Return of the Social: Rewriting the recent history of schizophrenia

I’ve long felt a certain ambivalence regarding Tanya Luhrmann’s work on psychosis (see, e.g., a much earlier post here).  Part of my frustration stems from Luhrmann’s disconnect, so far as I can tell, from the complexities of the user/survivor movement, and part from disappointment that  the tremendous potential latent in her topics of choice—potential, above all, to inject psychiatric discourse with the theoretical nuance I otherwise associate with contemporary medical anthropology—is so rarely realized.  Luhrmann’s latest commentary—an informal piece on the recent history of schizophrenia treatment, presumably targeting educated non-specialists—unfortunately only intensifies my frustration (and more than a touch of righteous anger) with her work.  Instead of careful attention to cracks and discontinuities, to politics and the machinations of neoliberalism,  Luhrmann sets out to tell what amounts to a surprisingly classic (and even more surprisingly uninformed) metanarrative of the ‘necessary progress’ of knowledge and freedom—knowledge advanced by scholars, and freedom, of course, for schizophrenia patients.  (Progress, admittedly, that is (always?) also a return to as Luhrmann puts it, “an older, wiser understanding of the mind and body.”) Here are a few of my complaints:

Bio-bio-bio…..gone?

Luhrmann’s noticeably Hegelian rendering of the history of the modern psychiatric treatment of schizophrenia goes approximately like this: for much of the early 20^th century, American psychiatrists attributed the development of schizophrenia to poor mothering, and turned to primarily psychosocial therapies informed by psychoanalysis.  The 1980s, in contrast, marked the introduction of an “antithetical” discourse—biomedical psychiatry, peaking with the “decade of the brain” in the 90s—followed more recently by the synthetic ‘return of the social’.  In a particularly memorable line—one that would stun both my activist and mental health services researcher colleagues—Luhrmann announces, “It is now clear that the simple biomedical approach to serious psychiatric illnesses has failed… At least, the bold dream that these maladies would be understood as brain disorders with clearly identifiable genetic causes and clear, targeted pharmacological interventions…has faded into the mist.”  That the decade of the brain oversold itself and that biopsychiatry has—as for the last half century at a minimum—been strongly contested by activists, as well social and community psychologists and psychiatrists, is undeniable.  That biopsychiatry has “faded in to the mist”…? Let me attempt to unpack a few of the complexities Luhrmann ignores.

First—the on-the-ground knowledge of my colleagues aside—research in public attitudes in fact shows a steep increase in the affirmation of biomedical causal beliefs regarding schizophrenia over the past two decades.  (Climbing not only in the 90s, but every year since.)  Georg Schomerus and colleagues’ (2012) important recent meta-analysis helpfully aggregates this data.  Not only have biomedical beliefs and aetiological attributions increased dramatically over the last two decades; social acceptance and inclusion, in parallel, has declined even further.  While we might be tempted to conclude that such biomedical beliefs simply “augment” older psychosocial ideas, the authors point to a German study demonstrating the real-world difficulty individuals have actually integrating the biological and psychosocial: forced to pick the two major causes of schizophrenia, most respondents in this study gravitated strongly either toward an all-biological or all-psychosocial explanation.  The legacy of mind-body dualism, that is, endures.

Is it simply the “naïve” public that has failed to adopt a more sophisticated “biopsychosocial” model?  First, let us recall that the term biopsychosocial predates even the inaugural biomedical decade (in Luhrmann’s retelling) of the 1980s.  Indeed the stress-diathesis model of schizophrenia was most famously articulated in an influential article by Zubin and Spring in 1977, and prominently reiterated by Robert Liberman (in Schizophrenia Bulletin) in 1983 (“stress-diathesis” has featured in psychiatric textbooks on schizophrenia ever since).  Indeed, a quick search of the psychiatric literature (limited to each of the last five decades), reveals consistent use of the term biopsychosocial, including many seminal publications in the 80s and 90s by distinguished biopsychiatrists.  Further, we might recall that it was not in the 90s that Dr. Steven Sharfstein, former president of the American Psychiatric Association, famously proclaimed “we must examine the fact that as a profession, we have allowed the biopsychosocial model to become the bio-bio-bio model,” but rather in 2005 and again (in his final presidential address) in 2006.  More robustly psychosocial (and explicitly “med minimalist”) psychosis treatment approaches that activists and dissident psychiatrists have recommended for decades—including the Soteria House approach, the Maastricht approach to hearing voices, and Finnish Open Dialogue therapy—still have no seat at the table (nor even a seat in the auditorium, arguably) in American psychiatry.  Even disappointment with the lack of advances in the realm of pharmaceuticals—famously underscored by the NIMH CATIE and European EUFEST trials—has led not to greater investment in rehabilitation, but rather a reinvogorated search for biomarkers and novel targets. See, for example, commentaries by Tom Insel, director of the NIMH, here, here ) and here.  (The title of the last piece, an essay on the future of psychiatry, is particularly telling: “The Future of Psychiatry (=Clinical Neuroscience)”.)

Finally, a reader might propose that we at least concede to Luhrmann the observation that the fierce popularity of epigenetic research reveals a new level of meaningful “biopsychosociality” in psychiatry’s understanding of psychosis.  Does it?  Or is epigenetics simply a contemporary incarnation of the old stress-diathesis approach (which, as we know, had little real impact on psychiatric treatment)?  Here, perhaps we simply need to review the thrust of most actual epigenetic work:  these studies, particularly in the context of schizophrenia, most often trace epigenetic changes not back to the sociocultural environment as we typically understand it, but rather to the far more tenuously “socioenvironmental” womb.  In other studies, admittedly, the focus is childhood adversity.  Even there, however, the proposed alterations, accomplished, of course, through chromatin remodeling and other biological mechanisms during so-called sensitive periods, are understood as leading to largely “irreversible” changes in neural structure and/or function.  The upshot?  By the time a young adult is diagnosed with schizophrenia, what she is thought to have, quite regardless of its distal origins, remains very much the same “neurological disorder.”  To my knowledge, epigenetic theories have influenced prevention science to some degree, but carry little import for the actual treatment of established “disorders.”

(I will end this section here.  Luhrmann’s other claims regarding the “failure of genetic explanations” and the “discovery of social causes” are, I would assert, equally problematic; likewise her total omission of the role of the pharmaceutical industry (in the context of medicalization), academic discourse on “neurochemical subjectivization” and related reconfigurations of self, society and identity in the shadow of neuroscience (e.g. Rose’s work), the growing medical consensus that there isn’t even any such thing as “schizophrenia” qua a singular “disease entity,” and so on.  Since time is limited, on to other things.)

“The Recovery Movement”

In a narrative move that note only surprised, but also (admittedly), brought something of a flush to my face, Luhrmann attributes the “progress” she identifies to three primary factors (1) “disenchantment” with pharmaceuticals, (2) the failure of genetic research, and (3) the exemplary work of “a cadre of psychiatric epidemiologists and anthropologists.”  Curiously, the work of the US and international user/survivor movement, even in instances in which the synergy between advocates and epidemiologists (as in the British Hearing Voices movement—think Jim van Os) stares one in the face, is completely absent in this discussion. Instead,  “the Recovery Movement” (the user/survivor iteration of which can in fact be traced to the late 70s and early 80s) is rewritten as a consequence of the otherwise academic-scientific backlash she describes, rather than a prime cause.
Given the length of this critique (already), I will limit myself to a few brief points: (1) almost since its inception there has been no singular “recovery movement”, and recovery itself has been described in many forms and contexts (e.g. clinical or symptomological recovery, functional recovery, symbolic recovery, social recovery, even biological recovery), and has been promoted not only by advocates, but also a bevvy of different researchers, theorists, and clinicians.  Some iterations of recovery are entirely in line with biomedical models, emphasizing medication adherence, while others take a far more radical position with respect to recovery in the absence of any formal psychiatric intervention (sometimes involving embracing, rather than reducing, symptoms).  (2) The broader user/survivor movement has been grounded, more or less since its inauguration, on peer-run alternatives (see, e.g., Chamberlin’s (1978) On Our Own).  The nominal success and popularity of peer-led services thus arguably has far more to do with the movement’s consistent insistence on autonomy and mutual support (and non-violent political actions through the 70s, 80s and 90s) than any “new” 21^st century disenchantment with biomedicine.

(3) In another instance of a strange naïveté, Luhrmann insists that “the very idea of the recovery intervention upends the bio-bio-bio vision”. Really??!  Again,  I can only chalk this claim up to a complete misunderstanding of the division between basic psychiatric and rehabilitative services in the US, paralleled by a similar division in the domain of research.
As has—at the risk of repeating myself–been the case for decades, psychiatric rehabilitation—a domain of services including drop-in centers, peer support, WRAP, supported employment, supported education and so on—kicks in only when more basic services (almost ubiquitously centered around “frontline” pharmacotherapy) have been exhausted.  Access to such services is almost always limited to individuals with documented disabilities.  In any case, psychosocial rehabilitation, then, is and has always been an auxiliary (and unambiguously second-class) form of intervention or treatment.  Even when it comes to approaches such as Housing First (community psychologist Sam Tsemberis’ brainchild, which Luhrmann curiously refers to generically as “the new kind of [housing] intervention”), we must remember the temporal point at which such programs are offered.  As a colleague of mine—a clinical administrator who heads up a massive Housing First initiative in Chicago—has explained, the homeless clients they work with are homeless in large part because of the psychiatric system.  Most, she always says, must be treated as deeply traumatized by past (biomedical) inpatient hospitalizations.  (A former inpatient room-mate of mine, always, quite accurately, referred to the inpatient ward as a “pharmaceutical holding cell.” In any case,  with the continued development of rehabilitative interventions (rehabilitation, we always need continue to ask ourselves, from what?) we see not so much the fading of biopsychiatry as the tragedy of the under-funded rehabilitation and community mental health systems that are somehow supposed to pick up the pieces (as indeed, once again, they always have).

Contesting or Reifying Medicalization?

            A few final complaints.  While psychiatric rehabilitation and user/survivor-led critique is nothing new—the sharp intensification of targeted criticisms of pharmacotherapy, increasingly backed by both hard science and investigative reporting, arguably is.  The contemporary “radical mental health movement”, for instance, is in many ways less focused on the further development of structurally auxiliary services, than a direct ‘attack’ on psychiatrists’ (and the pharmaceutical industry’s) relentless efforts to further expand diagnostic categories, promote over-simplified biochemical theories of disorder, and continue to expand the multi-billion dollar international psychotropic drug market.  New developments, along these lines, include Will Hall and colleagues’ notably popular “Harm Reduction Guide to Coming Off Psychiatric Drugs.”

Evidence and first person accounts, along these lines, increasingly attest not only to the largely metabolic and/or sedative “side effects” Luhrmann describes, but also addiction, the iatrogenesis of secondary psychiatric problems, long-term neurological side effects, and the lack of evidence that antipsychotics have in fact in any way improved long-term outcomes (as Jobe & Harrow (2010) conclude; short term benefits are less ambiguous).  The absence of any discussion of these developments in Luhrmann’s essay, particularly in light of what I call the ‘Whitaker collective’s‘ growing influence on research and public discourse (demonstrated, for example, in the recent founding of the explicitly alternative Foundation for Excellence in Mental Health Care) is not only striking but disturbing.  Is the putatively “immersed” anthropologist really unaware of these developments, not to mention the political implications of their (her) omission?

A sort of oblique answer to this question can perhaps be discerned between the lines of her text.  Even as Luhrmann lauds the putative rediscovery of the sociocultural (qua Hegelian synthesis), that is, she continues to paint what disability advocates and theorists have long since identified as a version of the normatively-laden “medical-tragedy” narrative of disability.  Schizophrenia is thus “the most severe and debilitating of psychiatric disorders” (paragraph 1), and a “terrible illness” (2).  A few paragraphs down, Luhrmann qualifies her emphasis on the social with “To be sure, it would be too strong to say that we should no longer think of schizophrenia as a brain disease. One often has a profound sense, when confronted with a person diagnosed with schizophrenia, that something has gone badly wrong with the brain.”  In the very next paragraph her comparison is between schizophrenia and diabetes (perhaps she doesn’t know it, but this is a curious repetition of the popular and much criticized “illness just like diabetes”  or “medication just like insulin” analogies of schizophrenia and antipsychotics, respectively).  Further examples: “a decent place to live is sometimes more important than medication” (sometimes??); referring to the WHO schizophrenia outcomes studies, “families are far more involved in the ill person’s care in India. They come to all the appointments, manage the medications, and allow the patients to live with them indefinitely”; finally, in the context of peer service provision “clients have not always made good choices.”

The challenge of careful disability theory, to paraphrase Tobin Siebers, is not to capitulate to either romanticism or tragedy.  There is incredible heterogeneity among individuals who have been diagnosed with schizophrenia—some “recover completely,” many others do significant work in the areas of advocacy, research and the arts.  Nowhere are such individuals mentioned (nor, again, their contributions not only as advocates but as theorists and researchers).  Nowhere do we get a sense of the heterogeneity of the experience of psychosis either—experiences some see evidence of positive human diversity, “gifts”, processes of spiritual transformation, windows into the psyche, stark existential challenges, as well as biologically inflected disruptions—sometimes profound.

Nuance, attention to detail, critical self-reflection, and perhaps above all, greater engagement with those of us who actually “have” some form of “schizophrenia,” then, is disappointingly lacking in this text. Psychiatric or psychological anthropology, to repeat an earlier sentiment, always seems to have such potential.  Why then, in the US, with the exception of individuals like Kim Hopper, does this potential, so often, go unrealized?  “Engagement,” imho, cannot simply involve fieldwork with homeless women in Uptown; it must also involve involvement and engagement with the breadth and complexity of the mental health system (rehabilitation and clinical care and fully peer-run alternatives), the psychiatric research complex, federal funders such as the NIMH and SAMSHA, the prison system (here in Chicago prisons are by far the largest providers of mental health services), the diverse and multifaceted user/survivor movement, and the complex, recursive history of these institutions and discourses.  Surely, were Luhrmann engaged in all these ways, a true ethnographer of American psychiatry as I would see it, she would not have written the commentary she did.

About these ads