Thank you to all those who have been in touch about this. It would be wrong to say that the Critical Mental Health Nurses’ Network takes the following view, because a network of critical thinkers does not aspire to have just one view on a subject. However, our network (which is not something with a membership, but includes any nurse that wants to be involved and think critically about mental health nursing) is very welcome to add comments discussing the following post on the subject of this new/old development (which can be read about here: https://medicalgenomicswales.co.uk/index.php/health-professional-information/all-wales-psychiatric-genomics-service).
Very few people are qualified to fully interpret the findings or critique the design of the new research members of that group have published in Nature and I am not one of those people. But then it has been my repeated experience that very few of the people who believe that they can do those things know very much about mental health and mental health services and I always wonder where they are after the initial excitement has been seen in a more sober light. When the dust settles, the following general principles about genetic research into ‘schizophrenia’ tend to become important once more. Not only that, the people who present such research almost never have anything to contribute to discussion about the history and political implications of their claims. As such, they do not seem to be able to consider how their research will, or could potentially, be used within a complex society and complex mental health system. A less sympathetic view might even wonder if they really understand the breadth of meaning and context of their own work. I’ll explain:
Millions of dollars have been spent on trying to understand the genetics of ‘schizophrenia’. So far, that research has mainly been helpful in showing us that:
- ‘Schizophrenia’, while being a categorisation that many professionals believe they can accurately recognise, is unlikely to be distinguishable from other forms of mental distress when viewed genetically. This is a feature that genetic research findings share with neurological research into mental ill-health. The genome has not read the DSM, it seems. There is a general academic consensus that the neo-Kraepelinian attempt to junk the id and the ego and become credibly precise about diagnosis from the 1980s onwards has been unsuccessful, with invalid categories, unreliable in use and a pick-list approach that is partly responsible for the alarming ever-extending reach of diagnoses into the general population. These are things that have been reason enough for the NIMH in the US to refuse new grants to new research into ‘schizophrenia’. It would be good to hear what the South Wales team think about that.
- The well-documented problems with diagnostic validity and reliability of the categorisation ‘schizophrenia’ are therefore carried into any research on the subject. Whoever the 76,755 ‘schizophrenic’ subjects of the recently published research in Nature were, their selection was not at all uncontroversial for those reasons, and the huge number of them arguably does not increase the validity of the research but creates 76,755 individual questions about it.
- There is no simple relationship between complex human experiences such as ‘schizophrenia’ and genes. The fact that hundreds of biomarkers are being implicated by this and earlier studies does not mean that we are closer to discovering the ‘genetic cause’ of ‘schizophrenia’ but rather the opposite; what we are seeing is something spread across the DNA code and that means that gene-based explanation is at best very far away. Yet fresh results are always trumpeted with fresh optimism about causes and ‘targeted treatments’. So where are the ones that were promised last time?
- But ‘very far way’ may be too optimistic. Could the very question ‘what is the genetic basis of schizophrenia?’ demonstrate a misunderstanding about the sciences? Some of the first papers that argued for the need to change this reductionist understanding of the ways that the sciences relate to each other are decades old. For example, consider John Dupré’s seminal 1983 The Disunity of Science. The ideas he put forward have only become stronger through empirical study. Ironically, probably the best example is the completion of the Human Genome Project in the early years of this century which really ought to have put the idea of DNA as a ‘blueprint’ for determining people and our experiences beyond the reach of serious scholarship. Now we suspect that the phenotype and the genotype do not have that kind of relationship but rather the phenotype is an emergent property of genes and the complex ways in which they become expressed (influenced through the psychological/social/environmental aspects of human experience). In other words, good biological science supports the view that human body is irreducibly biopsychosocioenvironmental, not determined by biology. When it comes to the complex human experience(s) often called ‘schizophrenia’, we are not close to discovering things that can be referred to as ‘underlying causes’, because the word ‘underlying’ probably reflects a misunderstanding.
- Moreover, the field of epigenetics shows us that even where genetic biomarkers exist, claiming a causal relationship rather than one merely of correlation is extremely complex. With a few notable exceptions it is probably better to think of DNA as more enabling than determining. Once again, it just seems weird that epigenetics is so seldom mentioned in the papers that proclaim breakthroughs. Those of us struggling to understand the implications of mental health research in genetics are really owed some very clear statements in this regard.
- Great care needs to be taken in assuming (or implying) that the identification of genetic markers leads to treatment options. Even in the rare instances where we know of simple 1:1 relationships between genes and phenotype (and, as above, genetic research into ‘schizophrenia’ has proven this not to be the case), treatments have so far proven elusive.
In other words, if a group of genetic researchers and genetics counsellors in South Wales want to get together with some psychiatrists in South Wales, there is nothing to stop them. They are also free to express their desire to help people for which we can give them the benefit of the doubt, perhaps. However, it seems rather unlikely that there really is enough clear science that supports this new paring and there are a number of reasons to believe it is misleading and unhelpful to have created a health service on that basis. Firstly, even if they do have good answers to some of the issues above (what are they, please?), one does suspect that they will have to work very carefully or the required nuance will be entirely missing, or entirely lost, on the service-recipients and their families. Secondly, and perhaps most importantly, crucial concerns remain even if, on this occasion, one can say that I have misunderstood my studies in the Philosophy of Science, and all of the above points can be dismissed by this new research.
These concerns have to do with the history of the idea of genetic causes of mental ill-health. Canadian nurse professor Thomas Foth is certainly worth reading on this. The most recent 2022 book by Professor Andrew Scull is also illuminating, to put it mildly. The idea of a genetically caused mental illness (with one or two singular exceptions) is mostly just that – an idea – but it is one with a striking effect on who or what may be deemed responsible for suffering. Since it has such a strong effect on responsibility there are very few who could believably claim to have no vested interests in the idea (or they might claim it, but are they qualified to do so?). Let me be more clear: psychiatry’s constant legitimacy problem has periodic escalations and a fresh (or rebooted) genetic explanation doesn’t half let them off the hook about the terrible recovery rates.
Despite the cheery stock photos on the website of this new service, there is nothing cheery about the history of this idea, which was one of the major influences on the social Darwinism that, from the later 1800s, drove psychiatry in the UK, France, and the USA to eugenics and subsequently, drove the logic of the Third Reich. Remember that the gas chambers were created first for the ‘mentally ill’ (and those with learning disabilities) and were staffed by doctors and nurses, not SS guards. For those who find this allegation to be too forthright, please consider adding Foth and Scull – for instance – to your reading list. The fact that an idea has been the root of genocidal abuses in the past does not mean that it can never be discussed again. But abuses are not at all confined to the past. The idea of a ‘welfare trait’ is certainly not far below the surface at the Institute of Psychiatry. The ability of neo-liberalism to find ways to make societal distress into individual pathology is the subject of countless contemporary critiques of social/economic policy in general and psychiatry/psychology in particular. It would be good to hear in what ways the new All Wales Psychiatric Genomics Service feels that 2022 is different enough from the past to mean that we can be adequately reassured.
It would be so welcome to see them engage wider scholarship from the humanities on the subject of mental distress rather than to attempt to isolate distress within DNA. In 2018, that scholarship found fresh focus with the publication of the Power Threat Meaning Framework (Johnston and Boyle). Many people, from service-recipients to service-providers and a lot of academics, in the UK and very internationally, find it to contain highly plausible and useful explanations about the origins of distress/acute distress (i.e. the concerns psychiatry describes as mental illness) within society and expressed in individuals. Perhaps there is a caution not to replace biological determinism with a social determinism – fine, while you are considering if it amounts to that, don’t just accept it, throw it into the mix. What is the view of the South Wales Psychiatric Genomic Service about the Power Threat Meaning Framework?
Jonathan Gadsby, 2022