Obviously I agree that we are asked to deal with problems we have no hope in hell of helping but I think it is a shame that psychiatry has turned its back on the social nature of the specialty. Once upon a time medical students went into psychiatry because it concerned itself with social problems. in fact when psychiatry was at its most social it was at its most popular with as many of 10% of medical students going into the specialty. Conversely during the 90s when psychiatry was at its most biological,residency programs were forced to closed or downsize and relied heavily on IMGs because no one wanted to do it). For those who had an interest in social justice and humanitarianism psychiatry was the natural choice. Not any more. the main social psychiatry association is run by psychologists. medical students interested in social justice go into family medicine or pediatrics. psychiatrists today are completely unfamiliar with the classical or contemporary literature on social psychiatry. Like it or not, poverty, inequality, homelessness, crime, discrimination, marginalization, and so on are inexorably intertwined with mental disorder. There is no discrete boundary between "social problem" and "mental illness" because "mental illness" is a social problem. Social, political and economic factors influence mental illness at every turn: from who gets sick, the form and content of their symptoms, and the illnesses they develop, the treatments that are available, the course their illness takes, and the outcome of their life-story. The social world also influences the lived experience of mental illness, including all too frequently stigma, prejudice, discrimination, inequality and exclusion.
If anyone is interested this is the transcript for a talk i gave at the IPS meeting last year on the decline of social psychiatry:
In the 1960s and 1970s, psychiatrists concerned themselves with problems of crime, racism, violence, gender inequality, human rights, war, nuclear disarmament, and how the sociopolitical influenced the mental. Though American Psychiatry’s brief foray into solving the social ills of the time proved too-overarching, by the 1980s American Psychiatry had all but completely abandoned the social world, instead locating the sources of discontent not in society, community and state, but brain, cell and molecule. The remedicalization of psychiatry and the ascendance of a new biological psychiatry were intimately tied to the politics of neoliberalism, and psychiatry’s increased focus on brain and biology helped obfuscate the wider social determinants of mental health. The failure of neuroscience and genetics to revolutionize the treatment of mental illness, the emergence of social epidemiology, and the growing concern about the widening of inequality in our society mean the time is now ripe for psychiatry to re-engage with the social world.
A few days ago I was talking to some psychiatry residents about this upcoming symposium and they asked me, “what is social psychiatry?” This question will surprise no one but should astound everyone, especially if we were to replace “social” with “biological”. No medical student or resident would ever ask what biological psychiatry is, but social psychiatry’s decline has been so precipitous that psychiatrists of today are not familiar with psychiatry’s foray into social ills, social commentary, and the focus on the social roots of illness. Many of the classic studies in the field like Faris and Dunham’s study of Schizophrenia, the Midtown Manhattan Project, Hollingshead and Redlich’s work on social class and mental illness, Brown and Harris’ work on life events and illness have escaped a generation by. The critiques of psychiatry of the 60s from the likes of Goffman, Szasz, Laing, Foucault and so on have escaped a generation by. “Antipsychiatry” is more likely to be associated with Scientology today than any credible critiques of the profession.
For one definition of social psychiatry we can turn to the WHO’s 1959 technical report on the subject. This committee was chaired by Robert Felix who was the first Head of the newly formed National Institute for Mental Health. Felix said amongst other things: ““[Psychiatrists should be] involved in education, social work, industry, the churches, recreation, and the courts, so that mental health care would be fully integrated into the total social environment” The 1959 report notes “social psychiatry might eventually provide the means of creating a saner or perhaps a completely sane world”. His successor Stanley Yolles wrote that mental health professionals should “improve the lives of people by bettering their physical environment, their educational and cultural opportunities, and other social and environmental conditions. The conditions of poverty, since they constitute a breeding ground for mental disease, require the professional involvement of the psychiatry”. Such a different conception of psychiatry that we have today. You couldn’t imagine Tom Insel the outgoing NIMH Director saying such words…
If you look at the APA meetings of years gone by you can also see a sea-change. The topics were more sociopolitical and community oriented up until the 1970s. By 1980, the pendulum had swung with a significant focus on biological aspects of psychiatry, psychopharmacology and the new DSM. We moved from society, community and state, to brain, cell and molecule. The forces at work were many, and I do not want to pretend that social psychiatry was ever a predominant force in American Psychiatry because it wasn’t. Much of what was social was eclipsed by the psychodynamic and the two curiously melded together with the effect there was much more focus on the individual’s psyche in the social world, or a look at family or group dynamics and not the structure of society itself. At the same time there was a real enthusiasm for psychiatry, the community treatment of the mentally ill, and social justice oriented medical students would choose psychiatry right up until the 1970s. The data that we have on recruitment clearly shows that psychiatry is at least popular when it is at its most biological. The heyday of psychiatry was after the second world war and the intervening years when psychiatrists concerned themselves not only with psychoanalysis and the new psychopharmacological agents but also social justice: racism, crime, violence, gender, inequality, poverty, even nuclear disarmament. As such psychiatrists were beginning to become aware of how the sociopolitical affected the mental. By the 1970s a growing awareness of the sexual violence that was perpetrated against women, and criticism of the Vietnam war coalesced into the diagnosis of PTSD which entered the diagnostic nomenclature in 1980 as a damning indictment of war in Vietnam and the war at home. Of note, unlike war neurosis, shell shock and similar terms beforehand, PTSD was viewed as a normal response to situations outside the usual range of human experience. Given that it was known this wasn’t the case well before, it could only be seen as a sociopolitical definition and not simply the state of knowledge at the time.
So why the decline? Part of the problem was there was no true social psychiatry. Psychiatry had always had a role in managing subjectivity and regulating conformity rather than liberation, unlike say the radical tradition in French psychoanalysis. Social psychiatry occupied a space in what was a primarily psychodynamically oriented psychiatry, one that privileged the internal over the external, fantasy over social reality. By the time more analytically oriented psychiatrists accepted the significance of actual life events and trauma, psychiatry had already moved on. Part of the problem was that many of the aims were too lofty. While a psychodynamically model provided a frame for intellectual analysis of problems far beyond the realm of mental illness, pragmatic solutions were not forthcoming, and ultimately not the in the province of psychiatry. Psychiatrists could not provide racial harmony, address inequalities and poverty, let alone have to power to meaningfully advocate for nuclear disarmament. And most crushingly, the optimism of following the community mental health act and the passage of Medicare did not lead to the funds to support the vision or the anticipated universal healthcare coverage for the populace.
What I want to focus on however is how the decline of social psychiatry, and the ascendance of biological psychiatry was intimately tied to the politics of neoliberalism. By this I am talking about a series of policies influenced by laissez-faire economics that promotes deregulation of industries, privatization, financial austerity, and the wide scale application of market forces in every sphere of life. Whatever positives may be associated with such policies: driving innovation, supporting business, allowing wealth creation proponents point out, these policies fail to protect to vulnerable in our society and lead to job and financial insecurity, and widening inequality which we know affect physical and health outcomes. These policies created widespread misery, which drives desire, which in turn drives consumption. Social psychiatry was a political threat because it highlights how the social, political and economic landscape influences mental health. By focusing on brain and biology, on molecules and cells, we obfuscate the wider causes of mental distress, no longer the product of an insecure economic landscape or a toxic workplace, but twisted molecules and defective genes. Biological psychiatry says the problem isn’t poverty, inequality, or social exclusion – the problem is you. As we can see the research agenda was significantly influenced by the political landscape – there was a precipitous decline in psychosocial publications in the AJP in the early 1980s. The politics of neoliberalism is a project that transforms collective social responsibility into private individual one. In this way it is antithetical to social psychiatry.
The second phase of the neoliberal agenda has been – for good or for ill – the transformation into patients into consumers. This may have had the positive effects that psychiatrist Joanna Moncrieff notes including leading the greater patient/consumer involvement in care and greater rights, but it also has the effect of transforming sickness that often has deep social roots into a market place. With the announcement that Tom Insel will join Google to help develop new technologies for mental illness the transformation is complete. Mental illness is now not only completely uncoupled from the social environment, it is also wedded to marketized one where companies vie to create and sell products – with little regulation of course – to those experiencing mental distress.
This has wider implications. By focusing narrowly on the individual and relocated the problem within the self essentially sees the psychiatrist managing subjectivity, in the role of adjusting individuals to situations we should not perhaps not adjust to, using pharmacotherapy. People come to see themselves as somehow fundamentally biologically defected. As sociologist Nikolas Rose noted, we have come to recode our mood in neurochemical selves. Psychiatry profited handsomely from the remedicalization of the profession. The DSM generated significant revenues for the APA, and a wider range of problems came to fall under the purview of psychiatry expanding the borders of mental illness. In turn, an unprecedented level of the population uses psychotropic agents. In recent years, accusations of an unholy alliance between the pharmaceutical companies and psychiatry, and the mass proliferation of psychiatric diagnoses, as well as the continual reshaping on the boundaries between mental health and illness have brought the profession into disrepute. The evidence base for many psychiatric interventions has been called into question. The validity of psychiatric diagnoses has also been criticized even from those within the profession. The increasing focus on the biomedical at the expense of the psychosocial has led some commentators such as Glen Gabbard and Leon Eisenberg to note that many younger psychiatrists do not appear to know how to even listen to their patients:
"The success of neuroscience has exacted costs.The very elegance of research in neuroscience has led psychiatry to focus so exclusively on the brain as an organ that the experience of the patient as a person has receded below the horizon of our vision. We had for so long been pilloried by our medical and surgical colleagues as witchdoctors and wooly minded thinkers that many of us now seek professional respectability by adhering to a reductionistic model of mental disorder. We have traded the one-sidedness of the brainless psychiatry of the first half of the 20th century for a mindless psychiatry of the second half."
Psychiatry hasn’t just become mindless it has also become aimless and placeless. There is no context to the genes and neural circuitry that have been so privileged in the emerging discourse for our psychic woes. If as is often claimed psychiatry is in crisis, then we are presented with a wonderful opportunity. We have the opportunity to learn from these mistakes. Most psychiatrists regard themselves as having a biopsychosocial orientation. For too long, the “social” has been an afterthought, if considered at all. And yet our brains do not exist in a vacuum. They operate within complex systems and interpersonal networks.
But is actually both unexpected and upcoming -- or kind of unexpected (long story) -- but anyway, being out $2k would have been a much more significant stressor just a few years ago. Now it's kind of, eh that sucks but whatever.
