WELFARE STATE
Mental health
What are psychiatrists doing?
Anthony Clare
Recently I attended the recording of a televised debate, to be shown on BBC 2 this autumn, in which the American psychiatrist, Professor Thomas Szasz, performed his usual polished magical trick of making mental illness disappear and four redoubtable champions of the art of British psychiatry strove mightily but with somewhat limited success to make it reappear again. Szasz, a formidable controversialist and the enfant terrible of organised American psychiatry, has long argued that the whole concept of mental illness is a myth, akin to witchcraft, a myth cultivated by a "society which, for reasons of its own, wishes to persecute those who do not accept its standards of morality, of behaviour, of living. Psychiatry in Szasz's view is an elaborate system, akin to the Inquisition, whereby such persecution is legitimised, wherein ostensibly deviance is treated but by a process of sophisticated social control it is in fact eliminated.
Now whatever the logical strengths and weaknesses of this argument, it is, I believe, instructive for those currently engaged in discussion concerning the scope and concerns of contemporary psychiatry in this country to consider those issues whirh Szasz raises and the atmosphere in which he practises. Psychiatry in the United States, its historical development influenced by psychoanalysis to an extent far greater than occurred in Britain, merits a respect sometimes bordering on awe for its pronouncements on matters not always clearly related to its central concerns. Psychiatrists in America freely comment upon complex social problem such as race relations, the Vietnam war, the problems of urban living, with the confidence of men believing they possess a special competence. Such is the diffuseness of the area supposedly falling within psychiatry's ambit that among the chapter headings in a prominent American textbook on social pathology is 'Radicals and Radicalism' alongside' Prostitution ' and ' Drunkenness and the Chronic Alcoholic.' It is not very long since, in response to a questionnaire from a newspaper, some 2,000 psychiatrists delivered publicly their individual diagnostic pronouncements on Presidential candidate Barry Goldwater.
To date, British psychiatry appears to have been spared this somewhat messianic grandiosity — indeed its practitioners are more often accused of possessing such a limited view of what exactly constitutes mental illness that they are dismissed as academic, out of touch, ignorant of the true basis of contemporary mental stress and hamstrung by an outdated medical model of ill-health. The Left is particularly virulent in its criticisms — the emphasis placed by contemporary British psychiatry on physical methods of treatment and the insistence of many psychiatrists that it is the patient and not society that is their primary concern are treated with an articulated contempt by those who are convinced that the major psychiatric disorders such as schizophrenia and overt manicdepressive disorders are created by a pathological society and that psychiatrists in concentrating on symptoms are little more than a sort of ' soft ' police.
It is probably fair to say that in so far as psychiatry in this country erred it did so on the side of caution and restricted itself to the study of abnormal mental phenomena, that is to say the phenomenology of mental illness, of associated physico-pathological changes and of physical treatments. It is true that British psychiatry has a proud reputation abroad for its social concerns such as its pioneering studies on the effects of institutionalisation, but in the main it has eschewed the more philosophical considerations of the relationship between the cultural values and prohibitions of society and the mental illness appearing within it. Now there are signs that psychiatry is widening the area of its deliberations.
Yet herein lies the danger that has so plagued American psychiatric practice. If, in that country, it sometimes seems that a psychiatrist is envisaged by a credulous public as one who cures anti-semitism, curbs race riots, analyses the fitness of political candidates, adjudicates on the relative benefits and dangers of pornography and delivers strictures on the psychopathology of war, so it would seem that in this country the public image of the psychiatrist may becoming equally ambitous. Whereas once it would have seemed to most intelligent laymen that a psychiatrist was one who concerned himself with the study of mental processes and events, normal and abnormal, now he assumes the mantle of a secular high priest, equipped with a prestigious jargon of his own, and is in many cases the administrative co-ordinator of an impressive array of social workers, psychologists and nurses deployed to cultivate the growth of a commodity rather quaintly termed ' mental health ' to a disturbed and chaotic community.
"Depend upon it," warned an eminent Victorian, "there is only one way of really ennobling any calling and that is to make those who pursue it masters of their craft, men who can truly do that which they profess to be able to do." Yet the press ures from society, from the political planners, from the Department of Health and Social Security have never been so for midably arrayed to persuade the psychiatrist to assume tasks for which he may be poorly qualified; or worse, for which he may indeed be as qualified as anybody else but which seriously interfere with that which he is best qualified and trained to do. It is true that psychiatrists are not among the most humble of men; they do not normally shrink from expressing their views, par ticularly when their views are avidly sought. No television discussion worthy of the name is devoid of a psychiatrist whose interventions provide the outline of Tom Stoppard's gymnastic Sir Archibald Jumpers — that jack-of-all-trades vision of the contemporary psychiatrist, ever ready to provide an explanation, especially for the inexplicable.
Yet all this sounds very academic to a public whose only concern is that there are not enough psychiatrists, that psychiatric hospitals are large, crowded and dilapidated, that there are people in them who should not be and, to judge by the latest NAMH report, people outsidewho would be better served in hospital. It sounds academic to those other profes sional workers struggling with the new Seebohm creations, the area teams, often overwhelmed by the apparently bottomless pit of social problems that now appear part of psychiatry's province.
Yet now is the time to take stock, to attempt an overall assessment of the psychiatric services, their resources, their function in society, their contribution within and outside the National Health Service, the time they should devote to the training of other workers in the helping professions and to counselling, the extent to which they should remain centrally pre occupied with the diagnosis and treatment of the large numbers in the population
with serious mental disorder. The movement of patients out of hospitals and into the community has resulted in an enormous and as yet unmet demand for trained personnel. Titmuss's warning,
issued nearly a decade ago, that we were in danger of transferring the care of the mentally ill from trained staff to untrained staff or no staff at all looks in retrospect more like a prophecy.
Dr Clare is Senior Registrar in psychiatry at the Maudsley Hospital.
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