in Philosophy, Thinking about psychiatry



The idea of ‘self’ is difficult to define but represents a set of ideas, representations and beliefs that are held about what it is to be a person.  As psychiatry is a subject concerned with thoughts, feelings, behaviours and relationships, how people view themselves and the accompanying attitudes of psychiatrists to this (our ‘gaze’) are central to its execution.  In Western cultures, we overwhelmingly choose to define ourselves in terms of our individual direction and achievements.  This orientation is often portrayed as an objective truth, but is in fact simply an extremely powerful cultural construction.

Construction or not, individualistic ideology has had a substantial influence on thinking about mental distress.  Psychiatrists have based much of their work on individualistic notions which as a consequence assume that emotional problems can be studied and understood separately from any other context.  When seeking to diagnose an individual as having a mental health disorder, current classification systems, when rigidly interpreted, require no consideration to be given to circumstances beyond a patient’s psychopathology.  Forms of emotional distress are then defined in terms of disordered individual experience and social and cultural factors are seen as secondary and may or may not be taken into account.

This approach sits ill at ease alongside patient experience.  The lives of people with mental health problems have often been very eventful, and normally not in a good way.  The message that life stories are largely irrelevant is then not always popular.  Gail A. Hornstein writes in OpenMind on this subject (link no longer available):

Many patients feel deeply wounded by the assumption that madness has no link to life experience. As Jacqui Dillon, Chair of the National Hearing Voices Network, England, said at a recent conference, “Pathologising the experience of people like me, who have suffered terrible trauma, only adds insult to injury and protects those who have abused us. Instead of asking, what’s wrong with you? people should ask, what’s happened to you?”

Our individualistic beliefs are understandable.  They are welcomed by some patients as they allow entry to the sick role and it can be comforting to regard suffering as something separable from the self and which for amelioration can be passed over to an expert.  It would also be strange if psychiatry had been immune to this central tenet of capitalist societies and the approach also proves expedient to research, where individual phenomena can be captured by way of surveys and rating scales.

However as a profession with regards to this, I would hope that we could, collectively, be more ‘self aware’.  This is not to suggest that mental health professionals are deliberately ignoring patients’ stories, that they are bad people, or even that mental health systems have been purposely set up in order to ignore the needs of vulnerable groups but it is interesting how dominant and rarely questioned ideas and discourses can work to render us blind to systemic inconsistencies and inadequacies.

The current paradigm allows the social and ideological origins of distress to be ignored and its implications side-stepped.  Our helpful – but not too helpful – approach makes possible the propagation of mental health services, who are actually supported by a fragmented and individualistic society.

In order to be truly transformative, mental health services would then need to be honest about the social, political and ideological conditions that often lead to mental distress.  Alas even if this were to magically happen, our message would be lost unless there was a corresponding move in greater society toward a value system where people seek satisfaction more from helping others rather than pursuing private advantage.

Proper leadership, that’s what we need.


Interesting link:

Individualism – Wikipedia


Addendum 10 September 2009

Here’s an interesting paragraph from Richard Bentall’s Madness Explained

When constructing the self, the child internalizes historically and culturally determined values.  It is therefore possible that the self as known to people of the past may have been quite different from the self as known to people living in the modern world.  Roy Baumeister has argued that for medieval Europeans, the self was relatively transparent, and was equated with visible manifestations and actions.  As life on earth was, at that time, believed to be a preamble to eternal bliss, there was no need to search for self fulfilment.  In modern Western societies, in contrast, the self is often viewed as a hidden territory that can only be known with difficulty, but which must be explored (perhaps with the technical assistance of a psychotherapist) if its special talents are to be fostered and self-actualization achieved.

Also from Psychiatric imperialism: The medicalisation of modern living by Joanna Moncrieff (link no longer available)

The medical model of mental illness has facilitated the move towards greater restriction by cloaking it under the mantle of treatment. This process of medicalisation of deviant behaviour conceals complex political issues about the tolerance of diversity, the control of disruptive behaviour and the management of dependency. It enables a society that professes liberal values and individualism to impose and reinforce conformity. It disguises the economics of a system in which human labour is valued only for the profit it can generate, marginalising all those who are not fit or not willing to be so exploited.

(this one makes more sense if you read the entire article…)

The person in the patient BMJ personal view Alastair Santhouse 1 November 2008 (restricted access)

Write a Comment


  1. Hmmmm. What about those of us who have had nothing of any real consequence ‘happen to us?’ Those who have been treated well by their surroundings and whose siblings have gone on to be fine?

  2. If you are unhappy and you see no point in investigating why this might me because you don’t think there is a reason then psychiatry can provide an anti-depressant for you.
    On the other end of the scale, if you have extreme paranoid ‘symptoms’ that seem to make no sense at all then it just might be the case that there are reasons why you have become paranoid that make complete sense to anyone willing or able to see them.

  3. Thank you for a wonderfully relevant article. I am reading increased awareness by clinicians about the correlation between trauma and many serious “mental illnesses” such as Bipolar Disorder and Schizophrenia. I think the effects of traumatic events are highly underestimated and that many mood and thought disorders are actually “pieces” of a traumatic symptomology.

  4. Interesting piece.

    Certainly the prevalence of distress and pain that remains in our affluent society suggests something isn’t working. But contra the critical clinical psychologists you link to I don’t think offering some degree of help to people who are suffering implies ignorance or denial of the societal or philosophical causes of that suffering. If my doctor gives me a painkiller for the pain caused by a broken arm I sustained while being mugged by socially disadvantaged youths I do not then blame a lack of medication for the pain. I will take the medication and, once I am better, I will then set out to tackle the social injustices which led to me being mugged (if I can be bothered!). Furthermore, as Diane notes, very often difficulties arise which do not require a sociopolitical philosophical enquiry or explanation. Indeed a sociopolitical explanation would seem to be quite beside the point for someone who is suffering depression because of a dysfunctional thyroid or recent brain injury.

    What really annoys me about critical clinical psychologists and psychiatrists is the moral high ground they take when they say stuff like this (from the link):

    “These therapies require changes to occur within the person (e.g. medication, ECT, cognitive therapy, psychodynamic psychotherapy) or their immediate family (e.g. family therapy) to restore the individual to ‘normality’, rather than offering any challenge to both the social and ideological conditions that give rise to such distress.”

    First of all, these therapies do not necessarily aim to restore someone to normality. Generally the aim is to reduce a person’s suffering or restore their ability to make decisions about their lives. What on earth is wrong with that?

    I know a couple of critical clinical psychologists and I still have little idea what they say to their patients or do for them (do they advocate martyrdom or do they suggest they petition Downing Street to renounce capitalism?). I’m also aware of the lack of any robust political solutions being offered within the field to solve the supposed problems (let’s be honest, they really should be politicians rather than clinicans). Why can’t the critics let mental health workers continue to offer the small comforts they can while they crack on and form the political party which will deliver the Utopia they so desire?

  5. The reason I wrote this piece was that I wanted to examine my frustration with treating people in my clinics who seemed to have predominately socio-economic (to give it a grand name) problems, and to whom I can only offer rather mediocre medical treatments.

    I don’t disagree with Diane that there are people out there who appear to have mental health problems that come ‘out of the blue’ and these people are perhaps well treated by the established diagnosis/intervention approach.

    However what I would like to see, and what this blog project is essentially about, is greater awareness/acknowledgement of the place that mental health services have in our society. There are lots of things that provide succour for what are essentially unfair situations – aid to Africa would be an example. As you can tell from my approach, I feel that robust analysis has a place in the solution. You could argue that in this case a more balanced post would be appropriate and I’d have sympathy with that viewpoint, it’s just that they’re rather boring to read, and no one comments on them….

  6. From what I have observed large numbers of patients in mental hopitals are not ‘ill’ at all, they have simply ‘graduated’ from one state run instituition – school or prison or army – to another.
    So one would hope there are professionals interested in asking why this might be rather than just dishing out pills, even if pills can be helpful in some cases.

  7. The idea that westerners are individualistic while non-westerners (orientals in particular) are collectivist may be an exaggeration.

    I’m curious by what you mean by “ideological origins of distress”. Is that like the Daily Show bit where they diagnosed an unhappy man with being a liberal? Or is this Frankfurt School stuff?

  8. Now you point it out, it is a slightly odd turn of phrase.

    I was referring to the connection between the ideology which underpins our society and distress of people within it. Our ideology is predominantly neoliberal which of necessity creates winners and losers.

  9. This statement – In order to be truly transformative, mental health services would then need to be honest about the social, political and ideological conditions that often lead to mental distress. – is true.
    Thanks for sharing.