Our brains aren’t moulded by abuse
So, is mental distress caused by faulty genes or by past experiences of childhood abuse? Maybe it’s neither.
Even before its official publication later this month, the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) has generated a war of words between the disciplines of psychology and psychiatry. DSM may be colloquially known as the psychiatric profession’s bible, but in the eyes of many other groups, it is neither scientifically valid nor of any practical use.
One such critic of both the DSM and psychiatry in general is the British Psychological Society’s Division of Clinical Psychology (DCP), which last week issued a statement claiming that ‘psychiatric diagnosis is often presented as an objective statement of fact, but is, in essence, a clinical judgment based on observation and interpretation of behaviour and self-report, and thus subject to variation and bias’. In this respect, mental illnesses differ from physical ones, as the latter can be tested for scientifically and can often be seen or touched (for example, a virus under a microscope, or a cancerous tumour).
Not only does the DCP argue that psychiatric diagnoses such as schizophrenia and bipolar affective disorder lack validity – it also argues that by wrongly portraying such conditions as being biological in nature, and therefore within the remit of medicine, psychiatrists and others fail to acknowledge fully the wider societal influences that can negatively affect people’s mental state. According to Lucy Johnstone, a clinical consultant who helped draw up the DCP statement, looking for biological causes and pharmaceutical answers to mental distress downplays ‘the overwhelming evidence that people break down as a result of a complex mix of social and psychological circumstances – bereavement and loss, poverty and discrimination, trauma and abuse’. There is, therefore, according to the DCP, an urgent need for a paradigm shift in how we understand mental distress.
In response, Simon Wessely, a member of the Royal College of Psychiatrists, argues that new research has shown genetic overlaps between several serious psychiatric disorders. For him, any classification system is like a map: it aids understanding but can also be revised if the psychiatric landscape changes in terms of a new and improved knowledge base. He also laughs off suggestions that psychiatry is trying to medicalise normal behaviour, especially in a climate where the struggle is ‘to protect services for those whose disorders are all too evident under any classification system’.
These provocative exchanges should not blind us to the fact that both sides in this debate have much in common. For example, while there certainly are some mainstream psychiatrists who adhere rigidly to a biological reductionist school of thought, many acknowledge the role of adverse social circumstances in the onset of mental illness, and, indeed, the importance of social support for prolonged recovery. There are also many psychologists, and indeed users/survivors of psychiatry, who will testify to the role of medicine in alleviating mental anguish. For example, your headache may be correctly attributed to your having had a particularly stressful day, rather than emanating from an internal biological fault, but this does not mean you cannot take a pill to alleviate the pain.
Such a meeting of minds is a good thing; the human condition cannot be understood within any individual discipline. Like the DCP, I have been critical of the expansion of psychiatric diagnoses introduced in previous editions of the DSM, and I have no doubt that the latest edition will continue this trend. So, would it be reasonable to presume that I am fully supportive of the DCP’s campaign to create a paradigm shift in how we view and treat mental distress? Not quite.
For me, the problem is not so much the need for a new, non-medical paradigm within which to understand mental distress. The problem is that one inadequate paradigm – biomedical determinism – is being replaced by an equally problematic one: that of ‘abuse as determinant’. Both within the psych professions and in society more broadly today, the marker of past abuse is increasingly the key framework used to explain people’s present-day problems.
According to the clinical psychologist Oliver James, abuse is the major cause of psychoses. He cites the case of a woman experiencing psychotic symptoms. According to the medical model, her experiences and behaviour are due to her inheritance of faulty genes, which predisposed her to the illness, a perspective that fails to take into account the impact of the sexual abuse she had suffered in the past. In his otherwise excellent book The Dialectics of Schizophrenia, the psychiatrist Phil Thomas makes a similar claim. He discusses the case of Jim, diagnosed with schizophrenia and treated, unsuccessfully, with medication. It was not until he remembered that he was sexually abused as a child by his grandfather, and that the voices had started soon afterwards, that Jim recovered sufficiently to lead a relatively successful life.
The idea that past abuse causes current problems is not confined to the clinic; it has become an increasingly popular belief in recent years. Pete Townsend of the rock group The Who, when arrested for using his credit card to access and download child pornography from the internet, said that he was carrying out research but also that he believed he was abused as a child. (Though he was not able to remember any abuse, he suspected it had taken place). Tony Martin, who was jailed for shooting dead an intruder in his home, also blamed his behaviour on abuse he suffered as a child. Similarly, the actor Chris Langham cited past child abuse in mitigation for downloading child pornography.
This social preoccupation with abuse, and the way people are encouraged to interpret their current problems through the prism of past sufferings, should be of greater concern than anything DSM-5 might come up with. After all, people actively engage with psychological trauma; they are not passive recipients of it; they actively interpret their experiences and in the process give meaning to their lives – a process that is as much influenced by the present as it is by the past. The Jimmy Savile affair and Operation Yewtree are illustrative of this trend, with people being actively encouraged to reinterpret past experiences through the prism of abuse. It would appear that the ‘new’ paradigm being proposed by many in the psychology community is already embedded within contemporary society.
Ironically, the reification of abuse by psychologists can have consequences that they did not intend. For example, in claiming that it is abuse and not biology that causes conditions such as schizophrenia, Oliver James’ intention is a laudable one, in that he does not want to pathologise sufferers. However, the uncritical acceptance of the discourse of abuse can lead to the opposite. In effect, James pathologises both those who did and those who did not suffer such abuse. The implication is that we should view those in mental distress as ‘child abuse victims’, while those who were not abused are by implication suffering from a ‘psychiatric illness’.
History has taught us the dangers of attributing catch-all explanations to mental distress. We ridiculed the idea of witchcraft in favour of exploring in more detail the reality of brain disease; then we downgraded brain disease and placed our faith in biomedicine. We may have now downgraded this medical model, too, but the exaltation of abuse as the key determinant of human distress can be as reductionist and deterministic as the models it is seeking to replace.
Ken McLaughlin is a senior lecturer in social work at Manchester Metropolitan University, England. His most recent book, Surviving Identity: Vulnerability and the Psychology of Recognition, is published by Routledge. (Buy this book from Amazon (UK).)