Fulford K W, Smirnov A Y, Snow E
University Department of Psychiatry, Warneford Hospital, Oxford.
Br J Psychiatry. 1993 Jun;162:801-10. doi: 10.1192/bjp.162.6.801.
There is a strong prima facie case linking the abuse of psychiatry with difficulties about the concept of mental illness. However, a survey of recent Soviet literature showed that the concept of disease employed in the former USSR (where abuse was for a time widespread) was similar to its counterparts in the UK and USA in being strongly scientific in nature. A number of factors--legal, bureaucratic and professional--are important in abuse becoming widespread. These, however, fail to explain why psychiatry, rather than physical medicine, should be vulnerable to abuse. It is here that the concept of disease could be important. A scientific model of disease suggests that a significant vulnerability factor is the relatively underdeveloped status of psychiatry as a science. This leaves room for poor standards of scientific work in clinical research and practice, factors which are recognised as important in the Soviet case. In addition to the scientific element, there is an evaluative element of meaning in the concept of disease. Hence a second vulnerability factor could be the evaluatively problematic nature of judgements of mental illness. It is concluded that a failure to recognise this factor greatly increases the vulnerability of psychiatry, not only to gross abuses, but also to inadvertent misuses of involuntary treatment in everyday practice. This conclusion, far from undermining the role of science in psychiatry, is a step towards clarifying its proper role.
有一个强有力的初步证据表明，精神病学的滥用与精神疾病概念方面的难题存在关联。然而，一项对近期苏联文献的调查显示，前苏联（精神病学滥用曾一度普遍存在）所采用的疾病概念，在本质上与英国和美国的同类概念一样，具有很强的科学性。在滥用行为变得普遍的过程中，一些因素——法律、官僚和专业方面的因素——很重要。然而，这些因素无法解释为什么精神病学而非物理医学容易受到滥用。在这方面，疾病概念可能很重要。一种科学的疾病模型表明，一个重要的脆弱性因素是精神病学作为一门科学相对不发达的状态。这就为临床研究和实践中科学工作的低标准留下了空间，这些因素在苏联的案例中被认为是重要的。除了科学因素外，疾病概念中还有一个意义的评价性因素。因此，第二个脆弱性因素可能是精神疾病判断在评价上存在问题的性质。得出的结论是，未能认识到这一因素会极大地增加精神病学的脆弱性，不仅容易遭受严重滥用，而且在日常实践中也容易无意地滥用非自愿治疗。这一结论远非削弱科学在精神病学中的作用，而是朝着阐明其恰当作用迈出的一步。
