Saturday, September 19, 2009

For many, more than what mental illness results in, it is the stigma that hurts more. The trauma, a patient has to live with while enduring and recovering from treatable mental illnesses, is immense—a psychosocial Gordian knot. This knot was a Greek legend, meaning an “intractable problem” awaiting a bold stroke. Only the man who unties the Gordian knot will go on to become the king of Asia, the legend goes. And Alexander unable to do it, strikes the knot with his sword to know where the ends are. This is called the Alexandrian solution.

So psychiatry also awaits (or may have had) its Alexandrian solution about strike the anti-psychiatry movement, who deny the very concept of mental illness, with the sword of plausible evidence. One of the popular faces of this movement is the Syracuse University professor, Thomas Szasz who paradoxically holds the Emeritus chair in psychiatry. His ideas have been sealed in his book Myth of Mental Illness, in which Szasz Thomas Szasz “describes psychiatry as a pseudo-scientific racket, as a science of lies; psychiatrists as abusers, as coercive.”

He still holds true to his first argument in The Myth of Mental Illness that the mind itself doesn't exist, that therefore mental diseases, diseases of the mind and mental illness itself don't exist, they are a fiction, mental illness is a metaphor and it's an exercise in social control, of deviant behavior. Let me deal with some of Szasz’s concerns one by one.

A product of the prevailing counter-culture of 1960s and 70s, Szasz professed psychiatry as a means to socially control patients and the society as a ‘therapeutic state.’ Counter-culture was a movement that reveled in “distrust of various kinds of institutions, particularly authoritarian establishments.” But down the years, things have changed not for the good always. But many things have been re-examined in new light. Psychiatry now has a biological face to it and mutant genes have been implicated in many illnesses; neuroscience has told us which neurotransmitter’s lack or abundance results in conditions like depression and schizophrenia. Various therapies have proved effective like cognitive behavioral therapy, which assumes that mental disorders originate in false beliefs and errors of logic, called cognitive distortions. Over time, these false beliefs (such things as “I can’t do anything right,” “I’m a total loser,” “If I say anything, they’ll all think I’m an idiot”) begin to occur automatically, so that the client never stops to consider whether they are even true.

Therapy therefore consists of identifying the false beliefs and distortions, and then treating them as hypotheses to be tested. In addition to helping people examine their false beliefs through gentle questioning, therapy therefore often also involves designing empirical tests of these beliefs. As homework, a client who fears meeting new people may be required to introduce himself to a stranger. Success at this task without any negative consequences will help to reduce his anxiety in such situations, and further success may eventually eliminate the fear and anxiety entirely, or at least to a sufficient extent that the anxiety is no longer a problem.

Current medical practice largely ignores this way of talking patients into recognizing their problems/challenges, in addition to drugging them.

Psychiatrists are power-mongers, who are keen on using their profession to isolate a patient from the society and inflict diagnostic categories on them, and see them decay by day. Not really. Szasz’s worry is that “psychiatrists, pharmaceutical companies and indeed the state are conspiring in the business of medicalising everyday life.” This is true to a certain extent, at least in today’s India where the medical profession has scared common people out of their minds. Enter any ‘corporate’ hospital and even a healthy being can freak out. I personally have experienced doctors telling me that my anxiety to know and the guilt of my ignorance is a personality disorder.

What is natural to human existence, and must be dealt individually and with familial help, is being reclassified as impairment. Workers injured at work are denied compensation because a flimsy classification has just entered the bible of psychiatry, Diagnostic and Statistical Manual (DSM). The DSM classifies the worker’s condition as adjustment disorder, virtually erasing all medical benefits. This is what Szasz should have voiced his professorial voice to, not being suspicious of the entire profession that has humane roots in the great French psychiatrist, Philippe Pinel, unchaining women patients considered insane at the Paris asylum. To end with, here’s a nice extract from Roy Porter’s Madness: A Brief History:

Pinel embraced the progressive thinking of the Enlightenment. If insanity was a mental disorder, it had to be relieved through mental approaches. Physical restraint was at best an irrelevance, at worst a lazy expedient and an irritant. Treatment must penetrate to the psyche.

During the Reign of Terror, a Parisian tailor challenged the execution of Louis XVI. Misconstruing a conversation he overheard, he then became convinced he was himself about to be guillotined. This delusion grew into a fixation necessitating his confinement. By way of psychotherapy, Pinel staged a complicated demonstration: three doctors, dressed up as magistrates, appeared before the tailor. Pretending to represent the revolutionary legislature, the panel pronounced his patriotism to be beyond reproach, ‘acquitting’ him of any misdeeds. The mock trial, Pinel noted, caused the man’s symptoms to disappear at once. (pp. 105)

Treating everyone and everything around as equal as you are and as important as you are, with necessary compassion and credible care — that’s what for me a medical practice is all about. A privilege earned by medical practitioners, by virtue of their degree but fulfilled by their character. They must strive for Alexandrian solutions to the psychiatric knot, which cannot just be unraveled by drugs or brain scans alone.

Note: Un-cited quotes are from the transcript of the ABC show All in the Mind.

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