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Authors' reply

Published online by Cambridge University Press:  02 January 2018

Pat Bracken
Affiliation:
Centre for Mental Health Care and Recovery, Bantry General Hospital, Bantry, Co Cork, Ireland. Email: Pat.Bracken@hse.ie
Philip Thomas
Affiliation:
University of Bradford, UK
Sami Timimi
Affiliation:
Lincolnshire Partnership NHS Foundation Trust Child and Family Services Horizons Centre, Lincoln, UK
Eia Asen
Affiliation:
Marlborough Family Service, Central and North West London Foundation NHS Trust, UK
Graham Behr
Affiliation:
Central and North West London Foundation NHS Trust, UK
Carl Beuster
Affiliation:
Southern Health NHS Foundation Trust, UK
Seth Bhunnoo
Affiliation:
The Halliwick Centre, Haringey Complex Care Team, St Ann's Hospital, Barnet, Enfield and Haringey Mental Health NHS Trust, London, UK
Ivor Browne
Affiliation:
University College Dublin, Ireland
Navjyoat Chhina
Affiliation:
Early Intervention Team, Cumbria Partnership NHS Foundation Trust, Penrith, UK
Duncan Double
Affiliation:
Norfolk & Suffolk NHS Foundation Trust, Norwich, UK
Simon Downer
Affiliation:
Severn Deanery School of Psychiatry, Bristol, UK
Chris Evans
Affiliation:
Nottinghamshire Healthcare NHS Trust, Nottingham, UK
Suman Fernando
Affiliation:
Faculty of Social Sciences & Humanities, London Metropolitan University, UK
Malcolm R. Garland
Affiliation:
St Ita's Hospital, Portrane, Ireland
William Hopkins
Affiliation:
Barnet, Enfield and Haringey Mental Health NHS Trust, UK
Rhodri Huws
Affiliation:
Eastglade Community Health Centre, Sheffield, UK
Bob Johnson
Affiliation:
Rivington House Clinic, UK
Brian Martindale
Affiliation:
Northumberland, Tyne and Wear NHS Foundation Trust, UK
Hugh Middleton
Affiliation:
School of Sociology and Social Policy, University of Nottingham and Nottinghamshire Healthcare NHS Trust, UK
Daniel Moldavsky
Affiliation:
Nottinghamshire Healthcare NHS Trust, UK
Joanna Moncrieff
Affiliation:
Department of Mental Health Sciences, University College London, UK
Simon Mullins
Affiliation:
Sheffield Health and Social Care NHS Foundation Trust, UK
Julia Nelki
Affiliation:
Chester Eating Disorders Service, UK
Matteo Pizzo
Affiliation:
St Ann's Hospital, London, UK
James Rodger
Affiliation:
South Devon CAMHS, Devon Partnership NHS Trust, Exeter, UK
Marcellino Smyth
Affiliation:
Centre for Mental Health Care and Recovery, Bantry, Ireland
Derek Summerfield
Affiliation:
CASCAID, Maudsley Hospital, London, UK
Jeremy Wallace
Affiliation:
HUS (Helsinki University Sairaala) Peijas, Vantaa, Finland
David Yeomans
Affiliation:
Leeds & York Partnership NHS Foundation Trust, UK
Corresponding
E-mail address:
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Abstract

Type
Columns
Copyright
Copyright © Royal College of Psychiatrists, 2013 

We are broadly in agreement with the thrust of Dr Das's analysis. In our original article, we cited Arthur Kleinman's call for ‘medicine in general’ to go beyond a technicalised understanding of ‘caregiving’ and we also noted the resonance between our position and that of Iona Heath in relation to general practice.

We agree entirely that ‘an active engagement with the notion of embodiment’ would represent a very positive agenda for all of medicine. Our experiences as human beings are shaped by our physiology and the particular way it has evolved over centuries. However, they are also shaped by the particular cultural and historical context in which, and through which, we come to know ourselves and the world around us. In the lived reality of human beings, mind, body and social context are inseparable. But a medicine that sees itself as, primarily, a set of technical interventions will always strive to compartmentalise and conceptualise illness in simplified causal models. This represents a challenge for all branches of medicine.

Are we wrong to distinguish psychiatry from the ‘rest of medicine’? Maybe. Bill Fulford has argued convincingly that the widely held view that bodily illness is ‘relatively transparent in meaning’ and less ‘value-laden’ than mental illness does not stand up to scrutiny.Reference Fulford1 For him, it is simply that the values inherent in our concepts of bodily disorder are just not as obvious as those involved in our discourse of mental illness. When the presenting problem is pain from an arthritic joint or from a myocardial infarction, there is usually agreement between the doctor, the patient and the carer about what the priorities are and what would count as recovery. However, as medical technologies (such as in reproductive healthcare) develop, more areas of disagreement emerge and ethical issues become more obvious. In the world of mental health, disagreements about values, priorities and frameworks have always been part of day-to-day work and thus value judgements more obvious.

However, although we accept this analysis, we are not entirely satisfied that this is the full story. When we put the adjective ‘mental’ in front of the word ‘illness’, we do seem to be delineating a particular territory of human suffering. This cannot be clearly defined and seems to resist easy categorisation. But the word ‘mental’ implies that this is suffering that emerges from the mind, and whatever the ‘mind’ is, it is not simply another organ of the body. In this way, there does seem to be some sort of epistemological difference between psychiatry and other branches of medicine such as cardiology, endocrinology or neurology. Problems with our thoughts, feelings, behaviours and relationships would seem to be more intimately entwined with questions of meaning and context than problems arising from lesions in specific organs of the body.

Whatever we make of the relationship between bodily and mental illness, psychiatry grapples daily with epistemological and ontological issues and has a long history of doing so. A psychiatry that is able to ‘move beyond the current paradigm’ might be one that can offer insights and leadership to other parts of medicine.

References

1 Fulford, KWM. Moral Theory and Medical Practice. Cambridge University Press, 1989.Google Scholar
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