My vision for the future of mental health is the one where the stigma of mental illness, still common place, particularly for providers, will be as unacceptable as publication without consent. Where the idea of workaholism, now considered a health hazard for the public, will extend to the caretakers as well. I hope for a reality where the superhuman facade for physicians is considered as deliterious as forced treatment for patients of the past; and the idea of allied health culture setting an example for healthy living not an idolised goal but the reality.  I hope our current standards of "work until you drop" will be seen in the future as both unhealthy and unethical for anyone physicians included. 

Planning any service/support without consumer input?

Perhaps the same way, the way we do not hold those things relevant today what used to be relevant 20 years back and had everything been relevant today that means we have ceased to grow 20 years back.

My vision for the future of mental health is the one where the stigma of mental illness, still common place, particularly for providers, will be as unacceptable as publication without consent. Where the idea of workaholism, now considered a health hazard for the public, will extend to the caretakers as well. I hope for a reality where the superhuman facade for physicians is considered as deliterious as forced treatment for patients of the past; and the idea of allied health culture setting an example for healthy living not an idolised goal but the reality.  I hope our current standards of "work until you drop" will be seen in the future as both unhealthy and unethical for anyone physicians included. 

like having chronically mentally ill living on the streets and being jailed instead of hospitalized

over- medication, poly-pharmacy, board and care homes, disregard to housing

long-term detention under the MHA in the absence of evidenced risks or illness

Dear Professor Mary Seeman, 

Your question is intriguing as stated, but also, as a philosopher as well as a psychiatrist, I wonder why you chose to ask about ethics as opposed to simply wondering which practices will become outmoded.

Also - and I know you will not agree with me - I think the work by Frieda Fromm-Reichmann and others at Chestnut Lodge has been misrepresented. The social determinants of health, now well-established in the literature, are more convincing and durable data than anything provided so far by so-called biological psychiatry and neuroscience. That includes everything related to attachment, parent-child relationships, and all that family therapy and social and cultural psychiatry represent. It may not be so simple as "refrigerator" and "schizophrenogenic" mothers, but let's not hide our heads in the sand. As a child and adolescent psychiatrist and family therapist - against the prevailing winds of consumer-oriented and positive psychology which I considered pop psychology at its abysmal worst - I see plenty of cold-hearted and indifferent parents of all stripes: male and female, biological and adoptive parents, and foster families alike. 

Now to your question as framed: 

1. Giving antipsychotics to non-psychotic children for behavioural control, now quite common, and for sleep problems (e.g., Seroquel is used liberally by my colleagues in Montreal for children in the absence of major psychopathology). 

2. "Indirect diagnosis." Whether it is bypassing the "Goldwater Rule" of the American Psychiatric Association by "analyzing" or diagnosing a public figure like the President of the USA or inferring and implying diagnosis in clinical practice about people we do not directly interview or otherwise examine, such as we still see routinely in any psychiatric evaluation interview. In my experience, besides ethical issues of consent, these supposed family histories are often simply wrong. The parents of the children I meet often cannot distinguish major psychopathology in their families of origin in reliable ways and only detailed interviewing, preferably with original records, can establish a reasonable hypothesis about what is transmitted in families, biologically and socially. 

A colleague of my acquaintance was taken to task for doing precisely this and I think his incautious approach stated in the chart was off-base (factually wrong) and callous. 

3. The current investment, across a wide spectrum of approaches and professions from psychology, psychiatry and psychoanalysis, in the fiction called "personality disorders" will be regarded the way we look at previous exaggerated concerns about masturbation and enuresis in children, not to mention how our field dealt with sexuality. Again, besides the ethical issue of whether we have a right to employ such obviously prejudicial labels like "narcissist," "borderline" and "psychopath," they are, quite simply often wrongly applied, even if we subscribe to the theory of personality disorders. Why do I question the theory of personality disorders? There is no consensual philosophy of psychiatry or psychology that defines what a person is, let alone consensus on what we mean by pathologies of such. 

4. "Practice guidelines" will be seen in the future as the imposition of a limited number of studies of practice, selectively chosen not only by the supposed evidence base but by a communal consensus which can be charitably seen as a common denominator of practice or by less charitable souls like me as a shared illusion. 

These are among some of my current concerns about the practice of psychiatry projected as a probable near-future. 

Regards, 

Vincenzo Di Nicola

Professor of Psychiatry, University of Montreal

Very interesting, Vincenzo. I wish I could be around 20 years hence to see which of these predictions have come close! 

You're right, I don't agree with you re parenting. Parents most definitely hugely affect the development of children. But from there to schizophrenia is a very long leap.

Dear Mary,

Understood.

But in our understanding of the rich reciprocity of factors affecting the construction of identity and what Michael Rutter calls "developmental psychopathology," small effects can have devastating impacts. This is as likely true for toxic effects on the developing embryo as it is for what Rutter again called "maternal deprivation" in his early work on this topic. I doubt that for some supposedly "resilient" children parental eccentricity could tip them into psychotic experiences, but inheriting the very genes that makes some parents odd and dysfunctional could put those children at risk for being triggered onto developmental paths that could possibly lead them to have perplexing experiences that may eventually be experienced and construed as psychotic. 

What is very exciting now is that many threads are coming together for a richer, deeper and more nuanced understanding of the no-doubt heterogeneous group of experiences that we have called "schizophrenia" for a century and more. And of course Eugen Bleuler himself imagined them as the "group of schizophrenias," while his son Manfred continued his studies of families, including the psychosocial impact of families, on this group of serious psychiatric disorders. 

Perhaps one of my most important predictions for the future is that we will see more clearly that ideologies - passionate engagements with theories or visions of the world - will be deconstructed. That is what evidence-based medicine is supposed to do but in fact, does not, as it gives even more authority to our often wrong-headed theories, as you perceive in the work of Chestnut Lodge. Only philosophy - or, call it what you will - getting to the roots of things in a radical deconstruction of our observations and theories - can do that.

In his hugely influential "General Psychopathology" (1913) Karl Jaspers concluded that:

If anyone thinks he can exclude philosophy and leave it aside as useless he will be eventually defeated by it in some obscure form or other.[1]

Reference: 

[1] Karl Jaspers, General Psychopathology, trans. by J. Hoenig and Marion W. Hamilton (1997), p. 770.

You are very persuasive!

 I enjoyed reading these further arguments and answers to the original question. I have thought some more on this and add that we even need to respect the relationship of the person with schizophrenia and their psychiatric provider, case managers, etc. Why is it that some can work so well and competently with this population and others cannot. And why is the ability to truly connect in understanding with a person who has schizophrenia not discussed in schools? Is it because that precise quality cannot be measured? Another thought about what practice would be considered unethical in the future; treating people with schizophrenia as if they have nothing to contribute, and the lack of focus on reciprocity. How can we facilitate opportunities for reciprocity and respect? It is not only the relationships that a person with mental illness experienced when they were young, but also the relationships that occur (or don't) after the illness.

The oxymoron outpatient commitment

Limiting person choice through 'evidence-based' practices only.  

Dear Michael Desisto, 

Since I work as a child and adolescent psychiatrist in mostly outpatient settings and in Quebec, I do not deal with this oxymoron, as you call it. I imagine that it means encouraging people to attend sessions and treatment to ensure their ongoing care and rehabilitation? 

As for evidence-based medicine (EBM) and the practices derived from it, the notion was invented at my medical school by David Sackett and Gord Guyatt. I had a running battle with Sackett from almost my first day of medical school. He was brilliant, convincing and compelling, with the passion of an Evangelist. I have a deathly allergy to Evangelism or Fundamentalism in any guise, including Democratic Fundamentalism and Scientific Fundamentalism.

I would have none of it. I arrived in med school fresh from postgraduate studies at perhaps the premiere psychological and psychiatric institute in the world at the time - London's Institute of Psychiatry. I didn't need and did NOT welcome the attitude of people like him who arrogated to themselves the truth about medicine through a method of experimentation known as the double-blind clinical trial. This did not and will not bring the Messiah, as we Jews say. No methodology will answer the fundamental problems of any field, it can only open new ways of asking the questions. But the questions themselves are not clarified or resolved by method. This is so clear to me as to be boring to debate and has been stated and restated by philosophers (notably Wittgenstein), psychologists and psychiatrists of many difference confessions. 

I see the future, if there is to be a future of psychiatry, as cleaving the field into two, as many have argued, and perhaps more than two. In terms of academic work and research, there will be the "hunters" and the "butterfly catchers," as Jerome Kagan wrote in his autobiography, "An Argument for Mind." The hunters want convergent, simplifying models, methods, and results. Claude Lévi-Strauss called them engineers. Kagan's butterfly catchers or "bricoleurs" as Lévi-Strauss called them, are more interested in divergent or at least broader theories and methods, accepting complex and inconclusive results, if any. I call them "technocrats" and "phenomenologists" in my writing. The vast majority of clinical psychologists and psychiatrists are not interested in the kind of research the academy routinely touts and values, and are phenomenologists, taking care of other people (and themselves). The technocrats are sometimes benign and care about people, but not too much, and not as a rule. In the name of criteria, methods, EBM, and other reductive and spurious criteria, they dismiss the vast majority of meaningful discussion about human behaviour. 

I know - I trained in behaviour therapy and psychoanalysts stupidly gave up the fight against this interesting but very limited and often offensive approach to human problems. For example, what does "eating behaviour" mean? How can you operationalize "love"? This leads to nonsense like "love behaviour"! Eating is different than the actual, specific eating behaviours that are part of a larger notion of eating. Love or amatory behaviours are a very concrete and limited part of love and loving. Not to mention that behaviourism could never conceive of and operationalize something like attachment. EBM and other reductive methodologies are very poor frameworks for our field. In the future, when phenomenological people like me make career choices, it will be for a field that values what makes us human and in service of those qualities. If it can be within psychiatry, so be it, if not, the technocrats and bureaucrats will inherit the field of reductive, positivistic science, that they will call psychology, psychiatry and neuroscience. 

And there will be another Chomsky waiting in the wings to do to these new versions of mechanistic medicine what he did to BF Skinner's behaviourism in the late 1950s. Skinner, although brilliant and creative, didn't know what hit him and never responded and never recovered despite his last hurrah in his provocative polemic, "Beyond Freedom and Dignity" (1971). 

Raymond Tallis, among others, is one of the new Chomskys of our field, weighing in on the reductivism of genes and brains. See his "ApingMankind: Neuromania, Darwinitis and the Misrepresentation of Humanity" (2011).  

See these reviews and make up your own mind: 

https://ndpr.nd.edu/news/aping-mankind-neuromania-darwinitis-and-the-misrepresentation-of-humanity/

https://www.theguardian.com/books/2011/sep/16/aping-mankind-raymond-tallis-review

Respectfully, 

Vincenzo Di Nicola

Professor of Psychiatry

University of Montreal

Thank you so much, Professor Di Nicola, for your response to my cryptic comment.  It is like my reaction when someone believes they are closer to the 'truth' when they find a metaphor of mind in the brain. 

Dear Michael, 

Yes, in an earlier era of our field, Arthur Koestler wrote a book about that called "The Ghost in the Machine" (1967) taken from Gilbert Ryle's "The Concept of Mind" (1949). Against their view, I believe two things: first, although I am not mystical in any way and hold by natural laws, I believe that there is indeed a "ghost in the machine," and second, that today most researchers hold by the opposite, that there is a kind of machine in the ghost. What I mean is that, unable to account for consciousness, not to speak of experience as the meaningful construction of the world, people have not only dismissed the "ghost" (both human consciousness and conscience) but they have intuited, or insisted that a machine is in there after all. Back to La Mettrie' "L'Homme machine" (Man a Machine, 1747)! The machinery inferred is much more sophisticated today, but not too much. Eric Kandel won a Nobel Prize not as a psychiatrist which he is but as a neuroscientist researching memory, using of course animals much lower on the phylogenetic ladder, like seagulls. Neuroscientists don't invoke the mind as a computer today as much as invoking neural networks modelled after computers and computers modelled after supposed models of the brain.

Today's best example and incarnation of the "machine in the ghost" is the discovery by Vittorio Gallese and other Italian neurophysiologists in Parma of mirror neurons. Now, I want to point out that what makes this magical and fascinating for researchers and the intelligent public alike is the key word, "mirror"! Mirrors are magical yet they exist in the physical world. Gallese brilliantly goes beyond neurophysiology to speculate about things as diverse as René Girard's mimetic theory to attachment and autism. But the allure is not in the science but in the magical word mirror.

First, philosophically and theologically, and now, scientifically, we have been looking for a "mirror of nature" for millenia! So, in spite of noteworthy advances, we are going around in circles. The people who fashion themselves progressivists believe in scientific progress that argues something like this: We went from mind as a reflection of God (Augustine and Aquinas), mind as nature reflecting God (Spinoza), mind as behaviour (Skinner), and finally, mind as brain (neuroscience). Denying such essential and unavoidable constructs as mind, consciousness, experience, the construction of meaning, attachment, relations, and many other human experiences isn't progress, it's reductivism. It is circular because the mirror is empty, both literally and metaphorically. What human experience is the mind mirroring in nature, in the social environment, and where does THAT come from? You see my point? Let's say a baby has mirror neurons (I find the idea very exciting!) that allow it to imitate its parents and others in the social surround and through imitation, that creates attachment, learning, language, and many other things or by default, the pathologies of such, where do the parents and others get their models which are transmitted by imitation to their offspring and others? Do we go back to the philosophical and theological notion of a first cause? I am not sure we should pursue what have been correctly rejected as pseudo-questions in philosophy (see David Hume and Ludwig Wittgenstein) such as first causes and other scholastic ephemera. 

Instead, people find mechanical or magical ways of resolving these issues. Today, it's mostly mechanical in the guise of science (although others, like religious fundamentalists, invoke magical or supernatural means). You see, people just love machines, technology and methodologies, and just don't want to deal with meaning. Mirrors in the brain (possibly real but unproven so far in humans) is just another version of Plato's shadows of reality in the cave of human experience where people are chained to the limits of their world. 

Hope that is of some help to unpack this thread. 

Regards, 

Vincenzo Di Nicola

Professor of Psychiatry

When I was a young 'behaviorist', I was moved by an Arthur Koestler and J.R. Smythies edited volume, Beyond Reductionism, which focused on life as an open system.  I recall being moved to a new level of understanding and meaning in my chosen field of psychology, and the emergent qualities of mind.  I also taught neuroscience at the time, and recall reminding my students that the workings of our machine was a metaphor of mind and had emergent properties as well.  In research applications, I was even asked to take blood from former patients of a psychiatric hospital 30 years after discharge!  I am dismayed sometimes that so few of my colleagues identify themselves as 'humanists'.  

I too believe that finding mirror neurons is a magnificent finding because it says that there is a metaphor in the nervous system for so many human and animal qualities...love, attachment, empathy, intellect.  

Thank you so much for your response.  Let's hope the ghost remains in the machine!  

A couple of thoughts. When does EBP directly conflict with patient centered care. We basically tell people whats best for them based on results that may not reflect their needs, and may simply be more efficient. And the other is the field of epigenetics. Human experience, even possibly inherited experience directly and profoundly influencing what about us that is perceived to be mechanistic.