7. Into the 21st century

‘Into the 21st century’ explains how there is an increased focus on how our body, and not just the brain, influences our mental health. Rapidly advancing computer technology, including artificial intelligence and virtual reality, is beginning to provide new treatment possibilities, not just support and simplify the old ones. The development of sophisticated imaging has supercharged the area of neurosciences and the increased understanding of genetics and the new science of epigenetics provide psychiatry with greater tools to identify and manage mental illnesses. A paradox with our increasingly technological and scientific advances is that the core dilemmas of psychiatry appear not to be diminishing. Psychiatry will survive the 21st century, but certainly it is changing.

5. Psychiatry under attack—inside and out

‘Psychiatry under attack’ focuses on the contradictions inherent in psychiatry. The mind–brain relationship is the big issue in psychiatry. It would be simple if psychiatry were just about ‘brain diseases’, but psychiatry concerns ‘mental’ illnesses. While many mental illnesses involve disorders of the brain, not all brain diseases are mental illnesses. Psychiatry originally viewed mental illnesses as inherited weaknesses. However, Freud and his followers shifted the balance to ‘nurture’. The ‘anti-psychiatry movement’ of the 1960s and 1970s, led by Szasz, Foucault, and Laing, condemned psychiatry as confusing at best and an instrument of social oppression at worst. There is now less opposition to psychiatry though disquiet remains about aspects of its practice.

4. Psychoanalysis and psychotherapy

‘Psychoanalysis and psychotherapy’ considers the contribution of psychoanalysis and psychotherapy to the field of psychiatry. It discusses Sigmund Freud and the origins of psychoanalysis, including his technique of free association and his map of the mind comprising the id, the ego, and the superego. It also describes the more mystical theories of Carl-Gustav Jung, including his concept of the ‘shadow self’. Different types of psychotherapies are outlined, including existential, psychodynamic, and behaviour therapies, which are used for phobias and obsessive compulsive disorders. Group therapy, counselling, family therapy, crisis intervention, self-help, and cognitive behaviour therapy are also discussed.

1. What is psychiatry?

Psychiatry deals with consciousness, choice, motivation, free will, relationships—everything that makes us human. ‘What is psychiatry?’ emphasizes that psychiatry is a branch of medicine that deals with mental illnesses. The definition of psychiatry is not based on theory, as in psychology or psychoanalysis, but on practice. The current view of mental illnesses and available treatments will determine what a psychiatrist is, and what he or she does. The hallmark of the psychiatrist’s trade is the interview. Psychiatric diagnoses rely on making a judgement about why someone is doing something, not just the observation of what they are doing. The most common psychiatric disorders, both organic and functional, are described.

6. Open to abuse

The nature of psychiatric practice lays it open to potential misuse. ‘Open to abuse’ highlights the unequal power relationship with dependent and vulnerable patients whose opinions and complaints can so easily be dismissed. The diagnostic process is inevitably subjective, relying on psychiatrists’ assessments of the patient’s motives and mental state, with no concrete indicators for diseases such as blood tests. The history of psychiatry is littered with shameful episodes of political abuse, hare-brained theories, and dangerous and barbaric treatments. The visibility of modern-day psychiatry, plus a well-informed public and a willingness to admit mistakes, are the most reliable safeguards against such abuses. Psychiatry is now engaged in evidence-based medicine—facts and figures taking precedence over theories and opinion.

3. The move into the community

‘The move into the community’ considers deinstitutionalization. Nearly every large mental hospital in the UK and most in the US and Western Europe have closed. The emptying of the institutions was partly due to the discovery of antipsychotic and antidepressant drugs, but changes in social attitudes towards the mentally ill, radical rethinking within psychiatry, and financial considerations were also influential. The first twenty years of community care were relatively successful. However, closures often ran ahead of provision of adequate alternative services. Stigma, an exaggerated sense of risk from the mentally ill, family break-up, high social mobility, and increasing levels of drug and alcohol use have made community care of the mentally ill more difficult.

2. Asylums and the origins of psychiatry

‘Asylums and the origins of psychiatry’ outlines the historical care of the mentally ill. If the mentally deranged could not be cared for within the family, they were sent to private madhouses for the rich and workhouses for the poor. The asylum movement began in earnest in the 1820s, aiming to provide moral therapy in a calm, spacious, rural environment. However, conditions deteriorated with overcrowding. The 19th century saw increasing research into mental health, especially in German-speaking Europe, with three of psychiatry’s most influential figures being Kraepelin, Bleuler, and Freud. Meanwhile, asylums had become even more overcrowded and neglected. Not until the 1920s did specific effective treatments become available.