Authors' reply

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.¹ 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.