Principles of Social Psychiatry

Principles of Social Psychiatry Second Edition



Principles of Social Psychiatry Second Edition Editors Craig Morgan and Dinesh Bhugra NIH Biomedical Research Centre and Institute of Psychiatry, King’s College London, London, UK

This edition first published 2010, Ó 2010 by John Wiley & Sons, Ltd. Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley’s global Scientific, Technical and Medical business with Blackwell Publishing. Registered office: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Other Editorial Offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK 111 River Street, Hoboken, NJ 07030-5774, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell The right of the author to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associatedwith any product or vendor mentioned in this book. This publication is designedto provide accurate and authoritativeinformation in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Library of Congress Cataloguing-in-Publication Data Principles of social psychiatry / editors, Craig Morgan and Dinesh Bhugra. – 2nd ed. p. ; cm. Includes bibliographical references and index. ISBN 978-0-470-69713-9 1. Social psychiatry. 2. Community psychiatry. I. Morgan, Craig, 1971- II. Bhugra, Dinesh. [DNLM: 1. Community Psychiatry. WM 30.6 P957 2010] RC455.P72 2010 616.89–dc22 2009050970 ISBN: 978-0-470-69713-9 A catalogue record for this book is available from the British Library. Set in 10/12 Times by Thomson Digital, Noida, India Printed in Singapore by Fabulous Printers Pte Ltd First Impression 2010

Contents List of Contributors ix Foreword xiii Mario Maj Preface xv Social Psychiatry: Alive and Kicking Dinesh Bhugra and Craig Morgan Part One Perspectives and Methods 1 1 The Historical Development of Social Psychiatry 3 Julian Leff 2 Why Psychiatry Has to be Social 13 Paul E. Bebbington 3 Categories and Continuums 31 Peter Tyrer 4 Social, Biological and Personal Constructions of Mental Illness 39 Derek Bolton 5 Social Science Perspectives: A Failure of the Sociological Imagination 51 Craig Morgan and Arthur Kleinman 6 Concepts and Challenges in Capturing Dynamics of the Wider Social Environment 65 Stephani L. Hatch and Dana March 7 Qualitative Research Methods 77 Joanna Murray Part Two Components of the Social World 89 8 The Social Epidemiology of Mental Disorder 91 Ronald C. Kessler, Philip S. Wang and Hans-Ulrich Wittchen 9 Families and Psychosis 103 Juliana Onwumere, Ben Smith and Elizabeth Kuipers

vi CONTENTS 10 Culture and Its Influence on Diagnosis and Management 117 Dinesh Bhugra and Susham Gupta 11 Culture and Identity 133 Julian Leff 12 Globalization and Psychiatry 141 Rahul Bhattacharya, Susham Gupta and Dinesh Bhugra 13 Trauma and Disasters in Social and Cultural Context 155 Laurence J. Kirmayer, Hanna Kienzler, Abdel Hamid Afana and Duncan Pedersen Part Three Social Determinants 179 14 Fundamental Social Causes of Health Inequalities 181 Jo C. Phelan and Bruce G. Link 15 The Sociodevelopmental Origins of Psychosis 193 Craig Morgan and Gerard Hutchinson 16 Depression 215 Tom K. J. Craig 17 Common Mental Disorders 227 Christoph Lauber 18 Suicide 237 Gwendolyn Portzky and Kees van Heeringen 19 Personality Disorder 249 Priya Bajaj and Mike Crawford 20 Drug Use, Drug Problems and Drug Addiction: Social Influences and Social Responses 259 John Strang, Michael Gossop and John Witton 21 Eating Disorders 277 Mervat Nasser 22 Social Factors that Influence Child Mental Health 285 Nisha Dogra 23 Social Determinants of Late Life Disorders 295 Robert Stewart Part Four Social Consequences and Responses 305 24 Responses to the Onset of Mental Health Problems: Issues and Findings from Research on Illness Behaviour and the Use of Health Services 307 Bernice A. Pescosolido

CONTENTS vii 25 Gender and Reproductive Health 321 Louise Howard 26 Stigma and Discrimination 331 Graham Thornicroft, Nisha Mehta, Elaine Brohan and Aliya Kassam 27 Taking Inequality’s Measure: Poverty, Displacement, Unemployment and Mental Health 341 Kim Hopper 28 Health Economics and Psychiatry: The Pursuit of Efficiency 371 Martin Knapp and Jennifer Beecham Part Five Social Interventions 385 29 Team Structures in Community Mental Health 387 Tom Burns 30 Prevention 397 Tristan McGeorge, Sean Cross and Rachel Jenkins 31 Principles of Social Intervention 411 Richard Warner 32 Social Interventions for Psychosis 425 David Kingdon, Yoshihiro Kinoshita and Stefan Gleeson 33 Social Management of Common Mental Disorders 439 Patricia R. Casey 34 Problem-Solving Therapy for People with Personality Disorders 449 Mary McMurran, Christine Maguth Nezu and Arthur M. Nezu 35 Social Support 461 Traolach S. Brugha 36 Modern Social Networking and Mental Health 477 Keir Jones, James Woollard and Dinesh Bhugra 37 The Psychiatric–Child Protection Interface: Research to Inform Practice 483 Colin Pritchard Part Six Global Mental Health 499 38 Mental Health in Europe: Learning from Differences 501 Mirella Ruggeri and Maria Elena Bertani 39 East Meets West: Current Mental Health Burdens in Greater China 517 Roger M. K. Ng and Zhanjiang Li 40 Social Psychiatry in India 531 R. Thara and R. Padmavati

viii CONTENTS 41 Social Psychiatry in Africa: Evidence and Challenges 541 Oye Gureje and Victor Makanjuola 42 Social Psychiatry in the Americas 551 Pedro Ruiz Epilogue 559 43 Where Next for Social Psychiatry? 561 Dinesh Bhugra and Craig Morgan Index 565

List of Contributors Abdel Hamid Afana, International Council for Torture Survivors (IRCT), Copenhagen, Denmark Priya Bijaj, Department of Psychological Medicine, Imperial College London, London, UK Paul E. Bebbington, Department of Mental Health Sciences, University College London, London, UK Jennifer Beecham, Personal Social Services Research Unit, University of Kent, Canterbury, and Personal Social Services Research Unit, London School of Economics, London, UK Maria Elena Bertani, Department of Medicine and Public Health, University of Verona, Verona, Italy Rahul Bhattacharya, East London NHS Foundation Trust, London, UK Dinesh Bhugra, NIH Biomedical Research Centre and Institute of Psychiatry, King’s College London, London, UK Derek Bolton, Institute of Psychiatry, King’s College London, London and South London and Maudsley NHS Foundation Trust, London, UK Elaine Brohan, Health Service and Population Research Department, Institute of Psychiatry, King’s College London, London, UK Traolach S. Brugha, Department of Health Scienes, University of Leicester, Leicester and Brandon Mental Health Unit, Leicester General Hospital, Leicester, UK Tom Burns, Department of Psychiatry, University of Oxford, Oxford, UK Patricia R. Casey, Department of Psychiatry, Mater Misericordiae University Hospital, University College, Dublin, Republic of Ireland Tom K. J. Craig, Health Services and Population Research Department, Institute of Psychiatry, King’s College London, London, UK Mike Crawford, Department of Psychological Medicine, Imperial College London, London, UK Sean Cross, WHO Collaborating Centre, Institute of Psychiatry, King’s College London, London, UK Nisha Dogra, Greenwood Institute of Child Health, University of Leicester, Leicester, UK Stefan Gleeson, Hampshire Partnership Foundation NHS Trust, Southampton, UK Michael Gossop, National Addiction Centre, Institute of Psychiatry, King’s College London, London, UK Susham Gupta, East London, NHS Foundation Trust, London, UK Oye Gureje, Department of Psychiatry, University of Ibadan and University College Hospital, Ibadan, Nigeria Stephani L. Hatch, Department of Psychological Medicine, Institute of Psychiatry, King’s College London, London, UK Kim Hopper, Nathan Kline Institute for Psychiatric Research and Mailman School of Public Health, Columbia University, New York, USA Louise Howard, Section of Women’s Mental Health Service, Health Service and Population Research Department, Institute of Psychiatry, King’s College London, London, UK Gerard Hutchinson, Psychiatry Unit, Department of Clinical Medical Sciences, University of West Indies, Mount Hope, Champs Fleurs, Trinidad

x LIST OF CONTRIBUTORS Rachel Jenkins, WHO Collaborating Centre, Institute of Psychiatry, King’s College London, London, UK Keir Jones, South London and Maudsley NHS Foundation Trust, London, UK Aliya Kassam, Health Service and Population Research Department, Institute of Psychiatry, King’s College London, London, UK Ronald C. Kessler, Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA Hanna Kienzler, Department of Anthropology, McGill University, Montreal, Canada David Kingdon, School of Medicine, University of Southampton, Southampton, UK Yoshihiro Kinoshita, School of Medicine, University of Southampton, Southampton, UK Laurence J. Kirmayer, Division of Social and Transcultural Psychiatry, McGill University and Culture and Mental Health Research Unit, Jewish General Hospital, Montreal, Canada Arthur Kleinman, Department of Anthropology, Harvard University, Cambridge, Massachusetts, USA Martin Knapp, Personal Social Services Research Unit, London School of Economics and Centre for the Economics of Mental Health, King’s College London, London, UK Elizabeth Kuipers, Institute of Psychiatry, King’s College London, London, UK Christoph Lauber, Department of Population and Behavioural Sciences, University of Liverpool, Liverpool, UK Julian Leff, Institute of Psychiatry, King’s College London, London, UK Zhanjiang Li, Beijing Anding Hospital, Capital Medical University, Beijing, People’s Republic of China Bruce G. Link, Mailman School of Public Health, Columbia University, New York, USA Tristan McGeorge, WHO Collaborating Centre, Institute of Psychiatry, King’s College London, London, UK Mary McMurran, Department of Psychiatry, Institute of Mental Health, University of Nottingham, Nottingham, UK Victor Makanjuola, Department of Psychiatry, University of Ibadan and University College Hospital, Ibadan, Nigeria Dana March, Department of Social Sciences, Mailman School of Public Health, Columbia University, New York, USA Nisha Mehta, School of Medicine, King’s College London, London, UK Craig Morgan, NIH Biomedical Research Centre and Institute of Psychiatry, King’s College London, London, UK Joanna Murray, Institute of Psychiatry, King’s College London, London, UK Mervat Nasser, Health Service and Population Research Department, Institute of Psychiatry, King’s College London, London, UK Christine Maguth Nezu, Department of Psychiatry, Drexel University, Philadelphia, Pennsylvania, USA Arthur M. Nezu, Department of Psychiatry, Drexel University, Philadelphia, Pennsylvania, USA Roger M. K. Ng, Department of Psychiatry, Kowloon Hospital, Kowloon, Hong Kong Juliana Onwumere, Institute of Psychiatry, King’s College London, London, UK R. Padmavati, Schizophrenia Research Foundation (SCARF), Chennai, India Duncan Pedersen, Douglas Mental Health University Institute and Division of Social and Transcultural Psychiatry, McGill University, Montreal, Canada Bernice Pescosolido, Indiana University, Bloomington, Indiana, USA Jo C. Phelan, Mailman School of Public Health, Columbia University, New York, USA Gwendolyn Portzky, Department of Psychiatry and Medical Psychology, University Hospital, Gent, Belgium Colin Pritchard, School of Health and Social Care, Bournemouth University, Bournemouth, UK Mirella Ruggeri, Department of Medicine and Public Health, University of Verona, Verona, Italy Pedro Ruiz, Department of Psychiatry and Behavioral Science, University of Texas Medical School at Houston, Houston, Texas, USA Ben Smith, Institute of Psychiatry, King’s College London, London, UK

LIST OF CONTRIBUTORS xi Robert Stewart, Section of Epidemiology, Institute of Psychiatry, King’s College London, London, UK John Strang, National Addiction Centre, Institute of Psychiatry, King’s College London, London, UK R. Thara, Schizophrenia Research Foundation (SCARF), Chennai, India Graham Thornicroft, Health Service and Population Research Department, Institute of Psychiatry, King’s College London, London, UK Peter Tyrer, Department of Psychological Medicine, Imperial College London, London, UK Kees van Heeringen, Department of Psychiatry and Medical Psychology, University Hospital, Gent, Belgium Philip S. Wang, Division of Services and Intervention Research, National Institute of Mental Health, Bethesda, Maryland, USA Richard Warner, University of Colorado and Colorado Recovery, Boulder, Colorado, USA Hans-Ulrich Wittchen, Max Planck Institute for Psychiatry, Mu ¨nchen, Germany John Witton, National Addiction Centre, Institute of Psychiatry, King’s College London, London, UK James Wollard, Surrey and Borders Partnership NHS Foundation Trust, UK



Foreword This second edition of Principles of Social Psychiatry burden on caregivers, as well as a new attention to the appears more than 15 years after the first one, and even social factors involved in access to care, resilience and a cursory comparison between the contents of the two recovery. Moreover, some issues of clear social re- editions clearly documents that the scope and the levance, such as the mental health consequences of impact of the social component of our discipline and disasters and the mental health problems in refugees profession have remarkably increased during the past and victims of torture, have now a much greater few years. visibility. There is now a more widespread awareness of Finally, the research evidence supporting the effi- the role of social risk factors even in the aetiology of cacy and effectiveness of psychosocial interventions mental disorders that had been traditionally perceived for major mental disorders, such as schizophrenia and to be mostly biological in their causation. Schizophre- bipolar disorder, has grown dramatically during the nia is a good example. The research evidence concern- past 15 years, and the shift from hospital-based to ing the association between some social factors – such community-based mental health care in several coun- as urbanicity and a history of migration – and the tries has generated a new interest in the link between likelihood of developing a psychotic condition is now theorganization of mental health services and patients’ quite robust, and there is also some evidence of a quality of life and satisfaction with care. synergy between these factors and familial liability in A psychiatric practice and a psychiatric research the causation of the disorder. that do not take the social dimension into account are Also increasing is awareness of the impact of social now unthinkable, and it is not surprising that the scope factors on the identification and the diagnosis of of these ‘Principles of Social Psychiatry’ is now mental disorders. The role of values in addition to becoming closer to a manual of general psychiatry. evidence in the diagnostic process is now widely One further feature of this volume is that it repre- appreciated. One of the most debated issues in the sents a bridge between different generations, with ongoing process of revision of the ICD and the DSM is some of the fathers of modern social psychiatry and the relationship between syndromal diagnosis and some young emerging researchers among the contri- impairment of social functioning. Furthermore, much butors, as well as a bridge between the core group of greater attention than in the past is being given to the UK scientists and leaders of several regions of the cultural relevance and acceptability of proposed diag- world. This gives the book a special flavour, which the nostic approaches, categories and criteria. reader will certainly appreciate. The past decade has witnessed a flourishing of research on the social consequences of mental dis- Professor Mario Maj orders, in terms both of stigma and discrimination and President, World Psychiatric Association



Preface Social psychiatry: alive and kicking Dinesh Bhugra and Craig Morgan NIH Biomedical Research Centre and Institute of Psychiatry, King's College London, London, UK The scope of social psychiatry is broad. Its remit of genetics and neuroimaging. This has led to some ranges from the impact of social structures and ex- inevitable hand wringing about ‘the future of social periences on the onset, course and outcome of mental psychiatry’ [1]. disorders, to the development and evaluation of com- It seems, however, that the obituaries are premature. plex social interventions and systems of service de- In the early 2000s, Professor David Goldberg lectured livery, to the influence of society on the construction widely on the topic ‘Social psychiatry: there is life of, and responses to, mental disorder. In this, it inter- after death’, and others have written in a similar vein sects with cultural and community psychiatry and [2]. Ironically, if the considerable advances in our with renewed interest in the philosophy of mental understanding of the human genome and the brain disorder, and draws from a number of disciplines, have told us anything, it is the degree to which the including social epidemiology, sociology and anthro- external environment impacts on and moulds what is a pology. This breadth is very much reflected in this flexible and adaptive biological system. As Leon current edition, with contributions from across the Eisenberg [3] notes: ‘... social psychiatry ... is alive social sciences. and well precisely because of genomics’ (p. 101). In its focus on the social dimensions of mental With hindsight, this was always going to be the case; disorder, social psychiatry occupies a somewhat pre- mental disorder in all its facets is intrinsically social – carious position given psychiatry’s primary orienta- it is both shaped by and in turn shapes the local social tion to the medical and biological. In many respects, and moral worlds of individuals. We can safely put to social psychiatry reached its peak in the 1960s and bed any angst-ridden concerns about ‘the future of 1970s following the closure of long-stay asylums and social psychiatry’. the relocation of care into the community. Since then, The contributions to this current edition reflect the however, social psychiatry (until recently at least) has breadth, necessity and vibrancy of social research in been in gradual retreat, pushed back by the seemingly psychiatry, and range from consideration of concep- inexorable advance of genetics and neuroscience and tual and methodological issues (i.e. the nature of their promise to uncover the basic biological under- mental disorder, how the social world can be studied) pinnings of mental distress. It is arguable that, as a to the social determinants of the onset, course and consequence, the scope of social psychiatry has outcome of mental disorders, to consideration of increasingly narrowed to health services research, mental health in a global context. This latter focus is leaving the business of aetiology to the ‘hard’ sciences relatively recent, and in part is a reflection of the

xvi PREFACE considerable changes that the world has undergone in Assembling this edition has, in itself, been a social the past 30 years, particularly processes of globaliza- enterprise. We would like to thank all our contributors tion, mass migration and rapidly changing social who, in spite of their busy schedules, have managed to structures. The perspectives and approaches typically deliver outstanding contributions. We are also grateful applied in social psychiatry may prove particularly to Joan Marsh, Fiona Mason and their teams at Wiley- useful in understanding how these rapidly changing Blackwell for an outstanding level of support and hard contexts impact on mental well-being and their work.In additiona note of thanks is hardly sufficientto implications for mental health care. What is more, the convey appreciation for all the work, sweat and toil contributions in this volume make it clear (if there was that Andrea Livingstone has put in behind the scenes. ever serious doubt) that understanding and responding to mental disorder is only possible if the social is considered in interaction with the genetic, biological REFERENCES and psychological; these are not competing alterna- tives, but constituent components of a single whole. 1. Lauber, C. (2008) Editorial. International Review of What we hope is that the essays collected in this Psychiatry, 20, 489–491. edition will provide both an introduction to core issues 2. Uchtenhagen, A. A. (2008) Which future for social and research in social psychiatry and a platform for psychiatry? International Review of Psychiatry, 20, future research that can further unpack how our social 535–539. lives contribute to the private (and social) misery of 3. Eisenberg, L. (2004) Social psychiatry and the human mental disorder. Perhaps then wewill know even more genome: contextualising heritability. British Journal of about how we can intervene to prevent and ameliorate Psychiatry, 184, 101–103. such suffering.

Part One Perspectives and methods



1 The historical development of social psychiatry Julian Leff Institute of Psychiatry, King's College London, London, UK Defining social psychiatry is not a simple matter as its realized the therapeutic potential of the group itself concerns and boundaries have altered over the years, (TheGuardian,Obituary,29August1990).Atthesame as becomes evident by tracing the history of the time Tom Main was working on a similar problem. He term. The Royal Medico-Psychological Association noted (personal communication, 1973) that the inci- (RMPA) had a section of Psychotherapy and Social dence of breakdown was higher in some army units Psychiatry that was established in 1946. The early than others, and these breakdowns could be legiti- meetings of the section focused on social psychiatry, mately viewed not only as throwing light on the pro- which, although never defined formally, was tacitly blems of the sick individual but on the organization to assumed to concern the study of social organizations, which he belonged (battalion, regiment, etc.). Main now considered to be the territory of sociologists, such studied these units in terms of disciplinary patterns, as Goffman, whose book on asylums was published in officer–man relations, welfare, social structure, roles, 1968 (see Chapter 5). The group, large or small, was role-relations and culture, capitalizing on a natural viewed as the entity on which social organizations experiment. Assuming that the assignment of soldiers were founded, and the term ‘social’ was used to mean to units was relatively random and knowing that they ‘appertaining to a group’. This conceptual framework were exposed to similar levels of combat stress, varia- originated from the experience during World War II tionsinpsychiatricillnessrateswereveryprobablydue of military psychiatrists, of whom the outstanding to differences in the social organization of the units. innovators were Maxwell Jones and Tom Main. From the experiences of Jones and Main with group JoneswaspartoftheMaudsleyHospitalteamatMill treatment and group structure emerged the concept of Hill Emergency Hospital, and was in charge of the the ‘therapeuticcommunity’, which Jones utilized first Effort Syndrome Unit with the remit to investigate the with returning prisoners of war and then established at cause of chest pains experienced by soldiers under Belmont Hospital, Sutton. It was therefore natural to stress.He beganto lecture to largegroups of soldiers in associate social psychiatry with psychotherapy when the hospital on the origin of their symptoms and soon the section was founded in 1946. Incidentally, when Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

4 PERSPECTIVES AND METHODS Jones wrote about his innovatory service in 1952 speakers. His topic was ‘preventive psychiatry’, which his book was entitled ‘Social Psychiatry’. In addition requires some explanation. to a concern with therapy, the section continued At the first meeting of the Executive Committee in with studies of various organizations, especially November 1973, the concerns of the Group were hospitals. subsumed under three main headings: In addition to Belmont, other psychiatric hospitals were influenced by the experience of military psy- 1. Promotion of the best possible organization and chiatrists. In Netley Hospital, which admitted soldiers disposition of community psychiatric services, suffering from psychiatric conditions, the psychia- both within the National Health Service (NHS) trists witnessed rapid recovery from serious symptoms and outside it. once men were removed from the stress of battle conditions. This instilled optimism about recovery, 2. Development of a liaison with allied groups, such which the psychiatrists brought into the ordinary as general practitioners and social workers, and psychiatric hospitals at the end of the war. While a also with similarly relevant groups not directly handful of pioneers, such as Duncan MacMillan, had involved with medical or social work functions established outpatient clinics outside the psychiatric such as teachers. hospital before the war, the new-found optimism of the military psychiatrists led to an increase in 3. Fostering of educational and scientific interests, discharges and a fall in occupied beds, which began such as postgraduate training in social psychia- in England and Wales in 1954, the year before the try, studies of social aspects of their treatment, introduction of chlorpromazine to clinical psychiatry. and epidemiological, evaluative and operational World War II also had an impact on psychiatric care inquiries. in the United States (US), but for different reasons from the UK. In Britain, conscientious objectors were It was anticipated that the Group would divide itself sent down the mines to extract coal, the so-called naturally into three working parties: the first area of ‘Bevin Boys’. In the US they were given the job of concern would be dealt with under the heading of orderlies in the psychiatric hospitals. These morally ‘Services’, the second under ‘Prevention’, and the motivated young men brought into the hospitals their third under ‘Epidemiology’. In effect these divisions humanitarian values, which were at variance with the amounted to the recognition of major differences in prevalent practice of custodial care. Their impact was interest, ideology and practice among the members of less revolutionary than that of the British military the newly established Group and its Executive Com- psychiatrists who were put in charge of the hospitals mittee. The discipline of psychiatric epidemiology as superintendents. That is one of the reasons why was well represented on the Committee by eight deinstitutionalization has been slower in the US than members drawn largely from the three Medical Re- in the UK. search Council (MRC) Units dealing with that field The RMPAwas superseded by the establishment of and the General Practice Research Unit at the Institute the Royal College of Psychiatrists in 1971, and two of Psychiatry headed by Michael Shepherd. The years later a Social and Community Psychiatry Group Committee also included a number of pioneers in the was set up within the College. Although it lost a development of community psychiatric services. nominal connection with psychotherapy, four mem- Although some of these had been involved in research bers of the inaugural Executive Committee were on studies, their reputation rested on their entrepreneurial the staff of the Tavistock Institute of Human Relations activities in creating innovative services. Their natural and one other was a therapist working with large affiliation was to the Services working party. The third groups. Furthermore, at the Annual General Meeting interest group on the Committee was largely derived of the College in July 1974 the Group organized a from the Tavistock Institute of Human Relations. Its session on ‘Prospects in Social and Community Psy- members can be viewed as providing the strongest chiatry’, in which Tom Main was one of the three link with the section for Psychotherapy and Social

THE HISTORICAL DEVELOPMENT OF SOCIAL PSYCHIATRY 5 Psychiatry in the preceding RMPA. The Executive the psychotherapists and the other members of the Committee evidently considered that the Prevention Psychotherapy and Social Psychiatry section of the working party was the most appropriate for them to RMPA. Hare, himself an epidemiologist, argued join, since Colin Murray Parkes was appointed as its forcefully ‘that the epidemiological aspects of social convenor. At the AGM of the College in 1974 each of psychiatry would develop more favourably in another the three speakers in the session organized by the soil, away from the immediate discussion and study of Group was associated with one of the working parties. psychotherapy’ [1]. John Wing spoke on ‘Epidemiology and research’, The uneasy association between psychotherapy and Jim Birley on ‘Community services’, and Tom Main social psychiatry was dissolved with the founding of on ‘Social and preventive psychiatry’. the College, when Psychotherapy shared with Child The association of the term ‘preventive psychiatry’ Psychiatry the distinction of being the first sections to with the therapeutic community movement is expli- be established. Interestingly, this predated by four cated by Hare [1] in his discussion of the relationship years the official recognition by the Department of between social psychiatry and psychotherapy. He Health of psychotherapy as a specialty. In contrast to identified two growing points in preventive psychia- the College south of the border, the Scottish branch try, one of these being group methods of treatment. He retained a section of Psychotherapy and Social Psy- viewed these as having close relations with psy- chiatry. Correspondence from its chairman indicated chotherapy, citing a publication by David Clark [2]. continuing conflict in aims between the two arms of Clark had established a therapeutic community at the Section. In 1981 the Group of Social and Com- Fulbourn Hospital, Cambridge, and later became a munity Psychiatry was granted section status during member of the Social and Community Psychiatry my chairmanship, and the existing working parties Group. Hare went on to argue that Maxwell Jones’ were discontinued, to be replaced by time-limited view of the functions of a therapeutic community working parties constituted to deal with specific is- broadened from an initial focus on the treatment of sues. In some respects this was a recognition that the established neuroses to include prevention. Hare con- initial ideological divisions had become less salient sidered the second growth area in preventive psychia- with the passage of time, and harmonious working try to lie in the domain of public health and to be relationships had become established. However, there represented by facilities such as hostels and work- is a need to sustain a boundary between social psy- shops. These were to become the remit of the Services chiatry and psychotherapy, partly to limit the territory working party of the College Group. of the former to a manageable area and partly to avoid The claim that therapeutic communities, or indeed acrimonious disputes over real or imagined imperia- any other form of psychotherapy, constituted listic ambitions. To this end, we will propose a defini- effective prevention was viewed with scepticism by tion of social psychiatry and in its exposition will the epidemiologists, since no research evidence was explore the possibility of establishing the boundary forthcoming. Considerable tension existed between referred to above. 1.1 A DEFINITION OF SOCIAL PSYCHIATRY Social psychiatry is concerned with the effects of the practitioners with little or no interest in research. The social environment on the mental health of the in- term ‘mental health’ is used in place of ‘mental ill- dividual, and with the effects of the mentally ill ness’ since there is a tradition in this field of the person on his/her social environment. promotion of health, beyond the prevention of illness and the accumulation of handicaps. The phrase ‘concerned with’ is preferable to ‘the In conceptualizing the social environment it may be study of’ since, as we have noted, many people who helpful to invoke the image of a pebble thrown into regard themselves as social psychiatrists are primarily water, generating a set of concentric circles becoming

6 PERSPECTIVES AND METHODS ever fainter with increasing distance from the pebble. trigger psychiatric illnesses. Past experiences include At the outer limit, culture exerts an effect, then moving relationships as well as happenings [9]. Whatever the progressively closer to the centre, workmates, friends theoretical construction proposed to represent past and family are increasingly influential. What is the experiences, be it self-concept (George Brown) or numerical lower limit of the social environment? Can latent schemata (Chris Brewin), it is difficult to main- two people be considered to form an environment? tain a clear distinction from psychodynamic theories The answer is clearly in the affirmative. Important concerning the self and its intrapsychic processes. research in the field has been concerned with the Some psychoanalytic theories are easier to reconcile influence of the family on the course of psychiatric with a socioenvironmental view than others, e.g. disorders. Depressed patients living with a partner and Freud’s seduction theory rather than his later renun- patients with schizophrenia living with a single el- ciation of it. However, the conclusion of this line of derly parent are examples of dyads that have been argument is that the topics of central concern to included in these studies and constitute legitimate psychotherapy, in its broadest sense, also fall logically subjects for research on social influences on psychia- within the ambit of social psychiatry. tric illness. Although psychotherapy and social psychiatry If dyadic relationships are fair game, then why not share a common interest in the origins of human the relationship between a therapist and client? It is distress, maybe they can be differentiated by their not possible to find grounds on which this should be preferred method of advancing understanding of its excluded. Indeed, there are precedents for this rela- determinants. Social psychiatry has relied heavily tionship being included in social psychiatric studies in on epidemiological techniques for its enquiries, in- the area of ‘illness behaviour’ and ‘help-seeking volving large numbers of subjects who are usually behaviour’. This research has included investigation representative of a particular population. By contrast, of the concepts of illness held by members of the research into psychotherapy and psychodynamics public, their views as to the appropriate treatments, until recent years has tended to be hermeneutic, rely- and negotiation between clients and practitioners over ing on the intensive study of individuals or small their respective models of illness [3–6]. It would be numbers of highly selected patients. However, current logical to extend these enquiries into relationships financial stringencies in the NHS are placing increas- between psychotherapists and their clients. Is theword ing pressure on all practitioners to provide evidence ‘relationships’ the key for which we have been search- for the effectiveness of their therapies. Partly in ing? Would it be tenable to argue that social psychiatry response to this situation, psychotherapy is beginning is legitimately concerned with client–therapist rela- to develop the academic arm of its discipline [10]. It is tionships but halts at the boundary to the psyche, predictable that psychotherapy will increasingly em- ceding intrapsychic events to psychotherapists of all ploy the research methods that are part of the stock in persuasions? This argument has been eroded by the trade of social psychiatry, diminishing the differences development of cognitive theories incorporating the in approach that we have outlined. individual’s concept of him/herself and theway he/she This extended argument has not led to the erection interprets external events [7]. In the extensive field of of a solid barrier between social psychiatry and psy- life events research, the notion of self-esteem has been chotherapy. The practitioners who belong to one or the invoked as a link between the lack of an intimate other seem to have reduced the tensions that were relationship and the depressing effects of events that apparent in their joint Group in the RMPA by devel- represent a significant loss [8]. oping a ‘gentleman’s agreement’ on territorial demar- Life events research is one example of the long- cation. We shall respect this agreement and the reader itudinal approach in social psychiatry. Although the will not find any chapters specifically dedicated to time-scale in this area of research is relatively short, it psychotherapy in this volume. However, many of the entails the same assumptions as longer-term research, contributors deal with topics that lie in the area of namely that experiences in the past are represented in overlapping interests between psychotherapy and so- the subject’s memory and operate in the present to cial psychiatry.

THE HISTORICAL DEVELOPMENT OF SOCIAL PSYCHIATRY 7 1.2 CROSS-FERTILIZATION Psychotherapy is not the only discipline that inter- Social psychologists have conducted numerous digitates with social psychiatry. Sociology, social studies of group processes, which are of direct rele- psychology, social anthropology and, more recently, vance to those topics in social psychiatry that emerged cognitive psychology have all made valuable contri- from group therapy. Medical sociologists have in- butions to the development of social psychiatry (see creased our understanding of the ‘sick role’ and of Chapter 5). Durkheim’s [11] classical study of suicide the relationship between clinicians and their clients. provided central themes for two of the British MRC Their work has illuminated the pathways traced by Units conducting research in social psychiatry (Norman individuals as they undergo the transition into patients Kreitman’s and Peter Sainsbury’s), while sociological (see Chapter 24). The studies of migrants, which critiques of institutions (e.g. see Reference [12]) stimu- constitute a substantial corpus of research within lated Wing and Brown [13] to initiate a line of research the field of social psychiatry, would have been very that continued for over three decades. The proposition ill-informed, if not fallacious, without the cooperation that social support protects against mental ill health of social anthropologists. These related disciplines derives from both social psychology and social anthro- have provided a cornucopia of theories, concepts and pology, and until recently was the major focus of techniques to enrich social psychiatry and stimulate its research in the Australian MRC Social Psychiatry growth. Examples of this cross-fertilization will be Unit [14]. encountered throughout this volume. 1.3 THE RISE OF BIOLOGICAL PSYCHIATRY During the second half of the twentieth century there in the US. This form of treatment has almost entirely was a steep rise in interest in and research on fallen into disuse, ousted by the introduction of the biological basis of psychiatric disorders, largely psychotropic medications and the lack of evidence stimulated by new techniques in imaging the brain and for the benefits of leucotomy. After a lapse of another the unravelling of the human genome. Biological fifty years, in 2000 the Prize was awarded to Arvid research was not neglected in previous decades. In Carlsson, Paul Greengard and Eric Kandel for fact two of the three Nobel Prizes for advances in the ‘pioneering discoveries concerning one type of treatment and understanding of psychiatric illnesses signal transduction between nerve cells, referred to were awarded in the first half of the twentieth century. as slow synaptic transmission. These discoveries Julius Wagner-Jauregg won the Nobel Prize for Med- have been crucial for an understanding of the normal icine in 1927 for showing that malarial treatment function of the brain and how disturbances in this improved the prognosis of patients with cerebral signal transduction can give rise to neurological and syphilis (general paralysis of the insane). He was a psychiatric diseases. These findings have resulted in contemporary of Sigmund Freud, who was disap- the development of new drugs’ (Press Release, Nobel pointed not to get the prize for his work on the nature Prize Committee, 2000). Of the three Laureates, all of unconscious mental processes. The next Laureate, working in basic science, Kandel was unusual in Egas Moniz, had been nominated twice for the Nobel having embarked on a psychoanalytic training, Prize for his development of the cranial angiogram which he abandoned for the laboratory. with his surgical associate, Almeida Lima, but was The successes of biological psychiatry gave rise to finally awarded the prize in 1949 for his introduction an optimism that a solution to the problems of the of lobotomy for psychiatric disorders. In the 1940s aetiology and treatment of psychiatric disorders was and 1950s more than 50 000 patients had lobotomies within grasp. Nowhere was this as ebullient as in the

8 PERSPECTIVES AND METHODS US, where the last ten years of the century were field of social psychiatry: Norman Kreitman’s in designated ‘The Decade of the Brain’. The embracing Edinburgh, Peter Sainsbury’s in Southampton, John of biological explanations for mental illnesses led to Wing’s in the Institute of Psychiatry in London, extravagant claims, such as the identification of the Michael Shepherd’s General Practice Research Unit gene for homosexuality, and was largely responsible in the same institution and George Brown’s in Bedford for the virtual extinction of psychoanalysis in the College, London. By the time John Wing retired in States. In the 1950s a psychoanalytic training was 1989 his and George Brown’s were the only two left. almost obligatory for anyone aspiring to practise as a I took over from John Wing for a period of six years, psychiatrist, and most heads of psychiatry depart- after which the unit was closed. George Brown’s unit ments had completed this. has not been continued after his retirement. At the time In the UK there was also a swing towards biological of the closure of my unit the MRC stated clearly that in psychiatry, butit was not as monolithic as in the States, future they would not support a unit that focused although it did have a dramatic impact in one sector; on social psychiatry without being integrated with the research units supported by the MRC. In the 1960s biological research. there were five such units engaged in research in the 1.4 SOCIAL PSYCHIATRY IN THE UNITED STATES The optimism generated by the experience of military were being discharged from the psychiatric hospitals. psychiatrists in World War II had a stimulating effect There were many unanticipated obstacles to be over- on the emerging social psychiatry movement in come, including the fact that a substantial proportion the US, as it did in the UK. Formal recognition of of people with schizophrenia needed prolonged and the changing atmosphere in psychiatry came with the sophisticated rehabilitation, which was not available creation of a National Institute of Mental Health in in the centres. There was also considerable opposition 1949. The Institute was faced with the major task of from the public who held stigmatizing attitudes. shifting the focus of care from psychiatric hospitals to Furthermore, there were entrenched financial inter- community services. The financial means to achieve ests, which the youthful workers lacked the political this were made possible by another milestone piece of experience to combat. legislation, the Community Mental Health Centres Widespread problems of homelessness developed Act passed by the Senate in 1963. This was a response among discharged patients, particularly in the cities. to President Kennedy’s call for a new approach to the The resource of using private landlords to provide delivery of services to people with psychiatric illness. board and care often led to abuse of the former The sum of 2.9 billion dollars was appropriated from patients, who received a minimal standard of shelter the federal budget for this purpose. and no care. Many of the discharged patients were The community mental health movement, which living in conditions that were no better than in the grew in strength from this injection of funds, was psychiatric hospitals, and a considerable number founded on the principles of social psychiatry, includ- ended up in prison, prompting the term ‘transins- ing the humane treatment of people with psychiatric titutionalization’ [15]. The financial provision for the illness, equality of access to health care, and the right centres was depleted by misappropriation of the fed- of all citizens to full participation in society. There is a eral funds by President Nixon in 1973. The net effect clear identity with the aims of the Civil Rights Move- of these problems was to sap the enthusiasm of the ment and of Feminism, both of which were making a proponents of the community mental health move- political impact during the same period. Many idea- ment, which largely failed to fulfil its aims. Brown listic young people took posts in the community ([15], p. 149) considers that ‘the last era of general mental health centres and attempted to provide a high optimism was the community mental health period, quality of care for the mass of long-term patients who roughly located in the decade and a half from

THE HISTORICAL DEVELOPMENT OF SOCIAL PSYCHIATRY 9 80 British Journal of Psychiatry American Journal of 70 Psychiatry Percent 60 50 40 30 20 1951 1956 1961 1966 1971 1976 1981 1986 1991 1996 2001 2005 Year Figure 1.1 Proportion of psychosocial articles in American and British Journals of Psychiatry (Reproduced with permission from Cambridge University Press) 1960–1975 ... many of the great promises of this Inspection of the two lines in Figure 1.1 shows that approach were not met. In this failurewe can locate the in 1951 the AJP published a small majority of psy- preconditions for the rise of a new biologism, a more chosocial articles, whereas the BJP published a great strictly biomedical and asocial view of mental health predominance of biological articles. Most of these and illness’. dealt with aspects of insulin coma therapy, leucotomy, In the US the interest in social psychiatry has not treatment of epilepsy and penicillin for neurosyphilis. been completely extinguished. Some enthusiasts con- During the following decade the proportion of biolo- tinue to develop innovative and cost-effectivecommu- gical articles in the BJP gradually fell, with a con- nity services, but the swing to a biological model of tinuation of the same topics, but also studies on mental illness has been overwhelming. However, de- electroconvulsive therapy and the newly introduced spitethevastsumsofmoneythathavebeenpouredinto psychotropic drugs: chlordiazepoxide, tricyclic anti- biological research in the US, the Decade of the Brain depressants and antipsychotics.During this decade the failed to introduce any novel treatment for psychiatric proportion of psychosocial articles in the AJP de- illnesses, while during the same decade psychosocial clined as controlled and uncontrolled studies of the treatmentsforschizophreniaanddepressionhavebeen new psychotropic drugs began to be published. established by randomized controlled trials, including Then between 1961 and 1966 there was a steep rise family intervention for schizophrenia [16], cognitive in the proportion of psychosocial articles in both behaviour therapy for schizophrenia [17] and couple journals, the slopes being almost parallel. However, assisted therapy for depression [18]. the difference in proportions between these two years’ An indication of the different historical trajectories issues was of much greater significance for the AJP 2 2 of social psychiatry in the US and the UK is illustrated (X ¼ 30.64, df.1, p < 0.001) than for the BJP (X ¼ by acomparison of articlesin the two principal general 9.46, df.1, p < 0.001). Both journals maintained the psychiatry journals in the US and UK, from which high proportion of psychosocial articles over the next the great bulk of world psychiatric research emanates: decade, the period identified by Brown ([15], p. 149) the American Journal of Psychiatry (AJP) and the as the era of greatest optimism for community psy- British Journal of Psychiatry (BJP). This study in- chiatry. As noted above, it also coincides with the volved an analysis of the topics of articles in the two development of the Civil Rights Movement in the US journals over the 55 years from 1950 to 2005, in which and the rise of Feminism. In 1966 the AJP included a a full year of journals for the first and sixth year special section of one issue on Social Psychiatry, and of each decade was scrutinized [19]. Articles were articles were also published on ‘The stresses of the categorized broadly as biological, social and neutral white female worker in the Civil Rights Movement in (not fitting into either of the other two categories). the South’ and ‘Psychological aspects of the Civil

10 PERSPECTIVES AND METHODS Rights Movement and the Negro professional man’. frequently part of a package linked to employment, so These topics constitute further evidence for the influ- that peoplewithout a job lose out. A high proportion of ence of the cultural and political environment on the people who develop schizophrenia are unemployed contents of both psychiatric journals, suggested by the at first contact with the services, 82% of African- timing of the rise evident from the graphs. Caribbean patients in a recent UK study [20]. Because In parallel with the declining fortunes of the com- psychoses are often life-long conditions, they are not munity mental health movement, the proportion of profitable for private insurance companies, and there- psychosocial articles in the AJP begins to fall. This fore usually fall under the state medical care system, in descent continues in an almost linear fashion over the which standards are uneven. By contrast, the UK next two decades, reaching its lowest level in 50 years National Health Service excludes nobody from health (34.8%) in 2001. At this point in time the AJP features care, regardless of their economic status and the almost twice as many articles of a biological nature as chronicity of their illness. It is truly comprehensive. psychosocial articles. By contrast, the proportion of Another important difference in practice is the psychosocial articles in the BJP, after a moderate fall tradition of home visiting in the UK. It was standard from 57.9% in 1966 to 46.3% in 1981, rises slowly for general practitioners to visit their patients in their but steadily to 59.0% in 2005, its highest level in the own homes, although this has become less common, 55 years of the survey. By chance the proportions in whereas in the US doctors work in offices, to which the two journals are virtually identical in 1986, when patients are expected to travel. In the UK, community the descending graph of the AJP crosses the ascending psychiatric nurses and community occupational thera- graph of the BJP. From this point, in terms of the pists regularly see patients at home, and psychologists publication of psychosocial articles, the two journals and psychiatrists do so when necessary. In fact, this is have been moving progressively further apart over the the ideological basis of community mental health next two decades. The BJP shows a significant in- teams and crisis teams, the aim being to ensure that crease in the proportion of these articles, while the everyone who needs the service has unrestricted AJP exhibits a significant decrease of approximately access to it. the same magnitude. As a result, by 2005 the differ- A damper on swings of opinion in psychiatry is ence in the composition of the two journals is highly provided by the inherent caution of the UK psychiatric significant. profession. Sceptical of embracing innovative move- How can we account for the opposing trends in the ments uncritically, British psychiatrists were not en- publication of psychosocial articles in the American thusiastic about psychoanalysis, and it did not achieve and British Journals of Psychiatry? They appear to the widespread acceptance that characterized Amer- reflect a genuine divergence in both the research effort ican psychiatry in the mid-twentieth century. There and in the practice of psychiatry. Research in social have never been more than four hundred trained psychiatry is more strongly influenced by clinical psychoanalysts in Britain. That is not to say that practice than biological psychiatry, which depends psychodynamic ideas and concepts have failed to heavily on technical advances in areassuch as genetics influence the practice of psychiatry in the UK, but and brain imaging. There are major differences in the they have been absorbed into an eclectic mix of structure of the health services in the two countries, approaches rather than becoming the dominant para- which determine the practice of psychiatry. In the US, digm. Similarly, while biological psychiatry has its health care is dominated by the private insurance adherents in the UK, few psychiatrists rely solely on companies such as Blue Cross Blue Shield, which physical methods of treatment, to the exclusion of offers health insurance in every US state. Their policy attention to the patient’s social environment, includ- is to reject applicants who have a pre-existing medical ing close relationships. condition. Peoplewith psychiatric illnesses often have In conclusion, the comprehensive nature of the a long prodrome before seeking medical help, en- National Health Service in the UK, the standard abling the insurance companies to exclude them on of care provided to all psychiatric patients regardless this ground. Furthermore, private health insurance is of diagnosis and chronicity, and the high proportion of

THE HISTORICAL DEVELOPMENT OF SOCIAL PSYCHIATRY 11 staff who see patients in the setting of their family 9. Brown, G. W., Bifulco, A. and Harris, T. (1987) Life through home visits, are conducive to a social ap- events, vulnerability, and onset of depression: some proach to mental illness. In combination with the refinements. British Journal of Psychiatry, 150, 30–42. traditional eclecticism of British psychiatry, these 10. Roth, A. and Fonagy, P. (2005) What works for whom? factors will ensure the persistence of social psychiatry in A Critical Review of Psychotherapy Research, as an ideological and practical discipline. However, Guilford, New York. the advances in biological psychiatry cannot be set 11. Durkheim, E. (1951) Suicide: A Study in Sociology, aside. The policy enunciated by the UK MRC during Free Press, Glencoe, Illinois. Originally published 1897 the Decade of the Brain is correct: collaboration is (translated by J. A. Spaulding and G. Simpson), F. Alcan, Paris. necessary between biological and social psychiatrists so that the advances in social psychiatry can be under- 12. Goffman, E. (1968) Asylums: Essays on the Social Situation of Mental Patients and Other Inmates, pinned by new knowledge of brain functioning, and Penguin, Harmondsworth. the discoveries of the workings of the brain can 13. Wing,J.K.andBrown,G.W.(1970)Institutionalismand be given a meaning through understanding of the Schizophrenia, Cambridge University Press, London. patients’ social environment. 14. Henderson, A. S., Byrne, D. G., Duncan-Jones, P. et al. (1980) Social relationships, adversity and neurosis: a study of relationships in a general population study. REFERENCES British Journal of Psychiatry, 136, 574–583. 15. Brown, P. (1985) The Transfer of Care: Psychiatric 1. Hare, E. A. (1969) The relation between social Deinstitutionalisation and its Aftermath, Routledge psychiatry and psychotherapy, in Psychiatry in a and Kegan Paul, Henley-on-Thames. Changing Society (eds S. H. Foulkes and G. Stewart 16. Pharoah, F., Mari, J., Rathbone, J. and Wong, W. (2006) Prince), Tavistock, London. Family intervention for schizophrenia. Cochrane 2. Clark, D. H. (1965) Adminstrative Therapy: The Role Database of Systematic Reviews, (3), Art. No.: of the Doctor in the Therapeutic Community, CD000088. DOI: 10.1002/14651858. CD000088. Tavistock, London. 17. Jones, C., Cormac, I., Silveira da Mota Neto, J. I. and 3. Mechanic, D. and Volkart, E. H. (1960) Illness Campbell, C. (2004) Cognitive behaviour therapy for behaviour and medical diagnosis. Journal of Health schizophrenia. Cochrane Database of Systematic and Human Behaviour, 1, 86–96. Reviews, (3), Art. No.: CD000524. DOI: 10.1002/ 4. Young, A. (1981) When rational men fall sick: an 14651858. CD000524.pub2. enquiry into some assumptions made by medical 18. Leff, J., Vearnals, S., Brewin, C. R. et al. (2000) The anthropologists. Culture, Medicine and Psychiatry, 5, London Depression Intervention Trial: randomised 317–335. controlled trial of antidepressants versus couple 5. Health Education Studies Unit (1982) Final Report on therapy in the treatment and maintenance of people the Patient Project, Health Education Council, London. with depression living with a partner: clinical outcome 6. Kleinman, A. (1986) Social origins of distress and and costs. British Journal of Psychiatry, 177, 95–100. disease: depression, in Neurasthenia and Pain in 19. Leff, J. (2007) Climate change in psychiatry: periodic Modern China, Yale University Press, New Haven, fluctuations or terminal trend? in Society and Psychosis Connecticut. (eds C. Morgan, K. McKenzie and P. Fearon), 7. Brewin, C. R. (1988) Cognitive Foundations of Clinical Cambridge University Press, Cambridge. Psychology, Lawrence Erlbaum, London. 20. Mallett, R., Leff, J., Bhugra, D. et al. (2002) Social 8. Brown,G.W.,Andrews,B.,Harris,T. etal.(1986)Social environment,ethnicityandschizophrenia: a case control support, self-esteem and depression. Psychological study. Social Psychiatry and Psychiatric Epidemiology, Medicine, 16, 813–831. 37, 329–335.



2 Why psychiatry has to be social Paul E. Bebbington Department of Mental Health Sciences, University College London, London, UK Psychiatrie ist soziale Psychiatrie oder sie ist keine Psychiatrie Klaus Do ¨rner [1] ... when my friend, Sam Guze [.. .] entitled his Royal College Lecture: ‘Biological psychiatry: is there any other kind?’ he meant the answer to be: ‘Of course not’ and he was absolutely right. When I ask: Social psychiatry: is there any other kind? the only tenable answer is: ‘of course not’ Leon Eisenberg [2]. 2.1 INTRODUCTION Social psychiatry has no precise definition, but has my view, these positions are not radical enough: been described, rather unambitiously, as a topic and a psychiatry has an essentially social component set of techniques of investigation. These techniques because the phenomena we seek to explain have are primarily epidemiological, but include methods of inherently social attributes. While mental illness is evaluating social processes in relation to psychiatric by no means totally social, it is essentially social. disorders. It applies to psychiatry the purposes of We must therefore start further back. Psychiatry is a epidemiology (identification of syndromes, refining branch of medicine. By this we assert that it shares the clinical picture of disorders, community health, with medicine its matter and its method. However, in individual risks, analytical and experimental epide- so doing, we open the door to complexity, as we shall miology, operational analyses of health services, his- see. The matter of medicine is the syndrome, and its torical epidemiology [3]). There are tensions between method is the construction of syndromes and their use those who, like Michael Shepherd [4], try to deal with in testing hypotheses of aetiology, mechanism, patho- the problem of defining social psychiatry by subsum- logy and treatment. Syndromes are hypothetical con- ing it under epidemiology and those, like John structs derived speculatively from clinical knowledge Wing [5,6], who take a broader view of its remit. In and intuition: patterns of medical phenomena are Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

14 PERSPECTIVES AND METHODS identified and grouped, with the idea that they will that if the latter are refuted we will nevertheless form useful substrates for investigation. Symptoms stick by the syndrome. Only, however, up to a point: are medical phenomena that constitute syndromes, there may come a time when there has been so little and syndromes are made up of patterns of symptoms gain in knowledge about the syndrome that we (there is thus an element of bootstrapping in this finally reject it on grounds of a lack of utility, intellectual process). If the various theories relating and rearrange the medical phenomena into new to a syndrome are well corroborated, we start to call forms [5]. them diseases. So far, we have been tellingly reluctant This medical method is also that used in psychia- to do this in psychiatry. If the theories about particular try. However, there is something unusual about the syndromes are not corroborated, we look for better symptoms used to construct syndromes in psychiatry. theories. Wing suggested that the term ‘symptom’ in psychia- Medicine, in this analysis, is thus very much a try is analogous to its use in medicine. This might Popperian venture, and an extremely powerful imply that the concept of symptom in psychiatry does means of generating knowledge. This is quite evident not completely map on to the concept as used from its spectacular progress over the last century in medicine, and I would argue that such is indeed and a half. Syndromes have primacy over theories, in the case. 2.2 SOCIAL MEDICINE AND SOCIAL PSYCHIATRY Social medicine is defined by its intentions: to under- the social element is usually regarded as external to the stand how social and economic conditions influence concept of physical disease. While it is true that health, disease and the practice of medicine, and to people’s social environment and their behaviour may promote conditions whereby this understanding can determine a relatively strong exposure to the physical improve the public health. In some respects social aetiological factors that lead to the disease, most psychiatry looks like the psychiatric version of this social factors are not themselves generally regarded endeavour. It is true that both rely heavily on the as being directly aetiological (the concept of stress is methods of epidemiology. Epidemiology is predicated an exception, but in relation to physical disorders, it is on the concept of disease (the central medical con- usually formulated in terms of its physiological and struct) and on the derivative process of case finding. physical effects). Social epidemiology involves the use of social Similar sets of assumptions are held by many concepts to explain patterns of health in the popula- academics who carry out social psychiatric research. tion. Such patterns are established by applying demo- Their research may be valuable, but the assumptions graphic and social constructs that themselves com- carry risks in social psychiatry. This is because of the monly arise from sociology. This, for example, would special nature of the disorders being investigated, include the distribution of schizophrenia in relation to based as they are on symptoms with very particular social class or urbanization [7–10]. In social medicine, attributes. 2.3 THE MENTAL NATURE OF SYMPTOMS All symptoms, whether relating to physical or psychia- self-reports enable the physician to focus on signs, tric disorder, are based on self-report. Thus the details broadly defined. These include both the appearance of of cardiac pain are elicited by a process of cross- the patient and the results of investigations. Thus the questioning about the nature of the experience. Such self-report is corroborated by external, consensually

WHY PSYCHIATRY HAS TO BE SOCIAL 15 verifiable, procedures, which are linked in turn to an the symptom has primacy over any accompanying ever-growing knowledge of underlying biological signs. processes. In order to consider these issues, I will relate most of This is not the case with psychiatric symptoms. the arguments that follow to schizophrenia, as it is There may be external signs corresponding to the generally regarded as having a major organic, i.e. internal experiences reported by psychiatric patients, neural, component. Schizophrenia is of particular but they do not command the same force of validation interest because it is the condition that tests most as in general medicine. Thus if someone behaves as strenuously both the psychosocial and the neural lines if they are hallucinated by appearing to talk to ima- of explanation. It does this because of the symptoms ginary voices,this has less value than clear self-reports on which the diagnosis is primarily based, viz. anom- from patients that they are indeed hearing voices. alous experiences and abnormal beliefs. These will be In psychiatry, the subjective content that makes up discussed in detail later in the chapter. 2.4 THE CARTESIAN AMBIGUITY AND SOCIAL PSYCHIATRY Mental states are categorically different from brain anguish on his face and the distress I feel watching him states, in that we experience them, as it seems, from is no doubt correlated with activity in brains that within. Nevertheless, mental states are generally taken happen to be 3500 kilometres apart, but it is certainly to be predicated on the existence of brain states. This is not explicable in any satisfying way in such terms. In of course a form of reductionism, perhaps the ultimate this instance, an adequate explanation must surely go reductionist tenet. As such, it is what Popper [11] beyond the neural to the psychological and the social. would call a metaphysical research programme, not While it may be interesting, it is not enough to know testable as a totality but open to critical evaluation and how empathy might be related to mirror neurones, capable of giving rise to testable and useful hypoth- and the neural systems underlying mirroring and eses, which then support the heuristic value of the mimicry [12]. We need to know the whys and where- programme. It is certainly plausible: although there fores of this individual empathic act. are people who would believe otherwise, I am pretty The activity of brains is somehow segregated so that certain I will no longer have mental states when my weareobligedtorecognizeanddistinguishinternaland brain dies. I also feel reasonably securely that, so long external realities. The latter is projected, such that we as I have a morsel of brain, there will be thoughts. In perceive and recognize it as external. In other words, it other words, mental states are predicated on the ex- is out there rather than in our minds. Although the istence of a brain in so far as the latter seems to be a ontological origins of the distinction between an inner necessary condition of the former. andanouterworldareamatterofdispute[13],itishard We must of course be very careful in our use of forhumanbeingstodisputethefactofthedistinctionat language in relation to brain states. To say that brains an experiential level. Our perception of an external do something is at best a metaphor and at worst a reality is so compelling we virtually never question it. category mistake. There is activity that underwrites We may question what we see but we virtually never propensity, but activity is not action, memory is not question that we see. We question our sensations, but memories. Nothing based on self-report is primarily a rarely the fact of our senses. neural construct. We are bolstered in this by a degree of corroboration The link between brain states and mental states is a so extensive that it is compelling in itself. Corrobora- matter of wonder, although philosophically disturb- tion can take the form of consistency – we recognize ing. However, there are circumstances in which it may things as we remember them – but also because of also appear trivial. In my living room I see a man consensual verification. In our external world are holding a child who is pale, bloodied and dead. The entities that look like us, with whom we communicate

16 PERSPECTIVES AND METHODS and whom we use to confirm our experience of the Unlike physical disorders, mental illnesses are world. always about problems engaging with the social world, It is relatively easy to confirm matters of physical and this is the way in which they are identified. The fact – the existence of given numbers on paper, the symptoms by which they are recognized have inherent position of mercury on a thermometer. However, social aspects, even when most bizarre. For example, social facts are more difficult. We may see our Prime auditory hallucinations usually take the form of voices Minister at a podium, we may agree on the actual and of people in a relation with the hearer. This is words he uses, but column inches are written in an the quality identified by the protophenomenologist attempt to arrive at a consensus about what he meant, Brentano ([14], pp. 88–89) as intentionality.He how it was received and what its implications are for asserted that mental states are directed towards things future events. Moreover, such judgements rarely different from themselves, and this distinguishes them achieve final consensus. (Politicians of course like to absolutely from physical states; all, and only, mental take refuge in the so-called judgement of history, but states exhibit intentionality. 1 happily that, too, is never final.) Mental illnesses may also have a basis in physical Unlike mental states, we perceive brain states on the malfunction, but this is not necessarily true, and outside. Indeed, in contradistinction to some other certainly not necessarily true in every case. Indeed, parts of our bodies, we have absolutely no direct attempts to findsuch physical features have so far been information about them from the inside. We infer them nonspecific or ambiguous. The implication is that the from the results of our procedures for realizing them, aetiology of mental disorders is guaranteed to contain particularly, these days, from neuroimaging. Thus the social components, and may indeed sometimes have contrary claim, that brains are predicated on the ex- predominantly social components. The position is istence of mental states,is equallydefensible; thebrain further complicated, as we shall see, by the fact is a mental construct, albeit one that is very well that abnormalities that appear qualitative may arise corroborated. Such is the compelling nature of our because of quantitative variation in normal processes experience of an external world we do not regard rather than in qualitatively abnormal ones. brains as mere figments of our productive imaginings. What is clear is that the syndrome of schizophrenia We thus readily believe that brains exist separately is built out of mental experiences that cannot be from us, and that functioning brains will exist after we mapped on to corroborative tests tapping into biolo- ourselves no longer have mental states. gical functions. This might be an empirical deficit Let us therefore accept the idea of the brain as the open to remedy, but I will argue that it is in fact a underpinning of mind. However, I would also argue conceptual one. The distinction between internal and that neural explanations are not the same stuff as external worlds, the possibility of error and the avail- mental explanations. They do not necessarily have ability of consensual verification are all central to the primacy and may indeed be unfit for purpose in some concept of mental symptoms and thus of mental circumstances. disorder. 2.5 MAKING SENSE IN AN ERROR-STREWN WORLD Making sense of theworld is what humans (and quite a but much harder when information is incomplete. few nonhumans) do. It relies on the receipt of infor- A major function of this activity is the resolution mation about the world and the analysis of that of discrepancies, and much psychiatric symptomatol- information in terms of our existing understandings. ogy reflects idiosyncratic solutions to the fact of Making sense is easy when we have full information, incomplete or incompatible information. There may 1 Interestingly, Brentano [14] did not insist that the things that mental states are about are extended and physical. They can be internal and mental, a view with parallels in modern psychological ideas about metacognition [15].

WHY PSYCHIATRY HAS TO BE SOCIAL 17 be neural impairments in our ability to receive in- is taken as a key feature of psychosis. There have been formation, arising variously from failing sense organs attempts to liken this to the denial and neglect or failures in parts of the brain and its functions. Other syndromes often seen with injuries to the right impairments in this ability are only neural in a trivial hemisphere of the brain. However, lack of insight into sense, for instance when distorted reception is the the nature of anomalous experiences seems in general result of incoming information discrepant with prior more likely to be a secondary process in which the information – we may not see something because we compelling nature of the experience of, say, hearing are not expecting it and we may reject information voices is set against the prior knowledge that voices because it is incompatible with an existing set of cannot be disembodied. It does seem unlikely that beliefs. There are other instances where we just do such a bet on relative likelihoods is central to the not have enough information. This is rather similar to psychotic process, particularly as insight appears a the efforts of thevoice recognition software I am using composite and dimensional phenomenon in a way to dictate this chapter. If I stumble, mumble or cough, that neglect syndromes are not. Lack of insight then it gives the impression of trying desperately to make becomes the resolution of discrepancies in a manner sense of something inherently nonsensical, resulting unconvincing to others. It is really no more than a in weird combinations of words. This is not a pro- statement that the individual is having to deal with a gramme fault. It may have parallels in the confabula- compelling experience. tion seen in the Korsakoff syndrome, which, interest- This emphasizes also that making sense of experi- ingly, seems at least partly to have social drivers: we ence is normally a collegial (and therefore social) confabulate partly because we know it is not normal or process. We check out our ideas with our fellows. Thus socially acceptable to have big gaps in memory. it is known both clinically and from research that Thus the human propensity to make sense of things social isolation reduces levels of insight [16]. It is also may misfire when there are discrepancies to be often apparent in relation to phenomena like folie a resolved. Consider an example: psychiatrists have deux (and a trois and a quatre) [17]. Finally, it feeds struggled with the concept of impaired insight, which into the development of odd ideas and delusions. 2.6 ANOMALOUS EXPERIENCES The term anomalous experience is increasingly used processes underlying the mental experiences corre- as shorthand for a range of odd symptoms held to sponding to the symptoms. This activity should be typify psychotic and quasi-psychotic states. They are distinguished from actual explanation – it is more akin of particular interest because they have inherently to exegesis, although it does increase the potential social components, and yet they involve transgression targets for explanation. An example is provided by of the distinction between inner and outer worlds. Frith in his interesting account of passivity experi- They may also seem odd, and this was the foundation ences as a combination of ‘forward memory’ and an of Jaspers’ un-understandability argument, to the effect exaggerated sense of agency (‘if it is not me, it must be that mental phenomena we are incapable of understan- someone else’) [19]. ding must have an additional cause, explicitly neural The descriptions of psychotic symptoms in the [18].Thiswouldincludesuchanomalousexperiencesas psychopathological literature have resulted in rela- hallucinations, passivity experiences or abnormalities tively precise differentiation, but a relatively uncritical of the experience of thought. Bizarre ideas would also acceptance that the individual symptoms so con- have a neural basis. These prima facie assumptions are structed are distinct [20]. Nevertheless, psychopatho- based on the oddity of the reported experience. logical analysis may also be used to clarify linkages There is still mileage in the psychopathological between symptoms conventionally regarded as sepa- refinement of our concepts of mental symptoms. We rate. For example, there are relationships between may amplify descriptions by attempting to discern the thought insertion, loud thoughts, thought broadcast

18 PERSPECTIVES AND METHODS and hallucinations. The essence of thought insertion is are externally projected. Such thoughts share this notthe idea of external origin (a secondary explanatory feature with some, but not all, forms of auditory delusion), but the loss of the sense of possession of the hallucinosis. mental experience. This is shared by other passivity Thus these four types of symptoms exhibit var- experiences, but also by auditory hallucinations. Loud iously the loss of the sense of possession, loudness and thoughts are thoughts acknowledged as their own by external projection, and the presence or absence of the people experiencing them, but they have the quality each of these three features determines which symp- ofloudnessthatdefinesourexperience ofsoundwaves. toms may be identified. Taking Jaspers’ view, they all This quality is one of the characteristic attributes of our look like candidates for an inherently neural explana- external world and is shared of course with auditory tion. However, there is considerable evidence that hallucinosis. Descriptions of thought broadcast have hallucinations at any rate are causally related to been disappointingly vague, but close attention to particularly extreme social experiences, examination the accounts of those who suffer from it reveals that of which at least allows us to set out in more detail the essential feature is the experience of thoughts that what is to be explained. 2.7 HALLUCINATIONS, PSYCHOSIS AND TRAUMATIC ABUSE The abuse of children is sadly common. A recent UK are not uncommon [32,33]. Hamner et al. [34] com- survey estimated a prevalence of childhood physical pared veterans displaying long-standing PTSD and abuse of around 24% and sexual abuse of about psychotic features with a sample of patients with 11% [21]; higher estimates have been reported from schizophrenia without PTSD. They found very few the USA [22]. By the age of 7 years, approximately differences in the form and intensity of the psychotic 17% of children from a nationally representative birth features, suggesting that schizophrenia associated cohort in the UK reported being bullied [23]. with PTSD is indistinguishable clinically from the This abuse has severe consequences for the mental condition in general. health of the victims [24,25]. In particular, it has strong People with psychosis have a very high prevalence links with psychosis [26,27]. Child physical and of PTSD, often undiagnosed [29,35]. High rates of sexual abuse is significantly associated with psychotic PTSD in people with psychosis and of psychotic symptoms [28,29]. Lysaker et al. [30] found that over phenomena in patients with chronic PTSD were con- 40% of people with schizophrenia had experienced firmed in their systematic review by Seedat et al. [36]. child sexual abuse. Using British National Psychiatric While the prevalence of major trauma is very high Morbidity Survey data, Bebbington et al. [24] reported indeed, rates of frank PTSD are appreciably lower relative odds of psychosis of around 12 in people who [37–41]. The severity of trauma is associated with the had experienced sexual abuse. Moreover, a history of severity both of PTSD and of psychotic symp- childhood abuse in nonpsychotic members of the toms [30,39,40]. Thus early trauma appears to create general population predicted the development of a nexus of interacting adverse consequences. new positive psychotic symptoms at a two-year PTSD is a condition defined essentially by an follow-up [31]. intimate relationship between the content of symp- These links between trauma and psychosis form toms and the experience of strongly traumatic events, part of a triad. Thus there are also links between in particular the phenomenon of re-experiencing. One trauma and post-traumatic stress disorder (PTSD) (by possibility is that some people who have been exposed definition), and between PTSD and psychosis. This to extreme trauma develop psychotic symptoms (de- has implications not just for the role of stress in the lusions, hallucinations) whose content is also closely aetiology of schizophrenia, but also for potential related to the details of the traumatic experience. If mechanisms. this happens, it may come about by a totally different Psychotic symptoms in response to combat trauma process from the genesis of symptoms in the majority were reported by Paster as long ago as 1948, and of cases of schizophrenia, or it may not.

WHY PSYCHIATRY HAS TO BE SOCIAL 19 Some might argue that florid symptoms in PTSD that the mechanism is not always a direct one invol- merely mimic psychotic symptoms. Thus, re-experi- ving the usual effects of trauma. encing may have a compelling visual or auditory Another aspect of the PTSD/psychosis link con- quality that could be mistaken for hallucinations. cerns the potential involvement of dissociative pro- However, even inveterans exposed to extreme combat cesses. Glaslova et al. [47] suggest that traumatic stress, the distinction between flashbacks and psycho- stress exerts its influence on schizophrenia precisely tic symptoms can be clearly made [42]. In other by increasing the tendency to dissociative processes. studies as well, the meaningful connection between Holowka et al. [48] certainly found childhood trauma the characteristics of trauma and the content of symp- was associated with the significant presence of dis- toms is not always apparent. Thus, Butler et al. [43] sociative symptoms in people with schizophrenia. felt that, in their series, the psychotic symptoms Kilcommons and Morrison [40] also reported that associated with PTSD were not themselves linked to dissociative processes consequent upon trauma were re-experiencing the trauma. associated with psychotic experiences, and with hal- Hallucinations seem to be particularly frequent in lucinations in particular. However, it should be noted psychosis associated with trauma. Thus, all but one of that this relationship has not been found in all stu- the Vietnam veterans with psychosis studied by David dies [49]. Irwin [50] suggested that the link between et al. [32] experienced auditory hallucinations. Sexual dissociative experiences and PTSD might arise be- abuse has been strongly linked to hallucinations in cause both were associated with childhood trauma. other empirical studies [40,44]. Moreover, the trauma/ However, controlling for childhood trauma did not hallucination link does not appear to be restricted to remove the association. schizophrenia. Hammersley et al. [45] found trauma The links between trauma and hallucinosis in psy- was also associated with auditory hallucinations in chosis may be an example of a situation where an bipolar disorder. This relationship was particularly abnormal concatenation of normal social circum- strong for sexual abuse that had occurred in childhood. stances results in an outcome that appears to represent Hardy et al. [46] examined the issue in more detail. a qualitative shift. It probably does this by activating a They found that in many cases where trauma precedes response propensity that is variably but widely dis- hallucinations, the hallucinations are only themati- tributed in human populations, i.e. to hallucinate [51]. cally related to the trauma – they did not often involve There are other aspect of psychosis where similar recapitulation of the traumatic event. This suggests processes might apply. 2.8 DELUSIONS Historically, the abnormal beliefs of people with The inevitable inference is that delusional ideas shade schizophrenia have defined the concept of delusion. into normal ideas. In other words, delusions were the ideas put forward Moreover, some people whom you would not wish by people who were regarded as mad. Again, it has to call deluded have ideas of strange content. The always been felt that the process of delusion formation distribution of unusual beliefs in the populace is was a qualitatively abnormal one that would be neural extensive. Many people are convinced of the truth of in basis. ideas that are not supported by available and acces- Delusions are beliefs that are held to be abnormal sible evidence. These include beliefs in astrology, primarily in content. It is possible to describe the alien beings, telepathy or ghosts. Political beliefs are characteristics of delusions (false ideas that are held held with strong conviction even though they may be with very strong conviction, are not amenable to untried, or indeed tried and found wanting. Many counter argument or contrary evidence, are not shared religious ideas if taken literally are demonstrably by others, and motivate behaviour). However, there is false (the one that particularly exercised Martin no criterion or set of criteria that is both sufficient and Luther was transubstantiation). Nevertheless, people necessary to define the phenomenon of delusion [52]. may adhere to their religious belief with extremely

20 PERSPECTIVES AND METHODS 30 y = 24.474e -0.2569x 25 Percentage of population 20 R = 0.9286 2 15 10 Figure 2.1 The distribution of Paranoia Checklist 5 items endorsed by students [58] (Reproduced from The 0 British Journal of Psychiatry, 186: 427–435 with per- 0 5 10 15 20 mission from the Royal College of Psychiatrists) Total number of checklist items strong conviction and they may act upon the idea, The distribution of odd beliefs in the community sometimes to their own detriment. However, we do has been studied empirically. Freeman et al. [58] not generally choose to regard people of faith as found that 30% of an internet sample of students had having a psychiatric disorder. This is the social get- ‘paranoid’ beliefs, in other words, those reflecting out clause: we will accept that a strange and false self-reference and threat. Moreover, the cumulative idea is not delusional if it is widely shared. The frequency of individual paranoid ideas followed an urge to make categorical the distinction between exponential curve (Figure 2.1), with the relationship psychosis and normality leads us to discount unusual between them being hierarchical, such that more beliefs and experiences in people we would be extreme ideas were predictive of those that were less reluctant to see as undergoing a psychosis. extreme but not viceversa. At a single point in time the This has further implications for models of psycho- continuum is defined by differences between indivi- sis that invoke continuity with normal behaviour. It duals, who are thus located at individual positions on had become apparent by the late 1980s that paranoid the curve. However, people are themselves likely to ideation and anomalous experiences were not con- vary in a way that would place them at different fined to clinical groups. It is clear that the frequency of positions on the curve at different times, dependent auditory hallucinosis greatly exceeds the accepted on changing circumstances. In a sense, they would prevalence of psychosis (e.g. see Reference [53]). move along the curve. The distinguishing feature of those in contact with These findings have considerable relevance to the services is how upset they are by their unusual aetiology of psychosis. They imply that in some experiences [54,55]. Postulating continuities is an people movement along a continuum (indeed prob- important component of modern cognitive models ably more than one continuum) results in the emer- of psychosis (e.g. see References [56] and [57]), gence of psychosis. Thus the role of aetiology is to which argue that the emergence of psychotic phe- explain why particular people make this journey at nomena reflects abnormal combinations of largely particular times in their lives. In the genetic arena, this normal mechanisms. Thus people who hold cher- suggests a focus on quantitative analyses [59], along ished ideas typically have a confirmatory bias, being with the identification of quantitative trait loci [60]. In unlikely to consider alternatives impartially. These the psychological domain, it implies the convergence beliefs shade into what would be regarded as delu- of different psychological attributes – some cognitive, sional, since the thinking that underpins them is some emotional [61–63]. There are also implications similar in style to that in people with acknowledged for treatment, in particular such psychological treat- psychosis. ments as cognitive behaviour therapy [64].

WHY PSYCHIATRY HAS TO BE SOCIAL 21 2.9 THE SOCIAL NATURE OF PSYCHIATRIC SYMPTOMS AND THE GENETICS OF SCHIZOPHRENIA The social element in psychiatric symptoms and The hope is that better estimates of heritability can the consequence that they cannot map perfectly on to thus be obtained. This is a tacit recognition that mental underlying brain states may have caused a particular states and brain states are not equivalent and, indeed, problem for the genetics of schizophrenia. The that mental states have an additional psychosocial genetic project in schizophrenia is grounded on the component tending to attenuate the influence of in- assumption that abnormal brain states are necessary dividual genes. for the development of the disorder. The idea is of a Gottesman and Gould [68] suggested that this causal chain between genes, the proteins they approach potentially implies a deconstruction of the encode for, the enzymatic reactions mediated by the concept of schizophrenia. However, such a decon- proteins, the neurophysiological and neurocognitive struction would entail reconstruction: schizophrenia, functions served by the enzymes, and finally the but not as we know it. It is a serious acknowledgement symptoms we see in people with schizophrenia. It of our failure to establish a compelling aetiological might be anticipated that at every point in this chain narrative for schizophrenia if we can only deal with it some causal force is lost, resulting in an attenuated by opting to study the aetiology of something else. relationship between the gene and the schizophrenic This is on the way to acknowledging that the disease exophenotype. construct of schizophrenia has failed in its heuristic It has been clear for a long time that, if schizo- task. In any case, the concept of the endophenotype in phrenia is a genetic condition, it is polygenic. How- schizophrenia has also been challenged on heuristic ever, the search for the genes for schizophrenia has not grounds, as the genetics of the postulated endophe- been very successful. A number have been identified, notypes is no more robust than that of the but problems of replication have been rife [65,66]. exophenotype [71]. Moreover, it has so far been notably impossible to There is a troubling paradox in these molecular identify individual genes with relative odds greater genetic findings. As established from twin studies, than 1.3. Neither is it clear how many genes might be schizophrenia certainly appears to have high herit- implicated. It is likely to be a lot. If thegreatest relative ability. The diagnosis of schizophrenia relies heavily odds were indeed 1.3, we would need at least a on positive symptoms, and so the heritability of hundred to account for the accepted values for the schizophrenia must be the heritability of positive heritability of schizophrenia. Although we may know symptoms. However, such endophenotypes as their effects at the molecular level, we do not know have been postulated, e.g. abnormalities in working how these genes work to produce schizophrenia; nor memory [72], would link more directly to negative do we know if they act singly within given families or symptoms and to cognitive deficits. It may in any case whether they interact to produce schizophrenia more be questioned whether heritability, as calculated, is generally. The recent interest in copy number var- fit for purpose. Height is an extremely heritable iants [67] may not help much, as they are likely only to attribute, but we have failed so far to establish any account for 1% of the cases of schizophrenia, probably single gene to account for its heritability (e.g. see at the severe end and associated with clear neurolo- Reference [73]). Some of the discrepancies may gical features. Again the mechanisms of action are derive from the fact that heritability as calculated obscure. also encompasses gene–gene, gene–environment This unsatisfactory situation has led to the sugges- and environment–gene interactions, and these may tion that we should really be seeking the genetic basis be very complicated indeed. When we engage for the endophenotype of schizophrenia, i.e. the brain with the world, the world engages with us and may phenomena underlying the disorder itself [68–70]. change us.

22 PERSPECTIVES AND METHODS 2.10 THE NATURE OF ENDOPHENOTYPES AND THE NATURE OF MENTAL SYMPTOMS Caspi and Moffitt [74] argue that the biggest mystery imbalances in specific functions, particularly memory of psychopathology is ‘How does an environmental and executive functions, in comparison with controls factor, external to the person, get inside the nervous [78,79]. However, follow-up studies suggest that cog- system and alter its elements to generate the symp- nitive subtypes are not stable over time [80]. Indeed, in toms of a disordered mind?’ This mystery has a a ten-year follow-up of first-episode patients, IQ counterpart: ‘How do the biological correlates of appears to revert to premorbid levels [81]. mental disorders so constrain the mind as to generate There is some suggestion of cognitive impairment mental symptoms that are essentially about the ex- being related to genes tentatively linked to schizo- ternal world? How does the endophenotype translate phrenia, e.g. dysbindin and the val/met polymorphism into the exophenotype?’ in the catechol-O-methyl transferase gene [82]. It This question is made more difficult because neu- remains unclear if the impairment is general, or rocognitive studies are essentially a psychology of related to working memory or executive function performance, and abnormalities are generally con- [83–85]). It is also uncertain how specific the effect ceived as performance deficits. This lends itself easily is to schizophrenia. to the important question of negative symptoms in Attempts using neuroimaging to link working schizophrenia even though the associations are modest memory deficits in schizophrenia with abnormalities [75]. However, we diagnose schizophrenia primarily in dorsolateral prefrontal cortical functioning have from its positive symptoms. Thus we are left with the produced inconsistent results. The intention to search question of how deficits generate positive symptoms. for neurocognitive correlates of schizophrenia is well This is an ancient issue in psychiatry and neurology. founded, and may eventually produce more consistent Hughlings Jackson, following Russell Reynolds and results. It does remain possible that they may Herbert Spencer, differentiated negative and positive have environmental as well as genetic causes, symptoms in epilepsy in the 1880s [76]. His model of although this is an under-researched area. Brain dys- positive symptoms is that they represent excitation or function is in any case likely to have very complex release from higher inhibitory control. In other words, origins and consequences, given the way function positive symptoms are the consequences of negative almost certainly involves interaction at a modular symptoms. This assertion is open to empirical test: it level, and the capacity this allows for compensatory implies that positive symptoms presuppose negative activity [86]. ones. However, it is well established that negative How might neurocognitive abnormalities generate symptoms are not necessary for the emergence of the mental symptoms of psychosis? It is not difficult to positive symptoms. see how memory deficits could contribute. Thus an While the genetic basis has not as yet been sub- unrecognized failure to remember the location of stantiated, there is no doubt of an association between household objects might set the scene for wayward schizophrenia and various neurocognitive abnormal- interpretations: things that are not where they were ities. These involve both the cortex and subcortex, and might be thought to have been moved by interlopers. subserve several discrete cognitive functions. How- However, memory is a tool that enables us to engage ever, their nature remains obscure. They may com- with the world; it is not the engagement itself. prise dysfunctions in distinct domains, they may Some cognitive deficits have implications that are cluster, or they may represent a general neurocogni- clearly and centrally social. These concern so-called tive deficit [77]. While up to 30% of people with social cognition. For instance, as a group, people with schizophrenia perform within the normal range cog- schizophrenia perform relatively poorly on tests of nitively, it is possible that some high performers show theory of mind abilities [87]. Such theory of mind

WHY PSYCHIATRY HAS TO BE SOCIAL 23 impairment is associated with both negative and to process information about other people’s affect and positive psychotic symptoms, the latter including intentions could lead to misinterpretations of a para- paranoia and passivity experiences. There is some noid cast. evidence that social cognition may be relatively In general, neurocognitive deficits could be seen as independent of other forms of cognition [88]. Social exerting a tonic control; as causes, they are tonic and cognition also includes facial affect recognition and permissive, rather than obligatory. This may be the social cue perception. There is evidence of a degree of proper model for genetic abnormalities and changes in localization of these functions [87]. Facial affect dopamine metabolism. Dopamine may be the wind recognition, particularly for negative emotions, also that fans the psychotic fire [89], but you can have fire appears defective in some people with schizophrenia. without wind and it can burn without being fanned. Impairments in social perception in schizophrenia Social causes may operate in a similar tonic way. appear to have some specificity, not being so apparent External stress leading to affective changes may set in other psychiatric disorders. They are also relatively the circumstances out of which psychotic symptoms stable over time. Social cue perception involves the emerge, but does not guarantee their emergence. appreciation of more dynamic stimuli, usually in more These are examples of causes that are neither suffi- than one modality: for instance, individuals with cient nor necessary, and it is difficult to conceive of schizophrenia find it more difficult to identify the endophenotypic influences that could be sufficient and goals and intentions of people recorded on videotape. necessary. However, some social causes may shape It is comparatively easy to see how a relative inability symptoms directly, as I will argue below. 2.11 THE CONCEPT OF THE PSYCHOSOCIAL Theword psychosocial is used with some profligacy in both cognitive and empathic theory of mind, we can psychiatry, often without an adequately thoughtful easily understand that some events might be particu- consideration of its meaning. It implies the connection larly distressing, and thus may cause major affective between the inner and outer worlds, the fact that our and cognitive shifts in the persons exposed to them. perception of the outer world is an aspect of our inner The resulting subjective experiences, if sufficiently world, but that our subjective experience is of a reality extreme, may be identifiable as symptoms, and there we are effectively compelled to regard as external. may be enough of these for the criteria for depressive Social contexts, circumstances and events are seen as disorder to be met. However, affective changes them- outside phenomena, even though subjectively experi- selves may alter our perception of the events we have enced. It is easier to study the psychosocial reality by experienced. Thus the apparent link between event trying to control either the subjective or the objective and disorder may be spurious. component (rather akin to the ‘bracketing’ strategy In the early days of life event research, there was a employed by the phenomenologists). Psychologists dispute about whether the impact of events should be focus on subjective aspects; social scientists in con- assessed by the subjects themselves or be judged trast try to remove the subjective. This can be seen, for independently. This illustrates two principles. The instance, in cognitive models of depression, which, first is that the impact of life events represents an whatever their provenance, are simultaneously cog- interaction between the self and theworld. The second nitive and social [90]. is that it is possible to make a consensually verifiable A major area of psychosocial research that can be assessment of the component that is external to the used to illustrate approaches to the psychosocial subject. Researchers sought techniques that would concerns so-called life events (see also Chapter 16). enable the subjective element of the impact of events Difficulties in this sort of research arise from the fact to be stripped out. Initially, this involved panel ratings that different people have different experiences, and of lists of potential events preordained by the research- also perceive them differently. As human beings with ers. This certainly produces reliable ratings, but the

24 PERSPECTIVES AND METHODS lists limited both the range and the individual attri- quality of intrusiveness is of particular interest in butes of the events that could be recorded. that it potentially links the demand characteristics of Brown and Harris [91] responded to this by having certain events to the psychopathological characteris- panels of raters assess the qualities and dimensions of tics of paranoid ideation. real events that their research participants reported in Over the last decade, several cognitive models of the course of a semi-structured research interview. psychosishavebeenpublished(e.g.seeReferences[56] The rating procedure involved the presentation of and [97] to [102]). They seek to identify the origins of vignettes of the individual events prepared by the psychosis by adducing interactions between social interviewer. These included demographic and situa- contexts, emotional tone and cognitive processing. tional information about the participant, and a detailed They have generated considerable research. Where description of the event and its context. The vignettes this has focused on attributes with a social cast, it is included no information about the participants’ eva- the subjective accounts (attitudes or attributional style, luation of the event, their emotional response or their for example) that are given primacy. A recent example psychiatric state. Thus the subjective elements were using sophisticated statistical techniques to provide an removed so that raters could arrive at a consensus account of psychological mechanisms in paranoia is estimate of the impact such an event would have on the given by Bentall et al. [103]. Based on structural average person facing equivalent circumstances. The equation modelling using data from 173 people with output is an objectivized assessment of a rather parti- serious psychiatric disorders, the most plausible model cular type: it uses theory of mind as a way of identify- for paranoia included separate effects of a pessimistic ing the likely psychological consequences of the thinking style and impaired cognitive performance. It event, in other words, its social, emotional and cog- thereby links cognitive style with processes having a nitive demand characteristics. Although it may at first clear social component (pessimism). sight seem so, this is not tautological, as rating the In some cases considerable effort is put into con- event in this way retains the possibility of refuting trolling the social environment in order that charac- the event/disorder link being investigated. It does have teristic subjective responses can be investigated. Thus the disadvantage that the rating reflects complex ideas standardized virtual reality scenarios have been used about the interplay of event attributes in eliciting to study the nature of paranoid responses [104,105]. responses. For this reason, the overall concept of Such studies complement the social research repre- contextual threat has been refined, so that events can sented by life event studies, but the full possibilities of be rated in terms of more specific attributes, such relating both sorts of variable to specific symptoms of as loss, humiliation and intrusiveness [92–96]. The psychosis have not yet been realized. 2.12 CONCLUSION In this chapter, I have argued that the social element of our conventional disease categories, particularly in psychiatric disorders is inalienable, because the dis- moving to the investigation of specific symptom orders themselves incorporate the social world. Like types. While this may be unsettling, we might thereby Leon Eisenberg, I see biological and social research as break out of what has signs of becoming a research inseparable necessities if we are to attain a full aetio- impasse. logical account – in some ways this conclusion would suitably be termed a ‘no brainer’. However, the con- sequences for the shape of an effective research REFERENCES programme are profound. It is not just that we must research putative social and biological causes: we 1. D€ orner, K. (1972) Einleitung, in Soziale Psychiatrie must also test models that explicitly integrate these (eds K. D€ orner and U. Plog), Neuwied, L€ uchterhand, influences. This may imply some deconstruction of pp. 7–20.

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3 Categories and continuums Peter Tyrer Centre for Mental Health, Imperial College London, London, UK Ever since the time of Harvey it has been realized that necessarily dehumanizing; it can be a great aid to medicine cannot progress unless it has some form of selecting treatment, predicting prognosis and main- shorthand that allows the essentials of disease to be taining proper care across a variety of settings. communicated unequivocally to others. In short, we Although many of these comments may be self- cannot do without diagnoses. Classification in evident they are worth repeating because in the con- psychiatry has lagged behind that in medicine and text of social psychiatry the criticisms of classification related disciplines and to some extent has been in general are often more pronounced. Because social scorned because of its failures in this regard. This psychiatry tries to deal with aspects of a person’s is unfair because psychiatric disorders are extremely symptoms, functioning and context almost any form difficult to classify and we do not have the advantages of classification will be found wanting. However, it of our medical colleagues in being able to draw on a will not do justice to the tremendous variety in this great deal of additional independent information that subject to abandon the task of sorting them out into enables our classifications to be validated. Never- some reasonable order, as this leads to anarchy. theless, psychiatrists have been slow to accept the Throughout this chapter the advantages of categories principles of formal diagnosis and classification and and continuums (it might be better expressed as con- have been all too ready to dismiss these notions as tinua to keep with the original Latin, but as the word relics of some outdated ‘medical model’ of psychia- ‘continuums’ is widely used I beg to be irregular) in a try that should have no place in a humane and under- good classification will be addressed. The focus of the standing mental health care system. This view fails to chapter is mainly on the diagnosis of psychiatric take account of the importance of classifying all disorders, but of course categories and continuums conditions for purposes of efficiency and commu- are used across the field of social psychiatry and so nication; if every problem we come across in practice some of the principles described here can be extended is unique we have to spend a very long time com- far beyond the field of diagnosis. I am concentrating municating our accounts of this person to others and on the question of diagnosis because here there is spend a much longer time treating them as we go most controversy. There is little argument that if you through the process of trial and error in testing all the are comparing the intensity of a psychiatric symptom remedies known to man. Labelling patients is not it is reasonable to use a rating scale that has a wide Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

32 PERSPECTIVES AND METHODS range of scores; in other words, it describes a con- it is argued here that this might led to confusion tinuum of severity. In diagnostic practice it is neces- and that strict rules are needed before categories are sary to use categories in order to become recognized; embraced. 3.1. DIFFERENCES BETWEEN DIAGNOSTIC CATEGORIES AND CONTINUUM An ideal diagnostic category is a discrete entity that the lines of the following responses to a set of usefully separates it from all other diagnoses or, in an statements: apt metaphor, ‘carves nature at its joints’. It therefore stands alone and its simple description should be able 1. Strongly disagree to indicate its cause, its nature, its likely presentations (signs and symptoms), its course with or without 2. Disagree treatment, and its outcome. I have been lucky with my health to date and the only serious illness I had 3. Neither agree nor disagree was pneumococcal pneumonia at the age of 5. Even at this time the diagnosis was close to the top level of 4. Agree the diagnostic tree. It describes the cause (the pneu- mococcus bacterium), the nature of its presentation 5. Strongly agree. (consolidation of the lungs), its presentation (high fever, tachypnoea and shortness of breath, with This can be easily transposed into a diagnostic dullness to percussion over the affected lung and format such as for the assessment of depression: impaired inflation of the lobe of the lung concerned), its course (excellent outcome in uncomplicated cases 1. No depression with universal response to penicillin and most other antibiotics) and its outcome (usually complete recov- 2. Mild depression ery in the absence of complications or associated comorbidity). 3. Moderate depression A diagnostic continuum is a spectrum from ‘no diagnosis’ to ‘complete diagnosis’. It can be 4. Severe depression formulated in many ways, most commonly in the form of an equal interval range of groups that can 5. Very severe depression. either have anchor points to identify them or a complete range with only numerical distance being In the extreme form of the continuum the diagnosis measured to indicate the point on the scale. Many can be represented as a line, commonly of an easily diagnostic continua in psychiatry follow the Likert measurable length (e.g. 10 cm) and the distance of a scale principle, named after its founder [1], which diagnostic point measured from either end (see was originally described to measure opinions along Figure 3.1). Diagnostic point ____________________________________________________________________________ No depression Very severe depression Figure 3.1 Illustration of a diagnostic point along a continuum