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Why have physical treatments tended to predominate?

From a user’s perspective, the fact that psychiatric treatments are biased more towards drugs and ECT is indeed a problem. Not only do patients (understandably) expect their subjective sense of well-being to improve as a result of psychiatric treatment, they have higher expectations of the helpfulness of psychological and combined treatments than physical interventions alone. Despite these expectations, in most mental health services physical treatments predominate or are simply the only form offered or imposed. When asked in an open-ended way, people with a diagnosis of severe mental illness tend to describe service responses which are overwhelmingly limited to medication. The strong bias towards drugs reflects bio-medical professional preferences at the expense of user choice.

Six mutually reinforcing contributory factors can be put forward to suggest why such a bio-medical bias exists.

1 The medicalization of psychological abnormality in the nineteenth century entailed a biological emphasis. Scull (1979: 165) quotes the following from the Journal of Mental Science in 1858: ‘Madness is purely a disease of the brain. The physician is the guardian of the lunatic and must ever remain so’. For doctors to ensure their jurisdiction over madness they had to assert or prove that it arises from some sort of physical pathology. Accordingly, the use of physical treatments is consistent with a bio-deterministic aetiological theory. If such a position is not persuasive, then arguably mental illness is actually a sort of social, educational or existential, not physical, problem. As an indication of this, psychoanalysis, the prototype of the modern talking treatments, became divided in its early years about whether analysts needed to be physicians.

2 During the 1960s, when large mental hospitals came under attack from a variety of sources, an opportunity was created for psychiatrists to shift their site of operation into mainstream medicine. Their preferred service delivery model was that of the District General Hospital psychiatric unit. Baruch and Treacher (1978) point out that this allowed psychiatrists to make a bid to rejoin mainstream medicine and thereby compensate for the low status traditionally enjoyed by their medical specialty. Whether this has actually led to an improvement of their status within medicine is uncertain. However, aligning itself with general medicine was made more credible by the content of its interventions being like other medical procedures. In the USA Kleinman (1988) also noted that medication use, and the professional image of psychiatry as a poor relation trying to improve its medical reputation, were intertwined.

3 Physical treatments are legitimized and encouraged by the profit motive. Drugs are a well-known source of profits for their producers. In addition to the profits accruing from the sale of psychotropic medication, these companies also sell drugs to offset the side effects of major tranquillizers (e.g. induced Parkinson’s disease). Drug companies promote their products through expensive advertising campaigns and sponsored events.

4 Although millions in each international currency are spent yearly on psychotropic drugs, they are still arguably cheaper to deliver than labourintensive talking treatments. For instance, minor tranquillizers are a cheap and quick way of disposing of emotional problems in the surgery. Likewise, a reliance on major tranquillizers to dampen down the agitation of psychotic patients, older people and those with learning diff iculties has been a cheap alternative to crisis intervention, intensive family support and psychological programmes.

5 If psychiatry exists, among other things, to control disruptive and unintelligible conduct, then physical treatments are highly suited to this purpose because they can be imposed in the absence of cooperation. Medication, psychosurgery and ECT can, in certain circumstances, be imposed on people against their will, whereas it is very difficult to conduct talking treatments with resistant subjects. Indeed, most psychotherapists argue that consent is a necessary precondition for any form of their treatment and that this condition of free choice is clearly compromised by a client being captive. However, group therapy has been used inside secure psychiatric facilities. Indeed, the therapeutic community approach to treatment is arguably well suited for social control as it uses group pressure and conformity to realign deviant conduct.

6 Although discoveries about the behavioural impact of psychotropic drugs have often been a result of accident rather than design, once the effects are demonstrated and they are patented and marketed by drug companies, they provide a spurious illusion that biodeterminism has been proven (bringing us back to point 1 above). The drive for pharmaceutical companies to produce both innovative and ‘me too’ compounds for profit has entailed their stimulation of biological psychiatric research both directly via research funding and indirectly. In the latter regard, Healy (1997) noted that even the patient who is drug ‘treatment’ resistant becomes a curious conundrum for neurospsychiatric researchers to solve using expensive medical technology to scan (live) and slice (dead) brains. The very use of that expensive technology then confirms the legitimacy of biological reductionism within psychiatry.

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