Our Psychiatric Future.
Psychiatry's biomedical paradigm of mental disorder has run out of steam. The hypothesis that neurotransmitters in the brain are the cause of mental illness and that psychopharmaceuticals act to repair damaged neurochemical pathways has no support. Yet a growing number of people are being prescribed drugs to treat mental distress every year. Calculations and statistics promoting the view that there is a growing epidemic of mental illness must be treated with care. Despite spending billions of dollars on research to identify biomarkers, a genetic component, or a source of disorder in the brain, no convincing evidence of such exists. For decades people diagnosed with mental illness have voiced their concerns with medical and psychiatric treatments, but have been ignored or too often had their words interpreted as the symptoms of people who do not have 'insight' into their illness. In Our Psychiatric Future, Nikolas Rose expertly argues these points by examining the history of psychiatry, recent developments in brain, genetic and pharmaceutical research, global mental health, as well as mental health service user/survivor advocacy to show us a way toward a new future for psychiatric knowledge and practices.
The book is an example of the best sort of sociology and critique in that Rose not only shows the limitations of psychiatry today, but also a way to build a new psychiatry that is far more attuned to the reality of what our current medical model calls "mental illness". Rose's psychiatric future is evidence-based, rigorous, neurobiologically informed, and has practical ideas on how to organize a mental health system that respects diversity in forms of life among human organisms within their milieu. The arguments are well made and one should expect no less given the author's own research which has spanned more than 40 years, including with the Social and Ethical Division of the Human Brain Project. He also has a great deal of personal experience with a loved one who has a diagnosis of severe mental illness.
Each of the nine chapters is aimed at answering its own question: what is psychiatry (Chapter 1)? Is there really an "epidemic" of mental disorders (Chapter 2)? Is it all the fault of neoliberal capitalism (Chapter 3)? If mental disorders exist, how shall we know them (Chapter 4)? Are mental disorders "brain disorders" (Chapter 5)? Does psychopharmacology have a future (Chapter 6)? Who needs global mental health (Chapter 7)? Experts by experience (Chapter 8)? Is another psychiatry possible (Chapter 9)? The answer to Rose's first question is that there is no singular psychiatry, but a heterogeneous set of practices with often incompatible conceptions of mental disorder. Further, even though psychiatry was intended to identify and treat severe medical conditions, it is now common for everyday behaviours to fall under the purview of psychiatric practices. Rose writes, "one might almost say that it is 'abnormal' to live one's life without coming into the remit of psychiatry..." (9). Yet, Rose acknowledges that care and recovery from most mild forms of mental distress never involve a psychiatrist and that referring to primary care as taking place in hospitals or the offices of psychiatrists and general practitioners is a misnomer. In fact, most people care for themselves or are cared for by family and friends. The formal health system is, at best, a secondary care system. The first chapter also articulates the sorts of things psychiatry does beyond the treatment of mental disorder. For example, it defines and delimits criteria for deciding who should be a candidate for treatment and is also important in articulating what mental disorder is, which is an incredible responsibility in that it determines not only what we know, but how we can know it. For several decades attempts to know mental disorder have focused almost entirely on the brain and neurotransmitters. In each chapter, Rose dismantles the many presumptions that psychiatry has made over the years and the means by which it defines and interprets human mental states. Recognizing the many limitations that Rose illustrates (including those described above), the final chapter provides a vision for the future with an invitation to psychiatrists to reconsider their discipline and the role it plays in mental health.
Rose's most important point is that the brain is not the source of mental illness and distress because accepting this observation--after decades of research and billions of dollars that has provided no convincing evidence--is a necessary first step in reorienting psychiatric practice. Rather, the brain is an effect of human evolution as social creatures--it is a social organ--and as such it is involved in nearly everything that humans do. Of course, the brain is involved in mental distress, but this does not mean we should presume that it is the causal factor. Violence, exclusion, isolation, and adversity--all articulated in the social determinants of mental health--act on the human organism affecting it and its brain. By examining disembodied brains without any recognition for their social, cultural, and material milieu we will not make any progress towards solving mental health problems. Categorical diagnoses must also be eliminated (Chapter 4). While they are useful for bureaucratic purposes, they fail to map onto the realities of mental distress and diversity within what Rose calls the "bandwidth" of human forms of life. His preference in light of this perspective is to refer to forms of mental distress rather than mental disorders. Psychiatry must also replace categorical diagnoses with formulation. Briefly, formulation is an individualized account that aims to make sense of a person's present difficulties with regard to their life course and current situation--their relationships, experiences with work and unemployment, their personal ways of making sense of the situation, and their experience of distress. Under this new model--a similar model had once been promoted from within psychiatry nearly a century ago--there would be a much greater role for peer support, increased involvement of service users and survivors in their own care, the care of others, and the evaluation of services. Psychiatrists would continue to have a role, but their role would be focused more on social science, social medicine, and community health promotion. Drugs would only be used as short-term solutions to settle acute moments of distress and with full knowledge of long-term negative effects on health. Under this new model, psychiatric research would not focus on the brain, but on the human organism within its milieu. The aim of such research would be toward a better understanding of the complexities of interactions between the biological and the social in affecting mental health outcomes. Given that many humans now live in cities, and more are migrating into them every day, Rose identifies cities as an important locus for this new psychiatry's interventions and for the promotion of "mental health friendly cities" wherein, "... all inhabitants--citizens, denizens, migrants, refugees..." (195) are afforded equal rights to the city. Leading by example, Rose has already begun a new research program examining mental health and megacities.
In completing the book, the reader is left with the difficult question of whether psychiatrists will be willing to accept so many changes to their paradigm and to relinquish a great deal of authority to their patients and supporters. Only time will tell, but if so, our psychiatric future is likely to be much more accepting, caring, and effective.
Engaging and well-written, the book will likely appeal to both an academic and a general audience with interests in mental health, public health, psychiatry, brain research, and their politics. Chapters could be enjoyed individually for their direct examination of particular topics, but in reaching the end of one chapter the reader will likely be compelled to move onto the next. While much theory informs the book and readers who know Foucault or actor-network theory will recognize these in it, those who are unfamiliar will not be bogged down with the interpretation of concepts like governmentality or subjectivization. Where Rose directly raises insights from such theory and related research he does so in a way that readers need not do any work to understand their meaning. I can imagine myself assigning the book, or sections of it, to undergraduate and graduate students alike.
Gary RS Barron
University of Alberta
Gary Barron is a generalist sociologist who is very interested in how categories and numbers are made and what they do once they are brought into the world. More traditionally stated, his scholarly interests are oriented around the politics and organization of knowledge, science and technology studies, health and illness, mental health and illness, the intersections of these with law, organizations, performance and strategy. He uses his sociological toolbox for subsistence purposes and to satisfy his curiosity with the world. His website is garyrsbarron.ca
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|Author:||Barron, Gary RS|
|Publication:||Canadian Journal of Sociology|
|Date:||Sep 22, 2019|
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