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EDUCATION AND DEBATE: Patrick Bracken and Philip Thomas Postpsychiatry: a new direction for mental health BMJ 2001; 322: 724-727 [Full text]

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'Postpsychiatry' - or merely 'Properly Funded Psychiatry'?

Jan K Melichar, Spilios V Argyropoulos   (24 March 2001)

Postpsychiatry and DSM as a Penal Code

Alejandro Cuevas-Sosa   (24 March 2001)

'Postpsychiatry' is Psychiatry in Learning Disabilities

Philip Barron   (24 March 2001)

We should also look at alternative methods in mental health

Frank Leavitt   (24 March 2001)

psychiatry in the real world

Michael van Beinum   (26 March 2001)

The sleep of reason produces monsters.

Casimiro Cabrera-Abreu, Roumen V Milev   (26 March 2001)

Postpsychiatry and Antipsychiatry: Old wine in new bottles.

Gopinath Ranjith, Rajesh Mohan   (27 March 2001)

Postpsychiatry and critical psychology

Mark Rapley, Alec McHoul, Susan Hansen   (28 March 2001)

Perfectionism in Post modern Medicine

Sidney Gold   (29 March 2001)

Postpsychiatry: a new direction for mental health

Sue Collinson   (30 March 2001)

Nature-Nurture Revisited

Joe Costello   (1 April 2001)

Broad-minded Psychiatry

Rufus May   (5 April 2001)

Postpsychiatry:'Riverdance' for traditional psychiatry

Patrick G Coll   (7 April 2001)

A resume of the above

Chris Manning   (13 April 2001)

Postpsychiatry: what a refreshing change?

Erik Milner   (13 April 2001)

Authors' response

Patrick Bracken, Philip Thomas   (13 April 2001)

Postmodernism is no philosophical basis for change

Colin hemmings   (13 April 2001)

Conflicts within psychiatry

Maurice Silverman   (19 April 2001)

Placebos and Postpsychiatry

Phil Harrison-Read   (19 April 2001)

Postpsychiatry: Rationality and the Individual Self Remain

Dan Beales   (22 April 2001)

Is postpsychiatry so radical?

Simon Smith   (3 May 2001)

not postpsychiatry,but politics

Alistair Stewart   (4 May 2001)

Postpsychiatry: a new direction for mental health

M S Raschid   (17 May 2001)

Postmodern What ?

Keith Dudleston   (25 August 2001)

All in the Family

Geraldine S Hatfield   (27 August 2001)

'Postpsychiatry' - or merely 'Properly Funded Psychiatry'? 24 March 2001
Jan K Melichar, Clinical Fellow & Honorary Fellow Psychopharmacology Unit, University of Bristol, Spilios V Argyropoulos Send response to journal: Re: 'Postpsychiatry' - or merely 'Properly Funded Psychiatry'?	The authors, in their article, seem to believe that the whole of modern biological psychiatry is uncaring, unfeeling and only willing to see the patient (or, as the National Service Framework so beautifully puts it, ‘service-user’) outside of any social context. As junior psychiatrists who are biologically minded, we would argue that this is a fundamentally flawed view. What the authors may be misinterpreting is that, given limited resources and almost no ability to influence social circumstances (how many letters supporting rehousing requests have been successful?), psychiatrists aim to diagnose/treat those elements of a patient’s / service-user’s problems and conditions that they are able to. Of course, the social context plays a great part, but it is a part we have had very little influence over – suggestions can be made, but there is often little, if any, funding for these to be implemented. Perhaps a better description of ‘Postpsychiatry’ would be ‘Properly Funded Psychiatry’. After all, the authors’ own example of ‘Postpsychiatry’ – of the 53 year old Sikh woman – could also be interpreted as an example of well funded transcultural psychiatry i.e. by putting her concerns/symptoms into the context of her own upbringing, a satisfactory outcome occurred. This could merely be due to enough resources being present to fund appropriate specialist staff and not because of any seismic shift in the thinking of the Bradford Home Treatment Service away from psychiatry as it is practised today. What we may lose sight of is that not everything can be explained by social circumstances. Attempts by ‘modernist sociological psychiatry’ in the Sixties to go down that path led to the mismanagement and undue suffering of a vast number of core psychiatric patients. The speculations of the R D Laing era that mothers of schizophrenics and society at large were entirely to blame for their children’s illness is the most pertinent example of this. Modernist psychiatry, throughout the last century, was bound to unproven psychological and sociological theories. Biological psychiatry rose out of the failure of the previous approach to bring around any significant improvement in people’s care. In a wider context, a similar issue of being unable to deal with the social context of a person’s problems may be one of the reasons why so few junior doctors are willing to become General Practitioners in run-down, inner city areas. After all, if your patient’s aches and (mental) pains are mainly due to their chronic deprivation (little changed since the Black report in 1978, which, together with much work since, showed that only global change of the surrounding environment can usefully improve a population’s health i.e. people living with damp and peeling wallpaper will never, as a group, improve, no matter how many health checks and targets the government imposes), then whatever you do may, after many years, seem, at the very least, disappointing. On the philosophical issue, the use of the term post-modern by the authors is clearly mistaken. The description of the characteristics of post-modernist society is not supported by the context in which the whole post-modernist debate has taken place. The only evidence that the authors are putting forward is a quote by Muir Gray. We argue that this is a gross misrepresentation of what post-modernism is about, a common occurrence when using this word in the Anglo-Saxon world. For anybody interested, we refer to ‘The Post Modern Condition’ by the recently deceased J.F. Lyotard. We resent the use of the word post-modern willy-nilly or as yet another wonderful buzzword. But, rather than losing ourselves in a philosophical discussion, we prefer to see the faults and failings in a grossly under-resourced service. Perhaps we should all be clamouring for more investment and, once this is in place, see what needs changing and improving. We prefer to leave our intellectual power struggles outside of the day-to-day care of the patients. Jan K Melichar MRCPsych & Spilios Argyropoulos MRCPsych
Postpsychiatry and DSM as a Penal Code 24 March 2001
Alejandro Cuevas-Sosa, Chairman Centro de Prevención y Tratamiento de la Violencia Sexual e Intrafamiliar Send response to journal: Re: Postpsychiatry and DSM as a Penal Code	Postpsychiatry and DSM as a Penal Code Editor - Bracken and Thomas' excellent article1 is plenty of enlightening concepts, like Porter's cite: "The rise of psychological medicine was more the consequence than the cause of the rise of the insane asylum. Psychiatry could flourish once, but not before, large numbers of inmates were crowded into asylums,"2 -or jails for inmates. Indeed, the categories created for Diagnostic and Statistical Manual of Mental Disorder (DSM), as it was said by Kutchins and Kirk "...reorient our thinking about important social matters and affect our social institutions."3 In accord with Webster's Dictionary, law is "a binding custom or practice of a community: a rule of conduct or action prescribed or formally recognized as binding or enforced by a controlling authority." In which case, DSM can be -and frequently is- seen as a Penal Code of mental behaviour -as it is presumably seen in medicine. A medical Penal Code with its jurisdiction within the realms of psychiatry, with well defined procedural rules and judicial proceedings, and well trained psychiatrist who, like judges, are mainly dedicated to settle the best way of administering medical "justice," and not just for treatment of "...over 300 mental illnesses, most of which have been 'identified' in the past 20 years."1 When lost of liberty -confinement- is a result of a professional judgment, we are talking about Criminal Law, not about medicine; of physicians acting like lawyers and, just in case, with their DSM-Penal Code at hand. Alejandro Cuevas-Sosa, M. D. Chairman of the Centro de Prevención y Tratamiento de la Violencia Sexual e Intrafamiliar, Apartado Postal 44-212, Col. Del Valle 03101, México, DF 1. Bracken P, Thomas, P. Postpsychiatry: a new direction for mental health. BMJ 2001; 322: 724-727. 2. Porter R. A social history of madness: stories of the insane. London: Weidenfeld and Nicolson, 1987 (cited by: Bracken and Thomas). 3. Kutchins H, Kirk S. Making us crazy. DSM: the psychiatric Bible and the creation of mental disorders. London: Constable, 1999 (cited by: Bracken and Thomas).
'Postpsychiatry' is Psychiatry in Learning Disabilities 24 March 2001
Philip Barron, Consultant Psychiatrist/Hon Senior Lecturer Camden Learning Disabilities Service/Royal Free and University College Medical School Send response to journal: Re: 'Postpsychiatry' is Psychiatry in Learning Disabilities	Bracken and Thomas propose that current psychiatric practice remains based largely on the medical model which asserts that the causes of mental distress are located within the individual and are largely a consequence of deranged biochemistry or 'neurological dysfunction'. This certainly is not the position in psychiatry of learning disabilities, where a bio- psycho-social model has been the preferred overarching model for a number of years. This model recognises the various contributions to different forms of mental distress from the organic/biochemical through to the social/environmental and incorporates the disease, psychodynamic, cognitive/behavioural and social learning theory models. Different models have varying validity depending on the condition in question but all may be employed in devising interventions and treatments. The evidence base remains inadequate but the bio-psycho-social model has enabled us to begin to overcome the damaging split between medical and social models which dogged services for people with learning disabilities for so long. Perhaps we are also practicing postpsychiatry.
We should also look at alternative methods in mental health 24 March 2001
Frank Leavitt, Chairman, Centre for Asian and International Bioethics, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, ISRAEL Send response to journal: Re: We should also look at alternative methods in mental health	There is also a need to respond appropriately to patient interest in alternative forms of psychiatry and psychotherapy: like One Brain Therapy, Bach Flowers,various forms of Meditation, Creative Imagination, etc. Anecdotal reports of success with these methods may be sufficient to warrant serious efforts to develop appropriate scientific methods for clinical trials.
psychiatry in the real world 26 March 2001
Michael van Beinum, Consultant child and adolescent psychiatrist Department of adolescent psychiatry, Possilpark Health Centre, Glasgow, G22 5EG Send response to journal: Re: psychiatry in the real world	I applaud the opening gambit of Bracken and Thomas in what needs to become a vigorous debate about future directions in psychiatry, but disagree with their arguments. They claim that "20th century psychiatry was based on an uncritical acceptance of this modernist focus on reason and the individual subject". It is as if the major influence on the 20th century of Freud and his insistence on the role of desire, and not reason, as the wellspring of human action had never been and psychoanalysis had not been a major component in the practice of 20th century psychiatry. Their focus appears to be narrowly Anglo-Saxon, as they fail to acknowledge European developments in psychiatry such as the influence of Lacan, Kristeva and Deleuze in France and Bassaglia in Italy. Indeed, they portray modern psychiatry as predominantly concerned with detaining people, and cite no references to studies of actual current psychiatric practice. The psychiatry I was taught and now practice in Scotland is all about working with patients in their social and cultural contexts and helping them manage complex social systems, including their families, employment, education and the law. Furthermore, they consistently and inappropriately assign agency to abstract concepts such as ‘psychiatry’. Psychiatry does not have agency, but individual psychiatrists, in their daily practice, do. Such misplaced concreteness is particularly unfortunate in an article opposing instrumental rationality, and hides the great variety of practice between individual psychiatrists. More fundamentally, they are unclear about their ontological and epistemological position, and fail to explicate their schema for uniting empirical causality with hermeneutics. Lastly, sceptical caution is in order when placing service users centre stage. Clarke and Newman, for instance, argued that managers, wedded to a rightwing capitalist ideology, use the ‘need of the consumer’ to break up state monopolies (1997:107-122). Bracken and Thomas raise important points. In particular, far more attention needs to be placed on a sound understanding of ethics and the philosophy of science in the training of psychiatrists. This would allow practising psychiatrists to have the conceptual apparatus to engage in a moral science of action appropriate to a multicultural Britain of the 21st century. References Bracken P and Thomas P. Postpsychiatry: a new direction for mental health. BMJ, 2001; 32: 724-7 (24 March). Clarke, J. and Newman J. The managerial state; power, politics and ideology in the remaking of social welfare. London, Sage, 1997.
The sleep of reason produces monsters. 26 March 2001
Casimiro Cabrera-Abreu, Consultant Psychiatrists Regina Mental Health Clinic, Regina, Saskatchewan, Canada., Roumen V Milev Send response to journal: Re: The sleep of reason produces monsters.	The sleep of reason produces monsters. Sir, We quote caption 43 of Francisco de Goya´s "Caprichos" as we have been left with a deja vu sensation after reading Bracken's and Thomas's article. Paul Gross and Normal Levitt (1994) in their influential and controversial book "Higher Supertition" , which initiated the "Science Wars" (duly forgotten or ignored by Bracken and Thomas) and lead to the famous Sokal's Hoax (Sokal, 1996, 1998) in the mid nineties, also quote Goya and give two meanings to his epigram: "When reason sleeps, the monsters of human pride, foolishness, malice, and cruelty emerge to do their worst. Thus it might be read: a maxim of the Enligthment. Yet it is true that utopian fancies that flow from an unjustified esteem for the power of reason can also breed monsters of violence, vengefulness, and tyranny, monsters the equal of those overthrown in reason's time. The judicious historian will always have both interpretations at his elbow, for history has abundant examples of each." Does the article by Bracken and Thomas merit such an apocalyptic criticism? There is no simple answer. We are tempted to say yes and no, in a typically pondered and laissez faire anglosaxon fashion. When they endorse a motley and protean discourse such as postmodernism to reflect upon psychiatry and the care of patients with mental illnesses, we become drastically "modern" and decry their pointless and vain attempt to reformulate psychiatry and mental illness under these conditions; however, when they bring to the fore the need to shun the doctrine that facts about society and social phenomena are to be explained solely in terms of individual facts (for a serious criticism of this view from an epidemiological perspective, see Díez-Roux, 1998), we can, wholeheartedly, sympathize with their opening statement: "The new commitment to tackling the links between poverty, unemployment, and mental illness has led to policies that focus on disadvantage and social exclusion." So, why our apparent ambivalence? (which we believe is shared by many psychiatrists in both sides of the Atlantic). What Edward Shorter (1997, p. ix) wrote, in his poignant preface to another controversial book, can throw some light to our frustration with this paper: "The history of psychiatry is a minefield. Both the revisionist and neoapologists such as myself risk being blown up by uncharted pieces of evidence. The very richness of the sources makes it possible to demonstrate through selective quotation just about anything. But what counts is gaining a sense of the central tendency, the larger picture." We are afraid that Bracken's and Thomas's fanciful efforts to address economic and social problems as they impinge on patients with mental illness via postmodernism, led them to substantial bias when quoting their sources. They certainly do not give a picture of the central tendency. They take issue with Griesinger, first, and with Karl Jaspers later; let us take the case of Griesinger, he is responsible for an unforgivable sin: "[Griesinger] seized on the early successes of pathology in explaining some forms of psychosis and asserted that this framework could be extended universally." Bracken and Thomas selectively quote Henri Ellenberger (1970, p. 241) ignoring, rather conveniently, the rest of the material presented by this author; Ellenberger, after affirming Grisienger's credo that "mental diseases are brain diseases", adds the folllowing: "Recent studies have shown to what unexpected extent Griesinger was a representative of dynamic psychiatry." Others (for example Hoff, 1995) have dispelled the myth of Griesinger as the proclaimed champion of biological psychiatry. But, is this so important? Is it fundamental to avoid this type of historical mistakes and misquotes? This issue is overshadowed by Bracken's and Thomas's postmodernist approach in which no matter what Griesinger said, the fact is that his scientific discourse is nothing more than another narrative with no privileged situation over shamanisn or the belief in witchcraft. They state this clearly when they get to the section of "Goals of postpsychiatry": "We also believe that in practical, clinical work mental health interventions do not have to be based on an individualistic framework centred on medical dianosis and treatment. [...] This does not negate the importance of a biological approach and also views it as being based on a particular set of assumptions that are themselves derived from a particular concern." This is the kind of nonsense that makes this article insufferable. Rigorous research in fields like history and philosophy of psychiatry is deliberately ignored in order to carry on with their own agenda: postmodernism in psychiatry is good because we say so; scientific endeavours are bad because they are eurocentric and inspired by racists and mysoginists. Although we are aware of the conceptual difficulties of our discipline (for a detailed discussion, see Berrios 1999) it is easy to become irritated and dismayed by "fashionable nonsense" such like this. By the way, this is the american title of a book written by Alan Sokal and Jean Bricmont (1998) in the aftermath of the Sokal's Hoax. Getting into a pointless war between postmodernist psychiatrist and those who somewhat perplexed get along with the clinical work would be a sad and delayed parody of the Science Wars mentioned at the beginning of this letter. References: Berrios GE. Classifications in psychiatry: a conceptual history. Aust NZ J Psychiatry 1999;33:145-60. Díez-Roux AV. Bringing Context Back into Epidemiology: Variables and Fallacies in Multilevel Analysis. Am J Public Health 1998;88: 216-22. Ellenberger H. The discovery of the unconscious: the history and evolution of dynamic psychiatry. New York. Basic Books , Inc., 1970. Gross PR, Levitt N. Higher superstition. The academic left and its quarrels with science. Baltimore and London: The Johns Hopkins University Press, 1994. Hoff P. Kraepelin. In: Berrios GE, Porter R, eds. A History of Clinical Psychiatry. The Origin and History of the Psychiatric Disorders. London: The Athlone Press, 1995:261-79. Sokal AD. Transgressing the Boundaries: Toward a Transformative Hermeneutics of Quantum Gravity. Social Text 46/47 (Spring-Summer 1996): 217-52. Sokal AD. What the Social Text Affair Does and Does Not Prove. In: Koertge, N. Ed. A House Built on Sand. Exposing Postmodernist Myths About Science. New York, Oxford: Oxford University Press, 1998: 9-22. Sokal AD, Bricmont J. Intellectual Impostures. London: Profile Books, 1998. Shorter E. A History of Psychiatry. From the Era of the Asylum to the Age of Prozac. New York: John Wiley & Sons, Inc., 1997.
Postpsychiatry and Antipsychiatry: Old wine in new bottles. 27 March 2001
Gopinath Ranjith, Specialist Registrars Maudsley Hospital, Denmark Hill London SE5 8AZ, Rajesh Mohan Send response to journal: Re: Postpsychiatry and Antipsychiatry: Old wine in new bottles.	Bracken and Thomas in their article (BMJ, 322: 24 Mar 2001, 724-27) offer a critique of the practice of modern psychiatry and promises a brave new world called postpsychiatry. But they fail on both counts. Despite enumerating the differences, their criticisms of psychiatry are no more than recycled arguments of the antipsychiatry movement: their vision is high on ideals and low on practical utility. They base their article on two assumptions: (i) the legitimacy of modern psychiatry is questionable and (ii) community care has failed and hence there is a need for a new theoretical framework in the post-asylum era. In support of the first notion they quote a book by one of the authors. No evidence is offered to back the second view. The studies that show the effectiveness of assertive community treatments find no mention (1). Most of their criticisms are flawed. Jaspers’ stressing the importance of form over the content of psychopathology provokes the authors’ ire. It has to be acknowledged that large scale crosscultural studies like the International Pilot Study of Schizophrenia (2) were possible by concentrating on the form of symptoms. These have led to an understanding of the universal experience of psychotic symptoms and went on to look at social and contextual factors as well. By polarising biological and psychosocial factors, Bracken and Thomas ignore the rapproachment that has happened recently as seen in the articles by Nobel laureate Eric Kandel (3) and psychotherapist Jeremy Holmes (4). The authors also attempt to portray psychiatrists as eager social controllers. The authors ignore the fact that the psychiatric profession has been in the forefront of the campaign to introduce more humane ways of helping those who are not capable of consenting to treatment (5). The stated goals of postpsychiatry are rather alarming. The undue importance to meaning and interpretations of subjective experience will invariably divert the focus from the distress and pain as well as relief of symptoms. Under the postpsychiatry model the patients whose symptoms may appear less “meaningful” or understandable are likely to be those who come from immigrant communities. The anecdotal information about the Sikh woman provided in the article, cannot be considered useful evidence to use in a clinical setting. It is obvious that all psychiatrists need to have expertise in dealing with patients from other cultures. However, this is possible within the current biopsychosocial framework of psychiatry where the importance of culture is being increasingly stressed. The future of psychiatry which is patient oriented and that which aims to alleviate distress and improve quality of life, does not come from fanciful thinking and recycled ideas. Bracken and Thomas’ effort reminds one of soldiers fighting on in jungles in a long lost battle. References 1. Marshall M, Lockwood A. Assertive community treatment for people with severe mental disorders. Cochrane Database Syst Rev. 2000;2:CD001089. Review. 2. Leff J, Sartorius N, Jablensky A, Korten A, Ernberg G. The International Pilot Study of Schizophrenia: five-year follow-up findings. Psychol Med. 1992 ;22:131-45. 3. Kandel ER. A new intellectual framework for psychiatry. Am J Psychiatry. 1998 ;155:457-69. Review. 4. Holmes J. Fitting the biopsychosocial jigsaw together. Br J Psychiatry. 2000 ;177:93-4. 5. Szmukler G, Holloway F. Reform of the Mental Health Act: health or safety? Br J Psychiatry 2000; 177: 196-200
Postpsychiatry and critical psychology 28 March 2001
Mark Rapley, Senior Lecturer in Clinical Psychology, Professor of Communication and PhD candidate in psychology Murdoch University, Alec McHoul, Susan Hansen Send response to journal: Re: Postpsychiatry and critical psychology	Bracken and Thomas are to be congratulated for their courage in facing and naming the dehumanising biological shibboleth of contemporary psychiatry - as indeed is the BMJ for publishing their valuable and thoughtful paper. Responses so far published serve, in general, more to make their case than to refute it: "biologicaly minded" psychiatrists (1), as was the case with their mad-doctor predecessors, do not offer evidence to support their rejection of Bracken and Thomas (2), but simply state that Bracken and Thomas are wrong - for instance in their use of the term "postmodern", or by appeal to misleading simplifications of earlier challenges to biopsychiatry (the blatant misreading of Laing on families being a case in point). This is a familiar tactic (see for example Boyle, 1990; Sarbin & Mancuso, 1984) (3, 4) to discredit critics of the coercive and inhuman practice of psychiatry. To argue, for instance, that the example Bracken and Thomas give of sensitive cross-cultural practice is actually "properly funded" psychiatry (1) is simply to continue the established practice of intellectual appropriation that was evident in the mad doctors' hijacking of Tuke's "moral treatment" in the nineteenth century. To suggest that, in learning disability, postpsychiatry is the norm (5) is to conveniently overlook the unheralded emergence in the late 1980s of so- called 'dual diagnosis' when psychiatry's institutionally-based power came under threat from clinical psychology. To seriously believe that non- verbal, non-ambulatory, people with IQ scores in the 45-50 range were, all along, displaying overlooked 'symptoms' of 'psychotic disorders' (which in both DSM-iv and ICD-10 require reports of odd experiences) is simply to strain credulity too far. That contemporary biopsychiatry is also "bound to unproven ... theories" which have failed to "bring around any significant improvement in people's care" (1) is amply demonstrated by the failure to date of biomedical research to identify any unambiguous sign of any putative mental disorder in the latest DSM or ICD and, simultaneously, to be confronted by a research base which demonstrates unequivocally that the routine infliction of brain damage on the (often unwilling) recipients of psychiatric "care" (6, 7, 8) is standard psychiatric practice. Why do neurologists attempt to control epilepsy? Because an enormous body of work suggests that epileptic seizures inflict brain damage. Why then do psychiatrists routinely recommend doctor-induced seizures for many of their 'depressed' patients? Bracken and Thomas have, in effect, blown the whistle on current psychiatric practice. They, unlike many of their subsequent commentators, are prepared to acknowledge facts such as the following: the US Supreme Court has before it a class action (which is highly likley to succeed) against Novartis, the American Psychiatric Association and CHADD for fraud and conspiracy over the invented 'disease' ADHD and the consequent promotion of Ritalin and other psycho-stimulants as a 'treatment" (9); that those who hear voices are not necessarily biologically disordered but rather are essentially indistinguishable from the 'normal' population (10); that the evidence base for supposed brain diseases like 'schizophrenia' is so slim and so routinely demonstrated to be self- evidently unscientific as to be worthless (3); and that the production of self-proclaimed 'medical' texts such as the DSM is so heavily influenced by prevailing socio-political concerns that it is more a reflection of contemporary prejudice than it is a psychiatric analogue for Gray's Anatomy. A body of work in critical psychology (11) has also begun to engage with the inhumanity of the pathologisation of everyday misery that biopsychiatry represents and proselytises. This work, and that of Bracken and Thomas, represents a real possibility for change. At the end of the day it does not matter whether Bracken and Thomas have used the term "postmodern" as Lyotard would have wanted or intended: such a criticism is the most transparent smokescreen possible. What matters is that here are two senior psychiatrists prepared to acknowledge that while the biological substrate of human action is necessary for both ordinariness and madness, it can not - ever - be sufficient explanation for either (12). References 1 Melichar, J.K. & Argyropoulous, S.V. 'Postpsychiatry' - or merely 'Properly funded Psychiatry', BMJ, 24th March, 2 Bracken, P. and Thomas, P. Postpsychiatry: a new direction for mental health, BMJ, 2001; 322: 724-727 3 Boyle, M. Scizophrenia: A scientific delusion? London, Routledge, 1990. 4 Sarbin, T. & Mancuso, D.Schizophrenia: Medical diagnosis or moral verdict? New York, Pergamon, 1984. 5 Barron, P. 'Postpsychiatry' is psychiatry in learning disabilities, BMJ, 24th March, 6 American Psychiatric Association, DSM-iv, Washington, DC, APA, 1994. 7 Breggin, P.Psychostimulants in the treatment of children diagnosed with ADHD: Part 1-Acute risks and psychological effects. Ethical Human Sciences and Services, 1999, 1, 13-33. 8 National Institutes of Health, Diagnosis and treatment of attention defecit hyperactivity disorder: Program and Abstracts, NIH Consensus Development Conference, Rockville MD, , 1998 9 Baldwin, S.Living in Britalin: Why are so many amphetamines prescribed to infants, children and teenagers in the UK? Critical Public Health, 10, 4, 453-462, 2000. 10 Leudar, I.& Thomas,P. Voices of Reason: Voices of Insanity, London, Routledge, 2000. 11 Holmes,G., Newnes, C. & Dunn, C.This is Madness, Ross- on-Wye, PCCS Books, 1999. 12 McHoul, A. & Rapley, M. Sacks and clinical psychology, Clinical Psychology Forum, 142, 3-11, 2000. 12 McHoul, A. & Rapley, M. Ghost/Do not forget that this visitation/ is but to whet thy almost blunted purpose: Culture, psychology and 'being human', Culture and Psychology, in press.
Perfectionism in Post modern Medicine 29 March 2001
Sidney Gold, Asst. Chief of Psychiatry Valley Service Area, Asst clinical prof. psychiatry, UCLA Southern California Permanente Medical Group Send response to journal: Re: Perfectionism in Post modern Medicine	Sirs: As a psychiatrist in a section of an HMO(Southern California) that provides prepaid Mental Health Services to more than a quarter million people, I am not struck by the conflict between psychiatry and anti psychiatry. Most subscribers want help for their psychological symptoms. There are few of the anti-psychiatry element coming to our offices. However, the issue of unrealized treatment outcomes often frustrates the patient as well as the provider of care. There is an unfulfilled expectation of complete cure. At the end of the day I am left with this thought, " Medicine is an imperfect science practised by clinicians who are less than perfect, providing care to patients who expect and demand perfect outcomes in treatment." Respectfully: Sidney Gold MD Asst Chief of Psychiatry, Valley Service Area, Southern California
Postpsychiatry: a new direction for mental health 30 March 2001
Sue Collinson Not back to the future again, please Send response to journal: Re: Postpsychiatry: a new direction for mental health	Editor - A little learning is a dangerous thing, and this is certainly borne out by the embarrassing spectacle of psychiatrists dabbling in the history of ideas1. Bracken and Thomas's light fingered trawl of European thought from the 18th to the 21st century, used as a framework for beating up on their own profession via an impoverished historical understanding of the development of attitudes towards the 'mad', left me feeling both disturbed and angry. Disturbed because as a patient I found much of what they said unsettling; and angry because I felt that the evidence used to justify an event called 'postpsychiatry' was dangerously flawed. Indeed, to play Bracken and Thomas at their own game, the Enlightenment philosopher John Locke (1632-1704) wrote about the mad that they 'do not appear to me to have lost the faculty of reasoning, but having joined together some ideas very wrongly, they mistake them for truths, and they err as men do that argue right from wrong principles'. I would say that this is a fair summary of Bracken and Thomas themselves. The authors state that it is hard to imagine another branch of medicine being challenged in the way that psychiatry has been. Where were they in the 1970s and 1980s, when women (and some men) mounted a powerful challenge to obstetrics, because they wished to redefine pregnancy and childbirth as a natural process that did not inevitably need medical intervention? Other medical specialisms have also strayed up strange paths to nowhere. There are some who think ECT is bizarre, but what about, for example, the huge craze during the 1920s and 30s for the transplantation of monkey glands into human testes for the purposes of sexual rejuvenation? Similarly, there are many sufferers from different conditions who have formed support or campaigning groups for much the same reasons as those suffering from mental illnesses have done: to share their experiences; to campaign for better services and resources; and, from time to time, to be critical of the very medical specialisms that have supported them through their illnesses. Bracken and Thomas state that the Enlightenment (which apparently only just ended at the onset of the recent 'decade of the brain') somehow 'promised' that rationality and science would overcome human suffering, almost as if this were rather a bad thing. It seems to me that there is something wonderful and optimistic in this, something that is worth remembering in these more cynical times. The Enlightenment did not produce a monolithic theory about humankind; on the contrary, the European world was set alight by a passionate discourse between the conflicting ideas of animists, mechanistic dualists, materialists, reductionists and vitalists among others. However, one can assert, according to Roy Porter, that all Enlightenment thinkers looked to science as the engine of analysis for gaining a better understanding of society, and within this context, medicine actually became interested in the 'wider laws of health and sickness, examining climate, environment and epidemics [and] certain physicians acquired an enlarged social awareness, confronting the interplay of sickness, medicine and society'. 2 The authors also state that the 'links between social exclusion, incarceration and psychiatry were forged in the Enlightenment era'. However, the building of the truly large asylums only took place from the 1840s onwards, well after the end of the Enlightenment, but fast on the heels of industrialisation. Before the Industrial Revolution, England had been a rural society. Never before had such unprecedently large numbers of people gathered to live so closely together, and in such unregulated squalor, as were to be found in the new, industrial conurbations. Big numbers needed big solutions. Dispersal back to individual hamlets and villages would have been as difficult then as it would be to carry out the 'repatriation' policies advocated by today's extreme right wing political parties. In addition, the huge county asylums were deliberately built out of town, where patients would receive the benefits of fresh air and being able to walk in the grounds and work in the gardens and farms. This nostalgic idea of trying to restore health and well being by returning people to a healthier environment was certainly taking 'context' into account. However, most disturbing of all was the persistent use by Bracken and Thomas of the term 'madness', as in the 'relation between medicine and madness', and 'psychiatry's promise to control madness', in a 21st century context. I have been suffering from a mental illness for over two years, but I am not, and have never been, 'mad'. It is my (perhaps deluded?) understanding that mental illness and madness are not the same thing, and that modern psychiatry is interested in treating mental illnesses. Notions of 'mad' and 'madness' are highly stigmatising. It is sad to see these terms still being peddled from within the psychiatric profession. Nor am I able to feel much enthusiasm for their suggestion that 'the voices of service users and survivors…be centre stage'. So often, this merely means that it will be occupied by those who can shout loudest. I have always believed that the most effective therapeutic relationship, in any branch of medicine but particularly in psychiatry, is the one where patient and clinician form a partnership, but where, as in Wittgenstein's explanatory model, there is an explainer and an explainee: in other words, the patient has sought the doctor because the doctor has expertise. When I was seriously ill, I was looked after by an experienced psychiatrist; as I became better, we worked together with my recovery as our common goal. The World Health Organisation has identified just one mental illness, depression, as a social and economic time bomb, which is already responsible for 4.2% of the world's total burden of disease and is the 5th leading cause of disability globally3. This is not the time for the psychiatric profession to sink into yet another paroxysm of therapeutic cowardice and self-indulgent, self-doubting, mea culpaism. And as for hermeneutics? It would seem that Bracken and Thomas are chasing the tail of their argument round and round the hermeneutic circle of meaning, and thus, are going nowhere. To let the Enlightenment have the last word: the eighteenth century surgeon, William Cullen, proposed that all pathology originated in a disordered 'spasm' of the nervous system. It is my sincere hope that this proposed postpsychiatric project is no more than a tic. Yours sincerely Sue Collinson London E8
Nature-Nurture Revisited 1 April 2001
Joe Costello, Principal General practitioner Spring Hill Medical Centre, Brisbane Send response to journal: Re: Nature-Nurture Revisited	Nature-Nurture Revisited As a practicing GP I was pleased to recently read Bracken and Thomas’ article, which brings to light once more old issues in Medicine. I work in the centre of Brisbane in a relatively affluent first world country. I consider myself a clinical pragmatist, that is I choose for my patients the most effective and efficient route towards resolving their ailments. In an ecology of increasing materialism – I use that word in its broadest sense – I have found it increasingly difficult to achieve long term sustainable solutions for my patients. I attribute this in part to a rather blinkered view of modern medicine as a whole as to how it is to progress into the 21st century. We are encouraged to think and behave as scientists and high rationalists. Our legal colleagues are never far away should we fail to act as per “best practice” and medical misadventure ensues. We are in the position of redefining our role in relation to our patients-clients and they also in relation to us. In this setting are unfolding new variations of old dynamics and issues pertinent to how we as humans see ourselves in relation to the big picture of our lives. In his excellent book, Man, Beast, Zombie, Kenan Malik recently asserts that we are returning to a prehumanist view of human nature, seeing ourselves as objects, disempowered and at the mercy of the whims of the Fates. Our vision is once again paradoxically becoming medieval. How we individually and collectively define ourselves as human beings is the core issue in Bracken and Thomas’ article. If we cannot achieve consensus on this issue, then I cannot see how Psychiatry or indeed any discipline can claim to heal that which it neither understands or believes such understanding to be extraneous to the task at hand. This is a much deeper issue than the biological versus the social: it is an issue about transparency, consultation and a willingness to collaborate with those with whom we might beg to differ. These are not “intellectual power struggles’ as suggested by one respondent, but are central as to how Medicine as a whole will evolve in the decades ahead. It is vital that this debate continues as no one party possess, or indeed is likely ever to possess the torch with which to penetrate the mist that shrouds our true natures.
Broad-minded Psychiatry 5 April 2001
Rufus May, Clinical Psychologist East London and City Mental Health Trust Send response to journal: Re: Broad-minded Psychiatry	Dear Sir/Madam I wanted to say how welcome it was to read the article entitled 'Post Psychiatry A New Direction In Mental Health', by P. Bracken and P.Thomas. I myself am a Clinical Psychologist, working in adult mental health services in East London. I have also had the experience of being a psychiatric patient who at the age of eighteen was given a diagnosis of Schizophrenia. It was refreshing to see a philosophy of care out-lined that is capable of embracing the complexity of working with madness in contemporary community settings. The Post Psychiatry proposed does not dismiss the expertise inherent in traditional psychiatry, rather it builds on both these advances and those of social psychiatry to offer a more broad-minded approach. Such a model of psychiatric practise is needed to encompass society's demands for more holistic mental health services that address the person in their social context rather than the just the illness in isolation. In my experience people's mental health problems can be meaningfully understood in the context of their life experiences. The case example in the above article illustrated this well. Thus an approach that focusses on making sense of unususal experiences and behaviour rather than on categorising it and pharmaceutically intervening seems very reasonable. Having researched in detail recovery processes from serious mental health problems, I can only confirm the need to value different frames of reference in working with psychosis. For example in peoples' accounts of the recovery process, spiritual explanations figure highly. Furthermore psychiatric 'insight' is not required to enable the person to rebuil their lives. Rather it appears that the individual needs to create a coherent account of his/her experiences that has some social currency. Working respectfully with different ways of thinking about unusual experiences is thus an important way of helping facilitate the recovery process. Long-term, what appears to have even greater weight in the recovery process is the re-gaining of a meaningful social role (work, vocation, family). This suports the authors' emphasis on considering ways to combat social exclusion processes. The historical account of western society's traditional tendency to go to some lengths to exclude the irrational was very informing. It helps explain the passion in the main-stream media for continuing to demonise mental illness by grossly exagerating the minimal association between conditions such as psychosis and dangerousness to others. A post psychiatry approach would fit alongside the growing mental health civil rights movement that seeks to counter social exclusion processes. I hope that such an article is the first of many that discusses how psychiatry can evolve to meet the changing needs of people with severe mental distress and confusion.
Postpsychiatry:'Riverdance' for traditional psychiatry 7 April 2001
Patrick G Coll, Clinical Assistant Professor,Dept of Psychiatry, University of Calgary Calgary, Alberta, Canada Send response to journal: Re: Postpsychiatry:'Riverdance' for traditional psychiatry	Traditions change in any profession as new knowledge emerges and sometimes a revolution is necessary if a profession stagnates. Dr's Bracken and Thomas eloquently outline a new direction for psychiatry based on a thoughtful philosophical critique of the history of psychiatry, providing a much needed challenge to the current dominant paradigm of bioreductionism. Traditional biological psychiatry does not serve many of our patients well.(1) The psychobable of the early 20th century has been replaced by biobabble. Physicians are routinely informing patients with mental health disorders that their condition is caused by a biochemical imbalance that can be corrected by drugs in the same way that insulin treats diabetes, despite the limited basis for this belief.(2) Lipowski has commented on the disempowering effect of this belief on patients : "Chemical imbalance confuses the distinction between etiology and correlation, cause and mechanism, a common confusion in our field. It gives the patient the misleading impression that his or her imbalance is the cause of his or her illness, that it needs to be fixed by purely chemical means, that psychotherapy is useless, and that personal effort and responsibility have no part to play in getting better" (3) Why do psychiatrists view neurophysiological approaches to mental illness as more valuable than others? The desire to remain a legitimate 'medical' specialty is certainly one, the pervasive influence of pharmaceutical companies another, the political need to distinguish ourselves from the non-medical therapists may also play a part. The eminent Harvard psychiatrist and anthropologist Arthur Kleinman has made observations similar to those of Bracken and Thomas on the limitations of the dominant current concepts in psychiatry: "In this golden age of biomedical research and treatments, we are witnessing the problem of what shall become of symbolic healing. Perhaps, over the next century in North America, it will wither away in the profession of medicine, to be practiced only in the folk and popular areas of health care. Perhaps it will continue to hang on as a marginal but inalienable aspect of psychiatry and the primary care professions, which themselves will be transformed into the high-technology image of the rest of medicine. This question must be asked of psychiatry per se: Can it continue to legitimize psychosocial problems, humanistic interest, symbolic interventions as medical concerns? If not, will psychiatry as we know it survive? Alternately, is there the possibility that by opening these medical concerns to the human sciences (psychology, sociology, anthropology, history, philosophy, literary studies) - by doing these things that run against the grain, so to speak - that psychiatrists can make the meaning of illness experience and the social sources of human misery and symbolic healing an integral part of a more broadly conceived science of medicine and health care?" (4) Drs. Bracken and Thomas are to be congratulated for rekindling this debate on the future of our profession. References: (1)Experiencing Psychiatry,User's Views of Services Rogers, A., Pilgrim, D., Lacey R., Macmillan Press (1993) (2)Blaming the Brain Valenstein, E., The Free Press (2000) (3)Psychiatry, Mindless or Brainless, both or neither? Lipowski, Z., Can. J. Psych.: 34:249-254 (1989) (4)Rethinking Psychiatry Kleinman,A., The Free Press (1989)
A resume of the above 13 April 2001
Chris Manning, Director of PriMHE Hampton Wick Send response to journal: Re: A resume of the above	Dear Sir Without pretending to have any knowledge of the history of psychiatry, I found myself completely bewildered by the array of answers and can now better understand why there are at least 350 consultant posts vacant in psychiatry in England, whether post-modern or not. Perhaps, psychiatry and those who still practise it should, at the very least, abandon the jargon beloved of academe, which is designed to induce a level of unquestioning awe in people -("More fundamentally, they are unclear about their ontological and epistemological position, and fail to explicate their schema for uniting empirical causality with hermeneutics") and concentrate on the highest common factors that could unite the profession. "Perhaps we should ALL be clamouring for more investment and, once this is in place, see what needs changing and improving. We prefer to leave our intellectual power struggles outside of the day-to-day care of the patients" - well, amen to that, although one suspects that the need for debate and a degree of mutual respect might help a lot of physicians deliver far better care to their patients (service users with a diagnosis). "I have always believed that the most effective therapeutic relationship, in any branch of medicine but particularly in psychiatry, is the one where patient and clinician form a partnership, but where, as in Wittgenstein's explanatory model, there is an explainer and an explainee: in other words, the patient has sought the doctor because the doctor has expertise. When I was seriously ill, I was looked after by an experienced psychiatrist; as I became better, we worked together with my recovery as our common goal". The model I deployed in general practice was one where I felt privileged to know what I knew and could not wait to pass it on, as soon as a person was ready. I viewed all my patients as having expertise (apart from anything else I needed their narrative and physical presence to function at all) from their first consultation- this had the benefit of keeping me in my place and esteeming them, especially if they were essentially sometimes unbearable (as indeed I could certainly be). It is now the perfect time to place each individual using services centre-stage - they are the subject of our interest and our mission is, with their help, as far as they can give it, to relieve their distress and help them regain and retain their balance and locus of control. A concern for people's mental health and the proper and humane treatment of those with mental illness are excellent benchmarks of a civilized culture. Further, this is where psychiatry is being led up an alley -instead of the key relationship between user and healthcare professional being centre stage and its delivery being supported by management structures and resources, they have become the short-term slaves of people with high political ambition who play to the lowest common denominators of fear and "rights", without any honest and open debate about key issues. Evidence based medicine,yes - but see if you can find it in management or politics. Medicine in general, and psychiatry in particular, could play a huge role in correcting this "power surge" by remaining firmly rooted to the biopsychosocial spot, whilst the Whirling Dervishes of Spin, wind themselves into the sands of short term political opportunism and populist and narcissistic cant. Yours Sincerely Dr Chris Manning www.primhe.org
Postpsychiatry: what a refreshing change? 13 April 2001
Erik Milner, Consultant Psychiatrist Villa 4, Walton Hospital, Chesterfield. Send response to journal: Re: Postpsychiatry: what a refreshing change?	Postpsychiatry: What a refreshing change? EDITOR-I would like to thank Bracken and Thomas(1) for their refreshing look at the link between the evolution of attitudes and that of service development within mental health services. I was particularly interested in the author's scepticism surrounding the assertion that mental disorders are mediated by neurological dysfunction, and that they can consequently be cured by specifically targeted drugs. I believe such doubts to be well-founded since this formulation ignores the range of personal and psychosocial factors that may affect the patient's engagement with services and compliance with medications. For the more severe mental illnesses, with the notable exception of clozapine, differences in efficacy rates between the range of psychotropic agents currently available are minimal. Therefore, positive therapeutic effects probably depend more on levels of engagement and compliance than the exact receptor specificities of the various pharmacological agents available. The magnitude of the compliance problem is illustrated, for example, in the case of bipolar affective disorder, where rates of poor compliance have been shown to be in the region of 40-60%. (2,3) This would indicate that the focus should be switched to approaches that might effect changes in levels of compliance and other such related variables. Such approaches may include the utilisation of culture-sensitive services and a move away from coercive care, as suggested by the authors, or indeed a range of psychosocial interventions and modes of service delivery. The example of assertive outreach springs to mind. The authors gave an interesting example of the use of a novel approach in a 53 year old Sikh woman with a history of affective disorder. However, at the same time they lay themselves open to criticism from the proponents of evidence based medicine. They state that, with the approach used, she remained well over a period of 12 months, "needing no drugs". However, they had earlier stated that she had a history of two admissions in the previous six years. Clearly it could be argued that follow-up over one year would be insufficient to evaluate the efficacy of the approach used both per se and in comparison to any earlier treatment packages tried in her case. Indeed the latency between episodes of affective disorder can often cause difficulties in the interpretation of studies of other treatments for this condition, particularly mood stabilisers. Hence, the recognition of the need for longer duration studies, of 2.5 years or more. (4) In this day and age there will be pressure to ensure that novel interventions whatever their nature be subjected to comparison to existing treatment modalities that have already been evaluated against the existing evidence base. Erik Milner consultant psychiatrist E.Milner@Sheffield.ac.uk Villa 4, Walton Hospital, Whitecotes Lane, Chesterfield, S40 3HW. 1 Bracken P, Thomas P. Postpsychiatry: a new direction for mental health. BMJ 2001; 322:724-7. 2 Colom F, Vieta E, Martinez-Aran A, Reinares M, Benabarre A, Gasto C. Clinical factors associated with treatment noncompliance in euthymic bipolar patients. J Clin Psychiatry 2000;61:549-55. 3 Keck PE Jr, McElroy SL, Strakowski SM, Bourne ML, West SA. Compliance with maintenance treatment in bipolar disorder. Psychopharmacol Bull 1997;33:87-91. 4 Kleindienst N, Greil W. Differential efficacy of lithium and carbamazepine in the prophylaxis of bipolar disorder: Results of the MAP study. Neuropsychobiology 2000;42 (Suppl.1):2-10.
Authors' response 13 April 2001
Patrick Bracken, Consultant Psychiatrists University of Bradford, Philip Thomas Send response to journal: Re: Authors' response	Editor, In a brief reply such as this, we cannot hope individually to address all the points raised in response to our recent article(1). We have therefore put down a few thoughts, which we hope will clarify some areas of misunderstanding. We hope to produce a book on the theme in the near future. Let us be clear from the start, the concept of 'postpsychiatry' is meant as a rhetorical device: a way of challenging current thinking, an invitation to imagine future possibilities, an indicator that radical change is already underway. In short, the aim has been to provoke a serious discussion about the theoretical underpinnings of mental health work in the 21st century. We are aware that the concept of the 'postmodern' is somewhat nebulous. However, like it or not, it is all around us. For our part, we believe it important to make the following distinction. The term "postmodernity" is often used to refer to a contemporary social, cultural and political condition, something we simply find ourselves in the midst of; the result, perhaps of an economic shift towards a 'more flexible mode of capital accumulation' (2). The concept of postpsychiatry emerges, not only from a recognition of this economic and cultural shift, but also from a more positive sense of the postmodern as a way of reflecting upon the world and our place in it. This relates to the 'postmodern environment' highlighted by Muir Gray (3). The last quarter of the 20th century witnessed a serious interrogation of the legacy of Enlightenment and an increasing realisation that science and technology would not solve all the problems we face as human beings. This was not, as some of our critics appear to believe, an attack on science or Enlightenment but a clearer realisation of their assumptions and limits. We agree with Foucault's contention that there is a need to get beyond 'the intellectual blackmail of "being for or against the Enlightenment" (4). For us, postmodernism is about facing the contradictions and difficulties of our situation as human beings without recourse to a belief that there will always be true and false ways of understanding and correct and incorrect ways of acting and behaving. In many ways postmodernism raises more problems than answers, but it can claim a greater degree of honesty than positions which continue dogmatically assert that they have the truth or the right path to the truth. The result of this is not 'therapeutic cowardice' (as Collinson asserts) but an openness to different frameworks and perspectives. Hence we welcome the emerging service user movement, and possibilities generated by groups such as the 'Hearing Voices Network'. We take particular exception to the comments made by Collinson. The position she adopts appears to be one of, 'I'm all right, so there's no need for any fuss'. She may have had a helpful encounter with a psychiatrist but unfortunately the same cannot be said for many others. In Rogers, Pilgrim and Lacey's large study of service user's response to the care they received, less than 50% found the attitude of their psychiatrist helpful (n=463) (5). 'Knowing Our Own Minds', the user-led research undertaken by the Mental Health Foundation (6), shows that most service users find a wide range of explanatory frameworks helpful in coping with mental health problems, and want more than psychiatry. In recent years many courageous users have spoken out about their experiences and organised to develop alternatives and to campaign for better statutory care. We find Collinson's characterisation of such people as those who 'can shout loudest' frankly offensive. A critical analysis of psychiatry from a historic-cultural perspective leads us away from the security of empirical science, with which most psychiatrists are at home, to the shifting sands of interpretation, opinion and values. This has a number of consequences. First, it introduces an interdisciplinary perspective that some of our respondents find deeply uncomfortable (Melichar and Argyropoulos; Cabrera- Abreu and Milev; Ranjith and Mohan; Collinson). Why is it that so often those who purport to defend reason do so in such unreasonable terms? Their assertions (unsubstantiated) that they are right and we are wrong confirm the point that we were trying to make. In particular, they highlight the need to introduce a much wider base for the education of psychiatrists, which over the last 25 years has become increasingly dominated by neuroscience (7). Those who accuse us of peddling 'antipsychiatry' have clearly been so aroused in their invective that they have not understood our paper. Developing a critique of something is not the same as simply opposing it. Our critique is meant to open up for discussion the assumptions and values inherent in psychiatric thinking. Those who claim that we are 'wrong' to hold the views expressed in this paper imply that there is a 'right' way to talk about madness (which expression incidentally, we consider to be less stigmatising than schizophrenia), that excludes or even forbids other perspectives. However they propose no justification for this position, which is simply asserted. If psychiatry is to have a positive future it will require those of us involved in the speciality to be open to a radical questioning of our own theories and practice. The positivism, which underscores traditional psychiatry, is only one philosophical doctrine alongside others. Surely a truly scientific attitude is one characterised by questioning and doubt, not by dogma and dismissiveness. We believe that the shift to postmodernity raises challenges but also important opportunities for doctors to redefine their roles. This in turn requires openness to the voices of those for whom psychiatry exists: service users. P. Bracken P. Thomas 1 Bracken P, Thomas P. Postpsychiatry: a new direction for mental health. BMJ 2001; 322:724-7. (24 March.) 2 Harvey D. The condition of postmodernity. Oxford: Basil Blackwell, 1989. 3 Muir Gray JA. Postmodern medicine. Lancet 1999;354: 1550-3. 4 Foucault M. What is Enlightenment? In: Rabinow P, ed. The Foucault reader. London : Penguin, 1984. 5 Rogers A, Pilgrim D, Lacey R. Experiencing psychiatry: users' views of services. London: Mind Publications, 1993. 6 Mental Health Foundation. Knowing our own minds: a survey of how people in emotional distress take control of their lives. London: Mental Health Foundation, 1997. 7 Pincus H, Henderson B, Blackwood D, Dial T. Trends in research in two psychiatric journals in 1969-1990: research on research. Am J Psychiatry 1993; 150: 135-42.
Postmodernism is no philosophical basis for change 13 April 2001
Colin hemmings, specialist registrar in psychiatry START Homelessness Team, Dugard Way, London SE11 4TH Send response to journal: Re: Postmodernism is no philosophical basis for change	Editor -- I share many of the ideals of Bracken and Thomas1, especially the need to emphasise meaning and the patient's perspective in clinical practice. But postmodernism cannot be a philosophical basis for these aims. Postmodernism is the most recent and extreme form of relativism, and social theorists such as Habermas and Gellner have pointed out its nihilism, defeatism and self-refutation.2 3 Postmodernism has been likened to an "Millenium cult" which now will increasingly fade. Post-modernists are paradoxically authoritarian when refusing even to consider the possibility of an objective reality or causal explanations. Unlike scientists, they seem unable to tolerate ambiguity, despite claiming to celebrate it. Postmodernism can be attractive in the lecture theatre, but not in clinical practice. If all interpretations are accepted as valid then ultimately this leaves no place for any universal morality, such as respect for another's opinion or consideration for the less fortunate. Postmodernism answers one question with another. How appropriate is this to clinical practice, when solutions are needed- and fast? Psychiatrists hold no absolute certainty in their work, but neither do physicists. Postmodernism contributes little to medicine beyond reminding us to recognise meanings, to be reflexive in our practice, and to be aware that the knowledge we gain is always tentative and influenced by its historical and social contexts. Postmodernism encourages a crisis of authority and representation. There is no assertion by Bracken and Thomas that for all our limitations, psychiatrists still know the most of all about mental illness. I recognise with them the need for debate on psychiatry's role in social control, especially the increasing pressure on us to be primarily risk assessors. Although we cannot claim to be "neutral, objective and disinterested" we can strive to recognise when we are not. There is little guarantee psychiatrists would be replaced in the process of compulsory care by others who are more "fair-minded", and every chance they could be replaced by groups who are less so. Other groups, with their own political agendas, may make claims to better represent our patients. For our patients, perhaps it could be "better the devil they know" in ourselves, rather than in those they don't. Colin Hemmings Specialist Registrar in Psychiatry START Homelessness Team, Dugard Way, London SE11 4TH cph@talk21.com 1. Bracken, P. and Thomas, P. Postpsychiatry: a new direction for mental health. BMJ 2001;322:724-7. 2. Gellner, E. Postmodernism, reason and religion. London: Routledge, 1992. 3. Habermas, J. The Philosophical Discourse of Modernity. Cambridge, Mass.: MIT Press, 1990.
Conflicts within psychiatry 19 April 2001
Maurice Silverman, Lately Consultant Psychiatrist Blackburn, Hyndburn & Ribble Valley Health Authority Send response to journal: Re: Conflicts within psychiatry	Dear Sir Bracken et al. theorise and speculate about conflicts within psychiatry whereby "Psychiatry continues to separate mental phenomena from background contexts." In particular psychiatrists are accused of regarding social and cultural factors as of secondary importance. I wonder what has led them to this point of view? It would be interesting to know the evidence for this amazing conclusion. If someone publishes a paper dealing exclusively with drug therapy in depression, this by no means implies that the author does not realise that other factors are involved in the causation of depression. It simply means that these factors are not the subject for consideration in this particular paper. I am a so-called general adult psychiatrist and I have been in psychiatric practice since 1945. I was always taught to take into account any factors that may be relevant to the patient's condition ranging from the exogenous on the one hand to the endogenous on the other hand. One's only concern was with the effect that these factors had on the patient. In my experience, in actual practice, the vast majority of clinical psychiatrists adopt a similar approach in their daily work irrespective of the labels that may be attached to them in other contexts. As far back as 1927 when D. K. Henderson and R G Gillespie published their Textbook Of Psychiatry which was dedicated to Adolf Meyer, they quoted Meyer in their preface, stating that his hypothesis regards mental illness as the cumulative result of "… unhealthy reactions of the individual mind to its environment, and seeks to trace in a given case all the factors that go to the production of these reactions." This was long before so called "postmodern" psychiatry. I wonder what is the source of the information gathered by Bracken and Thomas? My own surmise is that it is gathered from labels and abstractions that creep into publications as distinct from the daily toil of the vast majority of clinical psychiatrists. Yours sincerely DR MAURICE SILVERMAN Lately Consultant Psychiatrist Blackburn, Hyndburn & Ribble Valley Health Authority
Placebos and Postpsychiatry 19 April 2001
Phil Harrison-Read, Consultant Psychiatrist Camden & Islington Mental Health NHS Trust Send response to journal: Re: Placebos and Postpsychiatry	Editor - Braken & Thomas’s Article on “Postpsychiatry” is stimulating and touches on the importance to the individual of giving meaning and if possible value to their experience of psychiatric illness.¹ This constrasts with the traditional model in which psychiatrists’ understanding and explanation of mental disorders are often not found helpful or acceptable to patients and may lead in turn to rejection of or non-adherence to treatment. Although implying an holistic, culturally- aware approach to the management of mental disorders, whilst not seeking “to replace the medical techniques of psychiatry”, the authors miss an opportunity to make more explicit the practical implications of their approach for psychiatric treatment. Treatments which please and heal (“placebos”) cannot be dismissed as simplistic or unscientific.²Devising a placebo will require of the doctor the utmost sophistication and empathy with the patient’s plight if it is to be acceptable and effective. The therapeutic activity of a placebo can vary as much as that of any other intervention and there is no reason to suppose that the final common pathway of a therapeutic effect necessarily differs in a fundamental way when contrasting holistic therapy with biologically-based treatments such as drugs. However when drugs with powerful biological actions are therapeutically ineffective in mental illness, healing may still occur through accepting and treating the patient’s own notion of their illness, and this presumably operates through a different biological mechanism.³Finally, making available to patients the explanations and treatment they want and find helpful need not exclude the possibility of also delivering treatments which are justified on scientific grounds and are evidence-based. In fact this “consensual management” approach may be crucial for realising the full therapeutic potential of interventions with proven efficacy but variable effectiveness in everyday practice. Phil Harrison-Read consultant psychiatrist Department of Psychiatry, Royal Free Hospital, Pond Street, London NW3 2QG Competing Interest: - none 1. Braken P, Thomas P. Postpsychiatry: New Direction for Mental Health. BMJ 2001; 322: 724-7 (24th March) 2. Harrison-Read P, Tyrer P. The Application and Evaluation of Drug Treatment in Psychiatric Practice. In: King DJ, ed. Seminars in Clinical Psychopharmacology. London: Gaskell, 1995; 59-102. 3. Harrison-Read P. Neuroleptics in culture-bound syndromes. Br J Psychiatry 1986; 148: 106-107
Postpsychiatry: Rationality and the Individual Self Remain 22 April 2001
Dan Beales, Specialist Registrar in Forensic Psychiatry Edenfield Centre, Mental Health Services of Salford (NHS) Trust, Manchester, M25 3BL Send response to journal: Re: Postpsychiatry: Rationality and the Individual Self Remain	Postpsychiatry: Rationality and the Individual Self Remain Bracken and Thomas’s1 account of a possible “Postpsychiatry” contains a statement of what they see as major flaws in contemporary psychiatry. They suggest that a preoccupation with “rationality and the individual self” is “waning” and see any such preoccupation as a flaw. However they fail to suggest any convincing alternative theoretical framework to replace it. However much one sees their case example as presenting a “contextualised” psychiatry it can also be seen as fundamentally respecting their patient’s “individual self” and having as a central aim the restoration of her “rationality”. At the heart of this debate lies the extent to which severe mental illness can interfere with an individual’s capacity. Recent considerations of the need for reform of mental health law emphasise this as the central factor that should inform management, with a clear recognition that where capacity is lacking an individual’s rights need to be clearly protected 2. The aim of psychiatry is to restore individual agency (which is clearly linked to capacity) where this has been impaired by mental disorder. Respect for reason and individual personhood are central to this, as well as consideration of the way mental disorder, and its treatment, can affect a person’s ongoing sense of self, or individual narrative 3. There have been sophisticated considerations of the social basis of personhood 4, and there is ongoing debate about where the individual begins and the group ends 5. This work should not be seen as divorced from the extraordinary everyday problems faced by your average mental health worker, even if at first it may seem a world away. It is part of the essential conundrum facing every mental health worker of balancing the complex interactions between agency, biology and personhood that lie at the heart of psychiatry’s attempt to help every patient. The recent incorporation of the Human Rights Act into British law also needs to be clearly recognised before the individual is forgotten by psychiatry 6. This clearly relates to an individuals rights before the law, emphasising again how the centrality of personhood has been too easily sacrificed by Bracken and Thomas in their flight into postpsychiatry. Dr Dan Beales, Specialist Registrar in Forensic Psychiatry, Edenfield Centre, Mental Health Services of Salford (NHS) Trust, Prestwich Hospital, Bury New Road, Manchester, M25 3BL and Ashworth Hospital Authority, Merseyside. Email: dan@danbeales.freeserve.co.uk 1 Bracken P and Thomas P. Postpsychiatry: a new direction for mental health. BMJ 2001; 322: 724 –727. 2 Department of Health. Report of the Expert Committee: Review of the Mental Health Act 1983. London: Stationary Office, 2000. 3 Roberts G and Holmes J (eds). Healing stories: Narrative in Psychiatry and Psychotherapy. Oxford: Oxford University Press, 1999. 4 Burkitt I. Social Selves: Theories of the Social Formation of Personality. London: Sage Publications, 1991. 5 Dahal F. Taking the Group Seriously: Towards a Post-Foulksian Group Analytic Theory. London: Jessica Kingsley Publishers, 1998. 6 Macgregor-Morris R, Ewbank J, Birmingham L. Potential impact of the Human Rights Act on psychiatric practice: the best of British values? BMJ 2001; 322: 848-50.
Is postpsychiatry so radical? 3 May 2001
Simon Smith, Consultant Psychiatrist, South Shropshire CMHT, 25 Corve Street, Ludlow, Shropshire SY8 1DA Send response to journal: Re: Is postpsychiatry so radical?	Is postpsychiatry "a new direction for mental health" (1) or is it an exercise in re-branding of the status quo of British psychiatry? Bracken and Thomas use complex arguments to arrive at the viewpoint that mental health problems often cannot be understood within a rigid medical/biological model and that psychiatrists should consider psychological, cultural and social factors, including context and meaning. I would heartily endorse this and support their view that psychiatrists who only work within a narrow biological framework can disadvantage and alienate some users of mental health services. However, I feel that their insights are hardly an earth-shattering revelation. The vast majority of psychiatrists of my acquaintance realise the need to understand "social and cultural contexts", place "ethics before technology" and work to "minimise medical control of coercive interventions". So is postpsychiatry that radical a departure from the way most psychiatrists practice in this country, or is it any departure at all? The question of how much their individual practice differs from the norm can be tested in three questions: 1. Do they ever use medication to ease service users' mental health difficulties? 2. Do they ever admit service users to hospital? 3. Do they ever detain service users under the Mental Health Act? If they do these things then I would argue that their position cannot be so different from that of their colleagues and that postpsychiatry offers little more than "conventional" psychiatry in Britain today because there is little difference between them. Or perhaps the psychiatrists I know are, unknowingly, postpsychiatrists? 1. Postpsychiatry: a new direction for mental health. Patrick Bracken and Philip Thomas BMJ 2001; 322: 724-727
not postpsychiatry,but politics 4 May 2001
Alistair Stewart, consultant psychiatrist royal oldham hospital Send response to journal: Re: not postpsychiatry,but politics	NOT POSTPSYCHIATRY, BUT POLITICS "A chronicler who recites events without distinguishing between major and minor ones acts in accordance with the following truth: nothing that has ever happened should be regarded as lost for history. To be sure, only a redeemed mankind receives the fullness of its past". 1 Bracken and Thomas have certainly opened up an interesting debate. It is refreshing to find the wider politics of psychiatry being discussed in this way. It is also refreshing to read of their progress in providing helpful mental health services to people from ethnic minorities in Bradford.. However, their arguments in favour of "postpsychiatry" rest on a very wobbly philosophical foundation. We need a more secure base if we are to develop an effective analysis of how mental health services can help and not harm individual people, their families and friends and the wider society to which we all belong. We also need to be more modest about how much difference psychiatry can make, for good or ill - and less masochistic. There are useful things psychiatrists can do and are doing, but we have to be more realistic in our own expectations of how much we can do, as psychiatrists, to influence the lives of our patients for the better. Bracken and Thomas, following the trend of postmodernist thinking, give such importance to ideas - "the Enlightenment", "Modernism", "medical ideology" - that they fail to meet their own requirement for looking at "context", in other words the wider real world around us. In particular, by linking their argument to support for the approach of the current Government in producing the National Service Framework for Mental Health and "policies that focus on disadvantage and social exclusion", they ignore the reality of the Government's muddled thinking on the matter of mental health, and of the damage their other policies are doing to the same people we are trying, however imperfectly to help. "Ideas do not fall from heaven, and nothing comes to us in a dream".2 Bracken and Thomas start from the position that we need postpsychiatry and post modern medicine for our postmodern society. They appear to take it for granted that we are living in such a society.Apparently we entered this world in the last quarter of the twentieth century,but we are not told why. Postmodernism is a difficult thing to pin down, but it has been pinned down.3 As I understand it, the hard-line version of postmodernist thinking is based on the view that attempts to understand society as a whole are not only futile but dangerous and were the source of totalitarian regimes in the 20th century; there can no longer be any "grand narratives", only a myriad of different "narratives", "discourses", and realities. Everything is relative. The softer version of postmodernist thinking is that unprecedented changes over the last few decades in all aspects of human life and society around the world have consigned to the dustbin all previous attempts to understand ourselves. To the hardliners, it could be said that all things are relative but some things are more relative than others. Relative to the duration of human society, the last 60 years are but a moment; relative to the possibilities for the wholesale destruction of humanity they have been of decisive importance. Relative to the development of human civilisation, dyslexia is a very recent phenomenon, but it is a very real phenomenon for a child or an adult grappling with it today. Relative to a Bangladeshi family I am involved with through my work, I have had very different experiences of life, a different language and many different traditions, but I still believe that I should work with them to try and find a "common feeling language". This family want a decent health service just as much as anyone else in the town, and, as I am sure Bracken and Thomas would agree, we have a common interest in opposing attempts by fascist groups to march through our town. Some of my responsibilities to them are more those of a fellow citizen than those of a doctor. As to the soft version, when postmodernist thinkers claim to give the right response to times of massive change around the planet, they ignore the way such anarchic social and technological changes have been endemic to capitalist society for over 200 years: "the bourgeoisie cannot exist without constantly revolutionising the instruments and production and thereby the relations of production and with them the whole relations of society. Conservation of the old modes of production in unaltered form was on the contrary the first condition of existence for all earlier industrial classes; constant revolutionising of production, uninterrupted disturbance of all social conditions, everlasting uncertainty and agitation distinguish the bourgeois epoch from all earlier ones. All fixed fast frozen relations with their train of ancient and venerable prejudices and opinions are swept away. All new formed ones become antiquated before they can ossify. All that is solid melts into air, all that is holy is profaned".4 Some of the changes which are seen as breaking down old links and allegiances actually reduce the differences between people, countries and continents. "Globalisation", which is a word many politicians now use just before urging us to tighten our belts and work harder, actually means that the economic system presents an increasingly uniform face to people in all parts of the world in all conditions - Microsoft, Nestlé, Balfour Beattie, Bechtel, Glaxo Smith Kline, Shell, Macdonalds, Nike...... Contexts 1 - The history of the asylum The ideas which we identify as "the Enlightenment" were intimately bound up with huge transformations in the societies of Europe and North America during the 18th century, culminating in the American and French Revolutions. These new currents of ideas arose in response to these transformations and then in turn influenced them. The asylum system was one child of these upheavals of urbanisation and industrialisation, and became a social solution for certain people who did not fit into the new world and were thenceforth defined as "mad". The asylum institutions by and large did immense harm to the people subjected to them; partly they did so by keeping them out of sight, and this hidden nature helped the asylums to persist through the 20th century and even into the 21st. ( At the asylum where I was working in 1986, there was an outbreak among some long stay patients of tuberculosis - not exactly a "postmodern" disease, or even discourse. The public health doctors who came to investigate were unpleasantly surprised by the reality of a hospital which was only a few miles from the Health Authority Headquarters). The asylums did not develop in isolation. In Britain and elsewhere they grew alongside the degradation of millions of people by the factories, insanitary conditions, infectious disease, the prisons and workhouses, large scale prostitution, virulent racism, the rigid subjugation of women, and other aspects of Victorian progress. One of the principal forces driving the creation and maintenance of the asylums was certainly recognised by an American doctor visiting Victorian Britain: "This is a huge establishment... here hundreds are gathered and crowded. The rulers prefer such large asylums. They think them economical. They save the pay of more superintendents, physicians and other upper officers, but they diminish the healing powers of the hospital... the economy is not wise or successful."5 The effective community care of those consigned to the asylums was not unimaginable even in 1869, to people who wondered "whether, in fact, the same care, interest, and money which are now employed upon the inmates of our lunatic asylums, might not produce even more successful and beneficial results if made to support the efforts of parents and relations in their humble dwelling".6 Contexts 2 - Our dark places Given some of the sinister traditions of psychiatry, we certainly need to subject our practice today to close scrutiny, and keep foremost in our minds the maxim, first do no harm. In doing so we must once again attend to the context. The medical profession generally, and psychiatrists in particular, have to shake off many burdens of the past and present. The class position of doctors, the domination of doctors in the NHS by technologies which are financially profitable, and subordination to the requirements of the state, are some of these. Psychiatrists have participated in all kinds of harmful actions against their patients, up to and including wholesale murder, as happened in Nazi Germany.7,8 (Indeed there is evidence that the Nazi Party found that some doctors were initially ahead of them in their enthusiasm for this kind of barbarity).9 The medical profession is not above society, but of it, and it is dangerous for doctors or technicians or scientists to be politically illiterate. The dangers in our day are many. As Bracken and Thomas make clear, whatever the gains of the Decade of the Brain, the investment in research which it represented clearly fitted the priorities of politicians who want to locate the source of all kinds of individual and social distress and disorder in the malfunctioning of individual brains. These priorities are not exactly new10, though the arguments supporting them have become more sophisticated.11 At the other end of the spectrum, counselling and the diagnosis of post traumatic stress disorder are offered with patronising absurdity to the victims of disasters and wars, often triggered by the actions of the same countries which send the counsellors.12 Hubris in psychiatry always leads to nemesis, but usually not nearly soon enough. Contexts 3 - Psychiatry in Britain in 2001 Whilst some psychiatrists may be keen to extend the reach of the speciality into new areas, most of us in Britain today are trying quite hard to establish some limits to our role. This may be partly for philosophical reasons, but mainly because of the gap between what is expected of us, including in the National Service Framework and the numbers of psychiatrists and other mental health professionals available to do the job. This is at a time when the evidence base is becoming stronger for treatments and therapies which can be useful for people effected by a variety of mental disorders. Knowledge in isolation is not enough. We do our work in a country which has chronic structural unemployment, rising levels of substance use, a prison population which has increased by 25% over a ten year period, rising levels of violent crime, rising levels of income in equality and continuing economic and social disadvantage for people from ethnic minorities. All these things have a bearing on our work and in some ways set our limits. Sup with a long spoon The most worrying consequence of Bracken and Thomas' failure to put their philosophical arguments in this real world context is their support for the policies of the present government. The National Service Framework13 is certainly an important step forward, if only because it clarifies the issues to be debated. The NSF is about standardisation, as a way of bringing all mental health services up to certain minimum standards, even though the evidence base for these standards is necessarily imperfect. The NSF does not facilitate the direction of new resources at local priorities, and in fact the large financial resources which are meant to support it are still to be delivered. The NSF document also appears to ignore most of the social features of modern Britain mentioned above. Bracken and Thomas make little reference to the Government's White Paper for a new Mental Health Act.14 The White Paper appears to recommend a widening of the range of people whom psychiatrists will be expected to assess under the Act. The Government has rejected strong arguments for making the test of mental capacity integral to the workings of the Act and appears intent on pressing on with its oppressive legislation for people affected by its invented category of Dangerous Severe Personality Disorder. We must remember that it is the same Government which has managed to spend less on public services than its dreadful predecessor, which has encouraged racism with its disgusting attacks on asylum seekers (where is their social inclusion?); which has put the NHS in hock to private interests with its PFI schemes; which has sided with the big drug companies against the needs of the majority of people around the world affected by HIV,15 and which has yet to decide whether it wants to play a bit part in George Bush's version of Star Wars. . ALISTAIR STEWART Consultant Psychiatrist,Royal Oldham Hospital,Rochdale Road,Oldham OL1 2JH REFERENCES 1. Benjamin W., Theses on the Philosophy of History, in Illuminations. New York Shocken Books, 1968. 2. Labriola A., Essays on the Materialistic Conception of History, New York, 1966 3. Callinicos A., Against Postmodernism, London Polity Press 1989 4. Mark K., Engels F., The Communist Manifesto, Merlin Press, London 1998 5. Jarvis E., quoted in Porter R., The Greatest Benefit to Mankind. London Harper Collins 1997 p 5056 6. National Association for the Promotion of Social Sciences, quoted in ibid 7. Meyer J-E., The fate of the mentally ill in Germany during the Third Reich. Psychological Medicine 1988, 18: 575 - 582 8. Meyer-Lindenberg J., The Holocaust and German Psychiatry. British Journal of Psychiatry 1991, 159, 7-12 9. Hanauske-Abel H.M., Not a slippery slope or sudden subversion: German medicine and national socialisim. BMJ 1996, 313; 145-63 10. Clare A., Psychiatry in Dissent (first edition) London Tavistock 1976 pp 308-312 11. Raine A., Brennan P. et al High Risks of Violence, Crime, Academic Problems, and Behavioural Problems in males with both Early Neuromotor Deficits and Unstable Family Environments. Archives of General Psychiatry 1996, 63; 544-549 12. Summerfield D., A critique of seven assumptions behind psychological trauma programmes in war-affected areas Soc Sci Med 1999; 48; 1449-62 13. Department of Health, Modern standards and service models: mental health. London; Stationery Office 1999 14. Department of Health. Reforming the Mental Health Act, London, Stationery Office 2000 15. The Guardian March 31st 2001
Postpsychiatry: a new direction for mental health 17 May 2001
M S Raschid, Consultant Psychogeriatrician Wedgwood Unit, West Suffolk Hospital Send response to journal: Re: Postpsychiatry: a new direction for mental health	POSTPSYCHIATRY: A NEW DIRECTION FOR MENTAL HEALTH Patrick Bracken, Philip Thomas BMJ Volume 322 24 March 2001 Response – by Dr Salman Raschid: Convenor of the R D Laing Conference (The Royal College of Psychiatrists – Philosophy Special Interest Group) A Few Preliminary Points A general intellectual flabbiness appears to run throughout the article – consider one significant instance. Bracken and Thomas equate current Government policies with a “postmodern health agenda” and go on to criticise “the modernist agenda in psychiatry”. Such terms as ‘postmodern’ and ‘modernist’ need to be carefully defined, and this can only be done by putting them into a proper cultural/historical context (a process which would immediately reveal that they are words of many meanings). Incoherence and Contradiction Bracken and Thomas’s statement of the principles of ‘postpsychiatry’ strikes me as being a ragbag of incoherent ideas. There is one central, and major, contradiction: their statement that “Postpsychiatry … does not seek to replace the medical techniques of psychiatry …” negates the rest of their case – let me explain this. The ‘medical techniques’ of psychiatry are embedded in medical (or pseudo-medical) power structures, so that Bracken and Thomas’s postpsychiatry is essentially the standard/traditional form of psychiatry – entailing the use of medical and (or pseudo-medical) diagnoses, medication, ECT, admission to psychiatric units etc and so forth. In other words the medical techniques of orthodox psychiatry cannot even be understood apart from a particular socio- cultural matrix. Phenomenology Bracken and Thomas’s account of this area (philosophical and psychological) is one hundred percent wrong-headed. Karl Jaspers did not work “within the framework of phenomenological psychology developed by the philosopher Edmund Husserl”. Firstly, there was simply no such framework. Secondly, Jaspers increasingly minimised the influence of Husserl, and eventually dissociated himself from Husserlian phenomenology. (In the almost 900 pages of his General Psychopathology there are only two small references to Husserl, whereas there are 25 references to Freud, including four extended discussions.) Thirdly, the ‘phenomenological psychology’ Husserl lectured and wrote about was not an empirical discipline but rather what we would now call ‘philosophy of psychology’. Finally, and most importantly, Husserl’s philosophy is not based on the notion that “the mind is understood as internal and separate from the world around it.” Husserl had radicalised the Cartesian “interior focusing” through his theory of transcendental consciousness and the transcendental reduction so that he eventually became one of the most important fathers of the idea that in our perceptual experience of the world we are actually at the world i.e. the table that I am seeing before me (technically the perceptual noema) is a part of the actually experienced world and not an image, symbol or ‘internal representation’ (as held by classical British empiricism). Antipsychiatry Bracken and Thomas’s discussion is based on preconceived stereotyping, rather than upon an examination of the actual tendencies/movements labelled as ‘antipsychiatry’. Consider their statement “antipsychiatry argued that psychiatry was repressive and based upon a mistaken medical ideology, and its proponents wanted to liberate mental patients from its clutches.” The thoroughly tendentious nature of this bold declamation is exposed by its curiously self-referential character (see their note 32 on page 727). There are fundamental differences in theory (and practice) between – for instance, the American T S Szasz, the Frenchman Felix Guattari and our own R D Laing. Nevertheless, none of these approaches has anything to do with “liberating mental patients from the clutches of medical ideology”. R D Laing’s work is based upon a most intellectually disciplined base – that of modern European philosophy (existential-phenomenology). It also has an important antecedent in the work of the great American pioneer H S Sullivan (1892 – 1949) – as Laing freely acknowledged. Laing had demonstrated the social intelligibility of many of the symptoms of patients medically diagnosed as suffering from ‘schizophrenia’. His theoretical formulations and therapy (or healing or reintegration) entail a complete unheaval of the traditional psychiatric set-up (in sharp contrast to the conventional practice implied in ‘postpsychiatry’). Laingian psychotherapy and psychosocial (milieu) therapy of psychotic patients has been demonstrated to be effective: in the distinguished work carried out in the Philadelphia Association households in London, by Dr Loren Mosher in America and of Professor Luc Ciompi in Switzerland University, Bern. This Laingian movement represents a most potent challenge to conventional psychiatric thinking and practice. Key References: R D Laing: The Divided Self (1960) London, Tavistock Publications R D Laing: Sanity, Madness and the Family (1964) London, Tavistock Publications R D Laing: The Voice of Experience (1982) London, Allen Lane R D Laing: (Review of Karl Jaspers) General Psychopathology (1963/4) International Journal of Psychoanalysis Aron Gurwitsch: Studies in Phenomenology and Psychology (1966) Evanston, Northwestern University Press Edmund Husserl: Phenomenological Psychology (Lectures Summer Semester 1925) (1977) The Hague, Martinus Nijhoff Karl Jaspers: General Psychopathology (1963) Manchester, Manchester University Press Herbert Spiegelberg: Phenomenology in Psychology and Psychiatry (1972) Evanston, Northwestern University Press Herbert Spiegelberg: The Phenomenological Movement: a historical introduction (1984) The Hague, Martinus Nijhoff
Postmodern What ? 25 August 2001
Keith Dudleston, Consultant Psychiatrist Scott Hospital, Beacon Park Road, Plymouth. Send response to journal: Re: Postmodern What ?	Bracken and Thomas claim that our society is asking for a different kind of psychiatry and a new deal between health professionals and service users. They claim our society rejects the recent "decade of the brain", the scientific method, and the belief that madness is probably caused by neurological dysfunction. In part they support these assertions by referring to the national service framework for mental health. However this framework concerns only people of working age. I point out that their comments are directed to one speciality in psychiatry. This is that which tries to help adults in mid life suffering from conditions commonly referred to as psychotic disorders. Psychiatry is much more than just this activity. Bracken and Thomas should acknowledge these obvious comments although I accept that "Post General Adult Psychiatry" does not have quite the same ring ! Competing interests: none
All in the Family 27 August 2001
Geraldine S Hatfield, Retired Secondary School Counselor N/A Send response to journal: Re: All in the Family	I believe there is much misdiagnosis and overdiagnosis in the psychiatric community. However,when a diagnosis of psychosis is made, based on observed behavior or family reports of a family member's acute change from a rational,functional being to one who is completely dysfunctional and illogical,then it is time to coersively provide medication and support in a safe,confined setting until the person is free of false beliefs and destructive behaviors. I agree that there may be,in addition to biological brain disease,environmental,personal,social and cultural factors that influence a person's behavior. However,if active symptoms of severe and persistent mental illness in either schizophrenia,bi-polar or unipolar disorder,are untreated pharmacologically or even with electroconvulsive shock,there can be no constructive psychotherapeutic interventions. Misery loves company and there are vast numbers of mentally-ill people in support groups who are trying to help each other and themselves(the hearing voices project et al). But to participate in such groups, the symptomatic sufferers must recognize that they have an illness. There are many who never develop insight into their biologically -based illnesses. Psychotherapeutic interventions have not,in my experience,helped these ailing people. I speak from experience. The brain diseases in my family are genetically linked:my mother suffered a psychotic post-partum depression and committed suicide;my first husband, the father of my children still suffers from bipolar disorder(he decompensates frequently because he does not continue taking needed medication);two of my adult children have bipolar disorder and are doing well on their medication. I can name numerous other members in my family tree who need and take psychotropic medications. The personalities and personal problems of all these people are different. Their cultural and religious orientations are dissimilar. The one thing they have in common is their need for medication to function rationally,effectively and fearlessly in society. Let us never dismiss the importance of medication for those who truly have biologically-based illnesses.