illness'.  His exampe of schizophrenia located the concept, as opposed to Kraeplin, in wider notions of society and not in individuals.  The unity of mind and body is raised in a discussion of his existential approach. 

Treating just a brain or mind could also give way to an acknowledgment of alternative sites for treating the distressed.  Theraputic communities such as those founded by Laing do still exist in various forms, whereby conflict can be explored through co-presence with others.  Details of one such current example is found here: http://www.philadelphia-association.org.uk/ with other prior examples cited by Sarah Smith as follows: Kingsley Hall, Archway and The Arbours Association.

In a very recent paper 'Psychiatry Beyond the Current Paradigm' in the British Journal of Psychiatry, the various authors concur that relationships, meanings and values are seen as subervient or secondary within the current technological way of viewing things by the mainstream discipline of psychiatry.

The (positivist) technological view that the brain is the same as other organs is challenged, just as the view that the medicalisation of everyday life links in with the expansion of markets for psychotropics is mentioned too.  Where a new paradigm may emerge they say, will involve amongst other things greater engagement with the real experts of the 'service-user' movment.  Where cultural diversity is viewed as important, the non-Western lived examples of other routes to recovery are included. So too is a statement that psychiatry is not and should-not be just neurology, which may ignore social, cultural and psychological dimensions.

A closing quote from them surmises that "All forms of suffering involve layers of personal history, embedded in a nexus of meaningful relationships that are, in turn, embedded in cultural and political systems."

For what it's worth, Bracken et al in their 'new-paradigm' approach stop slightly short of what might also have been useful, an explicit broadening of psychiatry's location in the larger historical scheme of things.  Where useful non-western examples were cited, we could pick up on the theme by mentioning a recent BBC news article on Chad's only psychiatrist, Dr Egip Bolsane.

A view from Chad is that mental health issues are not talked about much and the concept of demonic posession, for better or worse, is said to prevail.  Where war, civil war, rebellion and coup alongside torture, imprisonment and employment of child soldiers are common; schizophrenia and other conditions are described as having quite frequent rates of occurence. 

It's more than likely that the major flaws in this brief initial contextualisation of psychiatry are the omission of a prior inclusion of gendered differences and those which stem from past views of race: as both are viewed by some as being still firmly embedded within the reproduction of social relations in general terms and will be present at each level of psychiatry; as discipline and practice.

By way of introduction to just some of the themes contained in psychiatry over the years, this post has been quite descriptive in nature.  It may be possible to extend some of the themes in the following post's dicussion of the social and medical models for distress or 'illness'.  That psychiatry is touching on something which is of real importance seems without question to all.  Whether the forms of what they see each day can still be explained more fully from outside their discipline, rather than from within, is an open question. 

Acknowledging inside matters

 

It is very hard to distantiate oneself from the process of being all about an obsession with mental health.  Dualisms aside, the totality of mental and physical wellbeing are but one of the things that people must acknowledge.  From an individual and independent point of view, there are many ways in which the partly fictitious realm of community shown by the graphic above is right now of great importance.

For the process of distantiation in general to be seen as part of a social world, keeping loosely defined inner-things at certain distances away from a 'self' is common practice for adherents to both dominant genders.  The gaps in what one person acknowledges to be their own psyche's (literally: psychic) territory will, it seems, always be traversed by multifarious others. 

In other words, some things a modern individual internalises for periods of time - long or short; other things a person outwardly rejects at every opportunity.

The energy transfers involved in this little model may well be documented in modern psychological circles; so too, there may be common currents that observers such as Joanna Moncrieff sees in the UK and US.  In a video discussion of her 'Myth of the Chemical Cure: The Politics of Psychiatric Drug Treatment'  one conclusion is that the inexorable rise in prison population and prescriptions for psychoactive medicines (measures taken against the various non-compliant individual) does, move hand in hand through debt-fuelled consumerism to make a clear pejorative statement that some people have inexcusable, internal problems.

The notion of a clear separation between internal and external in pure and unadulterated form may well serve some psychological purpose.  In pre-modern history, smaller, sometimes face-to-face communities it is said, lived based on personal dependence on one another, often for their very survival.  In modern times: one person's problem is squished through uneasy categorical and conceptual gymnastic exercise on the terrain of single-minded cognition until such time as the common body of the developed political nation-state sees that it must intervene.

To draw on recent historical examples of how something that starts inside people's heads can translate slowly but surely to reach many minds and become an external referent, might we listen to some music?  An original folk song may or may not find many musicians to retell it's melody, perhaps overlaid with porous verbal utterances?  One that plays in the background now is a professional US musician's re-telling of the possibly seventeenth century 'House of the Rising Sun'. 

To move that to the foreground other people in several places have begun to compare their ideas of race, sex and mental health in terms of simple parallels in anti-discrimination.  Moving carefully to say that open challenges to discrimination are in part legally protected in places such as the UK, might we know more of the links between these areas some day?

Representation in prisons, mental health units and so on, are not seen at a current uniforn rate, and the tortured tales that need telling must weave inner and outer tensions over the long and short time period, very intricately indeed. 

Using fairly simple terms, highly negative external referents surrounding and enveloping any given individual could then become part of them as a socio-biological organism.  Sartre's famous phrase that we are "condemned to be free" has raised sometimes gloomy arguments philosophically revolving around 'existence and essence', but is a useful phrase for me to briefly retell the age-old bemoanment of anomie and inner anger and to challenge these very sentiments at the same time from within. 

By way of echo, the recently deceased political philosopher Marshall Berman drew illuminations which include the following from the end of the book 'All That is Solid Melts Into Air'.

"To be modern, ... is to experience personal and social life as a maelstrom, to find one's world and oneself in perpetual disintegration and renewal, trouble and anguish, ambiguity and contradiction: to be part of a universe in which all that is solid melts into air.   To be a modernist is to make oneself somehow at home in the maelstrom, to make its rhythms one’s own, to move within its currents in search of the forms of reality, of beauty, of freedom, of justice, that its fervid and perilous flow allows."

When modern trouble and anguish take so deep a root as to bring a modern citizen into contact with a psychiatrist, it could be said that the situation is incredibly serious, and potentially grave.  Even Joanna Moncrieff, although painstakingly clear that psychoactive drugs do not provide magical cures to mis-perceived underlying chemical imbalances, does admit that there are 'some circumstances in which some drugs are useful'.

That concession is important, just as one would hope to find individual psychiatric practitioners on the front line willing to compromise with those whom they see before them.  One size never fits all, neither in philosophy, medicine nor a clothing retail outlet.   

Prominent American Allen Frances (of DSM IV fame), now wants to say the following:

"The evidence is compelling that we in the developed countries (especially the US) are overtesting for disease, overdiagnosing it, and overtreating. Wasteful medical care of milder or nonexistent problems does more harm than good to the individual patient, diverts scarce medical resources away from those who really need them, and is an unsustainable drain on the economy."

Thus, by way of statement alone, I must raise here the issue of the level to which it is beneficial to challenge dominant power structures?  Just because the medical model of psychiatry dominates in practice despite what many of us believe to be very unstable theoretical underpinnings, this does not mean that everything psychiatry or psychatrists say (or do) is false or wrong. 

Where complex currents take hold, having a 'diagnosis' as part of an intrinsic sense of self-worth can mean that (issues of medication aside) negative values are internalised.  However, being distressed ad infinitum or completing suicide in some circumstances, is argued to be worse.

To stand back from a potential melee may be all that we can achieve on this one- and just as a critique of psychiatry might help some to make their own minds up on their life journeys, a corresponding overstatement of clarity that all that has gone before and that goes on elsewhere is 'bad', may be just as unhelpful for any reasonable definition of the centre ground.

Like Marshall Berman, who saw in modernity something just as Marx did, which is entirely contradictory at its base, there may be some lives which by past standards slip through the measuring devices of how things were supposed to be.  Now, the proportion of the generation referred to as 'NEET' in the UK (not in employment, education or training) when they reach maturity with no concern for work references or housing ladders, will be a fascinating if potentially explosive development to witness. 

Whether internally or externally, perhaps the interplay of interpersonal constants and historical drive might find orchestrated voices are too rampant to ignore?  And finally, when known shouts from within and strong sentiments trapped inside for years break free to rejoin the fast flow of united existence, terrors of the past befitting of recurrent exposition elsewhere, will need to be understood, in full.  

The need for a large campaign

For a simple mind like my own, the ‘stigma’ thing that we have been wondering about lately can reside in only two places.  Crude models are all aspiring social scientists have sometimes so, here goes nothing.  Alterity can work only from the basis of a particular subject’s on-going self-perception against the other, which resides somewhere in the area of general understanding.  If you want to talk to children about this then perhaps individual and society are both useful abstract metaphors that we can all employ. 

To start like this, with grand pronouncements, is fairly usual when you want to try and pretend that your own perspective outweighs that of other people’s who you want to engage with.  It would be false though, to presume that a recent article I have read is not well informed, passionate, powerful and inspired, but may I also say overtly muscular and angry? 

Neither of these last two traits can be met with disapproval, for the potential in the would-be discussion is far too great for quarrel to dominate just now.  The article I am referring to is by Flo Bellamy and is available for perusal here.  With luck, a nuanced appreciation by way of an open letter that discusses some of the themes she raises might lead (more than two of us) onto something of deadly seriousness and urgent importance to a significant populace, the sort of populace that no statistical survey will ever capture or define.

If we start to talk about what’s important to you in your article ‘Time to Change- Why the UK’s largest stigma busting campaign increases stigma’ then it's because I acknowledge immediately the incredibly firm sense of value embodied in your choice of subject matter.  I concur, for whatever it’s worth, that the ‘time to change’ debate, for want of a better phrase, really does need some more vocal responses: be they admonishments or be they from those caught in the act of applause.  If cynicism teaches you anything, it’s the value of any publicity for loosely branded enterprise.

Let us start with your useful pointing-out that the Time to Change campaign (from here TtoC) is funded to the tune of £21 million pounds.  If we accept this as a figure then the UK population of over 63 million has little over 30 pence a head to be persuaded that their attitudes towards we 'crazy-folk' are deplorable and, that they should be ashamed of themselves.  The cost of a second class mail-shot for all households might be negotiable just within budget from some sort of warehouse with as few administrative staff as possible.

The point is not to mock, the point is that greater sums of money change hands at lottery terminals each week and I need to claim that firstly; that is not a large amount of money given the scale of the task and secondly, there is a misnomer of sorts in your appropriation of the campaign.  Do you really undervalue the plight of many millions of people within economic times where billions are common currency?

If we try to think of other similar movements to change those much vaunted ‘hearts and minds’, (for changing minds alone is an impossibility in my view) then do we have some suggestions for comparison between us?  Firstly, I might start with Jehovah’s witnesses and begin to run short of others when I mention extreme or less extreme political parties?  Perhaps a really controversial although slightly different example from macho-sport would be the ‘Kick it Out’ anti-racism campaign, which has both supporters and detractors.

The point for me is that the somehow mental terrain we’re on is a total-bastard mix of psychosocial and historical factors; or civil society in other words.  If, to explain my own view, I were to say that the two main competing explanations for the dynamics inherent in the formation of civil society still stem from GWF Hegel (1770-1831) and a certain K Marx (1818-1883) then perhaps I could also summarise as follows.

For Hegel, civil society embodies or actualises the moment at which tensions between competing forces say, are able to be resolved in eventual essence at the level of the state.  One might have less faith in the UK government than a German philosopher had in the final realisation of historical truth and absolute knowledge in general terms, and that is understandable.  Where Marx turns things on their head in theory, for better or worse, is by pointing to the contradictory nature of a civil society which frees the constituent elements of what would have been ‘spirit’ for Hegel and atomises individuated concerns irresolvably in what is referred to as the state/civil society complex.  For freedom and truth to be pregnant with their opposites of wage-slavery and false-consciousness might be going too far: but the importance of acknowledging the arena within which TtoC gains funding and operates cannot be understated.

On the first page of Flo Bellamy’s article the statistical claim is made that TtoC has hardened attitudes to a very difficult to define target group,  those of us in serious mental distress.  On statistical method, there are but three types (as the American author Mark Twain well knew when attributing the famous dictum to Benjamin Disraeli).  With no disrespect intended, we must start by acknowledging that he suggested three types of lie,  “There are lies, damned lies, and statistics.”  Similarly, if your later objection to the language and categorisation of vague biological illness devoid of personal content is to hold, we can’t use tickbox exercises using these very sick categories to work out what people think of ‘us’.

Although very serious, the more pertinent point here is that attitudes, even if recorded very near-perfectly and at crystallised moments of opinionated certainty- are subject to change in the manner of ebb and flow.  It is almost not worth saying that there are such things as general opinions, or general consensi which can be measured in numbers and that aren’t more accurately characterised in this example as smaller pockets of thought which are endlessly debatable.  Anyway, perhaps we can beg to differ on method as far as ‘stats’ go?

An observation to progress through is that Flo Bellamy has a very high opinion of the one campaign known as TtoC.  It almost seems like they are charged with ending distress for all within four short years.

We will need though, to discuss the ‘illness’ issue without further ado.  I can find areas for major consensus within the following  “The problem is not a biological illness, lying dormant somewhere in a genetic code in some poor unsuspecting random individual, the problem is that life can be really hard.”  The claim is extended, and rightly so in my view, that greater levels of social justice are needed.

Where the discussion might benefit however, is by using the comparative example of borders in the language of ‘illness’ and in the bases for common causes that would benefit all of us who have known forms of lived experience and severe distress, without discriminating against folk without a diagnosis.  It's a really complex area, but as I have tried to put across elsewhere and as you have stated in your article, starting lots of conversations in public places with something intelligible and of immediate benefit might be one of those things you just have to let slide for the time being.

While you may find my argument weak, the muddle of legal and general-linguistic concepts is probably something that can only be worked out by large scale mobilisation of individual participants who are open and incredibly forthright about their troubled histories (in as much as they have the time to explain on popular media channels) and which brings us to the point where critique is possible.  In other words, this is a practical question.  Therefore, one must pitch in and help, whilst being as careful as possible to walk the tightrope associated with volunteering for the campaign without falling off in disillusionment or feeling the need to become another willing martyr.

I do believe that there are very many helpful things that your article contributes, and of course perhaps we could both agree that it’s not just about TtoC.  The borders example spans day-to-day language, notions of academic discipline, aswell as political-geographical remits such as nation-states.  Is this really just a UK issue?  Is this even just a mental health issue?

With diagnoses that people have in common in mind, the move towards acknowledging what happened to a person, and of listening to us all unpack our stories as we aim to move forward is something really positive that your article contains.  Similarly, when you say to TtoC  “Help create a world where people don’t bully, don’t abuse, don’t discriminate, don’t place so much importance on career and hierarchy.”  are we really speaking of just one campaign?

By any other name; a move to harmonise the interests within a state in favour of ensuring that all people can work at least part-time if they wish, and no more than an inhumane number of hours if they don’t wish (or are not always able) - would in the context of our debate be a national-level-socialist-movement.  That is not an argument I would shirk, but the extensions to your view do need to be made explicit. 

The relationships between people, or social relations, predate and will outlive TtoC.  Where the history of concepts such as extreme distress and its occasional behavioural manifestation is concerned, we’re right to be clear that we’re well known to be less violent than most (sadly except where self-harm is concerned).  

At the current juncture, the people who put the campaign together and who work enormously hard to try and affect some sort of change, although not all-powerful, I believe have in fact raised the profile of struggle in general and have given a lifeline to many individuals to speak out for themselves and be in a better position to promote their interests after the campaign.  The networks in place and positive affects can’t be judged yet without damaging what is being done.

Very little ever changes overnight, but with the value of discussion based on experience I could tell you all about my roller-coaster ride with TtoC and how the highs and lows are nothing intrinsic or due to any sort of poor strategy or planning, more to do with the scale of what we are all up against, pre-distressed or not. 

I won’t take for granted that anyone has read this far, but just as you say there is a need to promote conversation based on truer categories than psychiatric diagnosis then perhaps we are saying that either TtoC or a new campaign will need to take a major stand on the availability of talking ‘therapy’; talking spaces, alternative ‘therapy’; alterative spaces.. then even that would be open to the major wave of criticism that an advance to new shores enables.  It seems, that when a fresh field is discovered for cultivation, the plough used to loosen the soil of contemplative thought soon gives way to the scythe used to slice through the green shoots of new growth.

If we really were a singular entity as mental health condition managers, or service-engagers, in the most polite way, we would soon be found out as fraudulent if we said that people can only be called ‘ill’ when accused of a crime, when in need of benefits, or when having trouble at work.  I would firmly maintain that the needs of many people are served by TtoC and whole-heartedly disagree with your main contention that the net result of the campaign, within its historical parameters, is negative rather than positive.

Whilst such a bold statement may be open to rebuke, where we may all need to look is in the direction of the sometimes gentle, sometimes bloodied, interplay of individual experiences with larger systems of culture.  The literary critic Raymond Williams, once uttered the refrain that ‘culture is synonymous with meaning’ and although the subjective meaning of the simple word ‘illness’ might be a badge of shame for one, the cultural construction of a common cause could alter human biology in ways that will only be retrospectively understood.

For individual minds to be overwhelmed in large proportion by societal misdemeanours might say more of the type of future campaigns that we should all be interested in forging from nothing, and living through despite everything.  With the exception of the drive to improve the wellbeing of those of us who persevere through almost unliveable anguish as part of a normal day, perhaps it’s not really about a campaign such as ‘Time to Change’, perhaps it really is time to change, everything, in, existence.

Moving on from stigma

Pausing on the concept of stigma to try and build upon ways of knowing about what we need to know, it is worth acknowledging the breadth of approaches beyond any simple or false dichotomy of the world owned by mainstream psychiatry versus it’s anterior and posterior oppositions.  In other words, although we know that even within psychiatric circles there is incredible disagreement there have also been formal currents since the 1960s such as: anti-psychiatry, alternative psychiatry and critical psychiatry.  In fairly recent times, and as noted elsewhere, the Royal College of Psychiatrists have even spent considerable time and effort on various media campaigns aimed at combating stigma.  

A fixed or determinate definition of stigma that people as individuals face might mislead any multi-faceted enquiry more than it assists, as if somehow the thing to be explained was more important than the on-going act of explanation of this, and other (observable) phenomena alongside other things we think to be real but cannot depict in words.  If you want to know more about enquiries into the theme of stigma then Erving Goffman’s 1963 work is widely renowned, referred to, discussed and available.

The history though, of attempts to understand what appears now as another spectre looming over the known human world, commences prior to this I believe; but let's start with the simple contention from chapter 2 of Rogers & Pilgrim’s ‘Sociology of Mental Health and Illness’ that from the 17^th century, largely European notions of other-worldly demons are used gradually less and less to explain and account for mental turmoil.  Where medical explanations arise, Foucault’s ‘possibility’ of psychiatry can be inserted, and as we reach the 19^th century Rogers & Pilgrim note that

“The early days of psychiatry in the 19^th century were heavily influenced by eugenic considerations- [and] it was assumed that a variety of deviant conducts could be explained by a tainted gene pool in the lower social classes.”

Class may be beyond our remit for this post, but needless to say that all actions do have a social context just as various factors in diagnostics in turn feed into living statistics and are almost impossible to remove from the historical process by an observer.  Jean-Paul Sartre is one individual whose existential inclination is said to try and look at the connections of socio-economic structures with the inner lives of individuals. 

And of his ilk?  Please do be aware of the critical theory embodied in the 20^th century Frankfurt School of Max Horkheimer, Herbert Marcuse, Theodor Adorno, Walter Benjamin and so on; in as much as their materialist Marxian-Freudian enquiries can help us.

To come at things from the perspective of an individual is difficult.  The synthesis of materialism and idealism is elusive in the real world just as in all of our small but ever expansive minds.  When it comes down to disagreements over the connections between individual words, such as illness, in relation to what we can detect and what we know too; then perhaps a step back is needed. 

My take on the theme is that the hypothetical spectrum from wellbeing to illness, if seen as a continuum, raises the question of at what point the balance is tipped towards illness?  The continuum may be a helpful way of viewing things, but the spectrum that ends in ‘illness’ may raise objections from many.  Psychoanalysts perhaps, may be amongst those who adhere to the view that we are all neurotic to the extent that may make us ‘ill’ someday, or some days- or neurotic some days at least.

In a token defence of the continuum model above, perhaps we need to point not just to the medical model but to the legal status of certain loose definitions of insanity in order to say, that with the best of intentions, we could temporarily conclude that nobody is ever ‘ill’.  The late Thomas Szasz, most famous for his ‘Myth of Mental Illness’ (1960), went to great lengths to challenge the 'illness' model.  

It does seem that in many circumstances his message can be accepted.  But think then, of the terms ‘not very well’, or ‘poorly’ and ask if these are any better for a person with visible signs of unknown malaise?  Terminological substitution is all that happens in some circles.. Not to mention the hermenutical extensions of known physical ailments being definitionally non-existent by the same logic that Szasz applies.

The previous point about legal status is relevant because if both a psychiatrist, or series of psychiatrists, in conjunction with various legal agencies such as healthcare assessors (for state benefit purposes) or perhaps employment tribunals or even courts of law, deem a person to be ‘ill’ and we deem them be ‘not ill’ then there is a problem.  Although a dialectical model of logic can say that they are perhaps both ‘ill and not ill’ the real world may have trouble keeping up. 

One cannot both reside in prison and be geographically free to roam, or work full time and volunteer full time simultaneously- unless of course we extend this example to ridiculous lengths.  Similarly, one cannot both be sacked and quit, although compromises could be sought.

It would seem reasonable to surmise briefly that we are very much on structural terrain which is non un-politicised.  The once feminist contention that the ‘personal is political’ can illuminate a world-view where high-politics (of statecraft and macro economics) perpetually disengages from the low-politics of body and interior aspects of mind.  We can’t really say that just because it's flawed to view issues of mental health in individualised terms that individual circumstances and even thoughts are irrelevant.  Even a utilitarian could agree that if enough people have neurosis or psychosis then there must be substantial shifts in accommodation of need.  

Where language is concerned R D Laing once pointed out the concern of a lack of adequate terminology to describe those nether regions of the brain which we all tread through each day and night.  Where misnomers such as ‘illness’ abound, is it currently better or worse to take away the one thing that may protect the rights of a potentially vulnerable individual?  Ah, I hear you say, ‘but if it feeds back into our self-understanding and is used as a basis to disable parts of the brain chemically over time, are we not all, well, kind of doomed?’

Without wanting to become sarcastic, I believe that the development of the human brain has taken more years than the development of neuroleptic medication.  In conjunction with-  and in opposition to-  other brains, our adjustments to the world continue on (despite recent headlines made elsewhere. In fairness, David Attenborough does acknowledge our on-going cultural evolution article here).  It seems plausible perhaps to say that if alcohol, caffeine, nicotine and other substances are included, most people use drugs of some sort. 

Where prescriptions are concerned, the proportion of us on powerful mind altering substances may or may not rise but; and excuse the purposeful double negative- this can’t have no long term effect.  The impossible magic pill to fix or regulate all aspects of necessarily organic and dynamic brain chemistry is a matter for stories and films alone, but if we carry on as we are,  without it one day we are truly damned.

Disney's Mickey Mouse as the Sorcerer's Apprentice

 

During recent times, it has been brought to our attention that the chair of the Diagnostic and Statistical Manual IV committee Allen Frances, has decided, for his efforts and sins, that medication has too large a role.  Now that DSM V is about, this leading US psychiatrist has made a significant statement.  It does need to be noted that more prescriptions are made in the US than in Europe to date, but areas for hope should always be incorporated into monologues and hopefully discussions too.

Practically once more, a good friend of mine once said that ‘society has the work:fun ratio all wrong’. Depending on how one sees both work and play, there are certainly issues to do with emphasis on economic (narrowly conceived) output (measured finitely and rationally) in relation to specie-al wellbeing.  Either as individuals or not, with enough of us in play, it may be necessary to move beyond complaining of unfairness based on historically subjective notions obtaining objective status against which present notions of equity are deemed too subjective and narrow..- and on towards some more rigorous conceptions.

Considering the wide reach of serious ‘mental health issues’- in the UK and beyond what does the future of health care look like?  What roles and space for talking and communication can be in-built and do we all need therapy?  Furthermore, what is a reasonable working day or week now, given consistent difficulties for some and also the lack of full employment for all amidst recurrent issues of growth, which regularly falls below David Harvey’s recent assertion that capitalism requires growth to be maintained at around 3% of gross domestic product in order to survive.

It’s not possible to extend this much now, but needless to say that of course, everyone struggles sometimes.  All I would suggest is that fighting illusory or real mental demons is different (if not separate) to having practical based problems.  The point is also, examples such as psychosis now brings increased problems for some people - and even if you conquer your great inner personal challenges you are then required to exist and compete in an imbalanced social world where the battles you have fought may mean next to nothing to anybody else.

Time to Change the debate

If concentric circles seem to ripple outwards from common misconceptions of benevolence some of us are left asking whether the fault lies with the would-be ‘do-gooders’, that is, in the act of benevolence itself, or with the enormous obstacles that they are faced with. The quick act of considering this short quote..

“It is just as foolish to fancy that any philosophy can transcend its present world, as that an individual could leap out of his time or jump over Rhodes.”[Hegel, Preface to The Philosophy of Right (1821)]

... will give a clue that my own view is that we are on deep rooted and enormously complex terrain whereby ancient wonders of the world are as likely straddled by one person than small charities (for example Time to Change and Time to Change Wales) can decisively interject on the panoramic reach of a world view which favours many things ahead of densely concentrated lived-experience and the necessary changes to everyday life which our current fascinations with the indefinable area of mental health presage. (Pause for breath).

An interesting question to commence with might be how many people have mental health concerns? For one, I don’t expect to find a definitive answer, or to overcome the continual reproduction of stigma and discrimination as part of existing and remade social relations. Given recent counter-edicts that I have been following (see the Powys Mental Health Blogspot or the following blog in at least two places Discursive of Tunbridge Wells and here) the themes are known to be numerous. But if the limelight that a few TV adverts (my favourite is this one), posters, radio slots, interviews, the odd celebrity and some necessary rhetoric casts an uneasy shadow on the other already-dispossessed who will claim that our common heritage of ‘mental distress’ can't and shan't ever be labelled as ‘ill’ (regardless of what we may sometimes do or not do, say or not say, need or want); then there is a problem.

Of course there are many different angles of approach and places of emphasis. The medical model of mental illness (sic) enjoys an enormous power base but even a small child could recite that there is a difference between an individual pancreas say, which if deemed deficient will need insulin, and millions upon millions of human brains that if deemed individually deficient and at fault, still communicate with other ‘brains’ and are developed, fed and maintained by more than the processes that occur within any one person’s skin. Whether it is accurate to say that the human brain is more complex than the furthest unknown reaches of the universe I do not know. But if we don’t yet understand one brain then the task of engaging with and altering amalgamated human action is even more difficult. Perhaps though, if we made the journey to the experimental collider at CERN in Switzerland and all put our heads in there some interesting results would follow?

To say that stigma (and discrimination) can’t be effectively quashed by a UK civil society campaign is a fair point. But not to laud the efforts of the small team who; are on finite contracts, have a fixed budget and who must fulfil ‘interesting’ ways of statistically measuring results in order to satisfy funders, for at least trying? Perhaps make up your own mind.

The larger picture, I would argue, brings us onto the question of the frequency of mental health concerns both in the UK and beyond. This, to have any relevance to a meaningful debate, has to sketch amongst other concerns the explicit points of the relationship including places such as the UK to the wider world and some central implicit aspects from known and recorded human history. Combined with individual perspective(s), I hope that we can honour the spirit of previous debates that I have witnessed that have stemmed from the Time to Change claim that ‘1 in 4 of us will have a mental health problem at some stage’through to the counter claim, that if extended too far, says that we’re all imminently and immanently at risk of meltdown of an apocalyptic scale.

That claim, just in case you’re wondering, is that we all have a mental health problem comparable with severe and often life-ending conditions. My innocent side hopes that although we all have on-going health and wellbeing concerns I would rather conclude less than‘1 in 4’ than more. Even this though, risks over simplifying the richly interwoven individual and social tapestry which we are all part of. A diagnosis may, or may not, be proof or otherwise of the severity of a person’s distress by comparison to another person who doesn’t have a diagnosis. By the same token, scientific, quasi-scientific or the science by proxy that modern psychiatry embodies, even during its most exact moments, will never be the pinnacle of knowledge that well-used philosophy happens to be. To be clear, science is a branch of knowledge, not knowledge in itself. Psychiatry may or may not be deemed science in turn, which is something to bear in mind when working out the sort of hierarchy that an attempt to challenge orthodoxy might entail some days.

Whatever view you find most endearing and whichever ones sit most comfortably with your own known or unknown position in space and time, we may safely conclude that we don’t really have accurate ways of describing those things that go on in our heads when we can’t sleep, or if and when psychoses or deep depressions take hold. Not to be a pessimist, but one can also paint a picture of a universe which is thought to be contributed of mostly dark matter and dark energy (neither of which we really know too much about) and of a human history which is, at the bare minimum, nine tenths unrecorded in any way whatsoever. From here, the idea that we are particularly different to pre-historic incarnations of ourselves that lay beneath stars and wondered about what was in them, and what was above, may either soothe or frighten. Language for one, has surely moved on greatly since then, as have the internal neurological receptors that register acute verbal signals in meaningful and emotive ways.

But even with highly sensitive measuring devices carried around with us at all times, most of us ought admit to regularly using imperfect ways of describing things which we don’t really understand. With possible danger around every modern city corner if you believe certain news outlets, it might be better to say that paranoia is a very sensible default position to assume. Similarly, although voice-hearing may have a long and rich history of incorporation in other cultures or that can be normalised within other spiritual currents, the small percentile who are pathologised for admitting to it these days might be the only ones who truly give time and effort to exploring every deep, dark corner; every nook and cranny within their own mind-space for the sake of functioning normally alongside others.

But, over time, how many people have had mental health issues that we can compare to the things we recognise today? And how many people in ‘non-western’ spaces have comparable or worse conditions than we know of here? Similarly, how do large scale known historical events such as wars, the spread of markets, industry and technology feed back into these questions? If indigenuity were to be a thing of the past, and modernity were to crumble around it’s already bowing edifices; what would a healthy post-modern mind and body be like on the whole? Perhaps these are the directions change is already occurring in and that we need to begin to acknowledge in more than tacit ways over the coming days, weeks and months.