By Tom Stockmann

Following its cancellation in 2020, the CPN conference returned online in 2021. 75 members met over a May afternoon to hear from three speakers, the talks sharing reflections on socio-political aspects of psychiatry. The conference was made possible by the hard work of Joanna Moncrieff, together with Vasiliki Gkofa and Johura Akther-Robertson.

First, Robin Murray reflected on his career throughout a shifting psychiatric landscape. Laing was the most famous psychiatrist during Murray’s training, but Eve Johnstone and Tim Crow’s assertion that schizophrenia was linked to increased cerebral ventricular size heralded an overwhelming shift to biological psychiatry in the 1970s. In line with the majority, Murray ignored the counter suggestion that the observed brain changes were antipsychotic related. He instead rode the momentum of this apparent scientific breakthrough, developing the influential neurodevelopmental theory of schizophrenia.

Murray sees this theory now, at best, as only partly true. Recent years have seen the death of the very idea of schizophrenia as a disease. Key to this have been large scale genetics studies linking only multiple, tiny contributors to risk. At the same time, there is finally mainstream acknowledgement of the importance of social factors in psychosis, something previously obscured by the dominant biological focus.

Murray made the point that a biological focus has let governments avoid responsibility for combating socio-political risk factors for psychosis. In the face of the latest evidence, this situation is untenable, and politicians and psychiatrists must prioritise efforts to prevent psychosis through social reorganisation.

Pat Bracken introduced an upcoming WHO QualityRights initiative. Drawing on the Convention on the Rights of Persons with Disabilities, it is to offer a guide towards a psychiatry centred on recovery and human rights. At present, Bracken argued, there is an overriding focus on technological aspects in psychiatry, such as diagnosis and treatment, which needs to shift to focus on values and ethics, meaning and contexts, relationships and power.

The WHO guide will contain various examples of good practice from around the world. Bracken highlighted the outstanding case of Trieste. There, with its origins in the work of Basaglia, is a focus on human rights and an openness to different understandings of mental health problems. There are close links with the political system, and a system-wide approach to mental health care integrates different services, such as housing, schooling, and employment.

Bracken drew parallels between the aims of both the CPN and this WHO initiative, to defend the CPN against recent accusations of uncertainty of purpose and action. A shift to a psychiatry based on a human rights and recovery agenda is intrinsically linked to the acknowledgement and harnessing of the social determinants of mental health. Here a clear a resonance with the priorities of the CPN, such as set out in the ‘Beyond the current paradigm’ paper.

Nicholas Rose reiterated the view of an overly technical, or mechanistic, mental health science. Highlighting the 2014 WHO Social determinants report, he pressed the need for a genuine social psychiatry to address causes of adversity across the world. A necessary step towards this is to better define the ‘stress’ that contribute to mental ill-health. He proposes integrating existing social and biological models through study of the ‘ecology’ of mental distress. Such models include that of ‘ecological niches’, the complex milieu which individuals inhabit, shape, and are shaped by.

There are many areas in which integrated biological and social processes within psychiatry could be further explored, including socially shaped epigenetics, socially modulated neuroplasticity, and social effects on the microbiome.

Rose’s overall message was that the human organism is essentially located in a socio-political environment. Psychiatry needs to adapt to this reality and radically broaden its approach. Here was resonance with Murray and Bracken – to create positive change, psychiatrists need to “get out of the clinic”.