Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Time to listen to other truths
- Sylvia Caras (13 April 2002)
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A True Understanding of DSM-IV
- Arthur Rifkin, MD (13 April 2002)
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Is depression a "disease"? And what about chronic fatigue syndrome?
- Constantinos Paschalides (14 April 2002)
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Re: A True Understanding of DSM-IV
- Chris L. Manning (15 April 2002)
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Dangerous severe personality disorder
- Robert H Chaplin (16 April 2002)
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Re: 'Non-Diseases'.
- Tom McGlynn (16 April 2002)
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Post-psychiatry is a useful protest but does not provide an alternative
- Riadh T. Abed, Rotherham S60 2UD (18 April 2002)
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What is the biomedical model?
- Shahid H Zaman (19 April 2002)
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Author's reply to Rapid Responses
- Duncan B Double, Carrobreck, Norwich NR6 5BE (24 April 2002)
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Psychospirituality
- Larry Culliford (25 April 2002)
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Post-Psychiatry: Science or Hermeneutics?
- Riadh T. Abed (29 April 2002)
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Re: Critical Psychiatry: Science and Hermeneutics
- Duncan Double, Carrobrack, Norwich NR6 5BE (9 May 2002)
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Re: Re: 'Non-Diseases'.
- Janet L Hutchison (22 May 2002)
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Double deviates from the norm
- Chris M Bowker (17 June 2002)
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I applaud Dr. Duncan Double.
- Dr. Terry D. Lynch (18 June 2002)
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Post-post-psychiatry
- Michael J Smith (24 July 2002)
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Re: Post-post-psychiatry and eclecticism
- D B Double (31 July 2002)
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Sylvia Caras, consultant www.peoplewho.org
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Just when science is finding its understandings more relative, fuzzy, chaotic, non-local, and influenced by the very observation, behavioral health is emphasizing the manufacture of what it is naming evidence and research --. today?s mental health paradigm is technological. But soul and feelings, and maybe even the brain, are instead non-linear, complex, holistic. It?s time to listen to those who have been mad, hear our truth, and develop a model for offering services that will advance real healing. Appreciations to Double for expanding the discussion. Sylvia Caras, PhD Founder, People Who www.peoplewho.org (Santa Cruz, CA, USA) |
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Arthur Rifkin, MD, attending psychiatrist Hillside Hospital, Glen Oaks NY 11004
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I don't think the issue is a conflict between a biological DSM-IV approach vs one emphasizing meaning. DSM-IV nowhere tries to establish a biological (or psychological)cause for mental disorders. It is neutral about etiology. It aims to use clear descriptions of symptoms to arrive at diagnoses that have validity from consideration of course, family history and response to treatment. Yet, many of the diagnoses in DSM-IV do, unfortunately, lack this validity, but are included because many clinicians think they are valuable categories. If there is a conflict over diagnosis, it isn't over biology, medicine, psychology, or sociology; it's over science vs nonscience. Since the etiology and pathophysiology of the major mental disorders remains unknown, as well as the alleged pathological psychological mechanisms, ie, not known by the usual canons of science, we cannot classify the way we would like, by understandng the causes and mechanisms. That leaves us with the necessity of using less certain means, such as usefulness. I'm sure we will revise diagnoses as we learn more. At a deeper level, the entire concept of mental illness requires that we, a priori, determine if the person is sick or not. Eg, does a mean bigot have a sickness? There must be reasons why someone becomes a mean bigot, but should we consider this a disorder? We commonly attribute free will to most people and consider them culpable, not sick, if they behave badly, except if we excuse them because they have a disorder that takes away free will. As long as we grant free will under some circumstances, we face this problem of separating choosen from unfree acts. Psychiatry, as all science, ignores free will and looks for causationg. If we choose to maintain the validity of free will there will remain the unbrideable gap between mad and glad that so roils the interface of psychiatry and criminal justice. I think the solution lies in abandoning the concept of free will, which would enable us to abandon the distinction between mad and glad. |
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Constantinos Paschalides, final year student Manchester Royal Infirmary, M13 9WL
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In this interesting debate about medicalisation, I think that psychiatrists may have a lot to say, as it is their boundaries that are being crossed by many “non-diseases”. So if we were to look upon psychiatry for enlightenment: would many – or indeed any - psychiatrists accept to call depression or CFS “non-diseases”? I doubt it. In fact, I can see the benefits for people if they get labelled with a disease: they do have “something medically wrong” with them, albeit a psychiatric disease, and rightly deserve other people’s sympathy, and all that the “sick role” entails. I can also see that this is a key reason for why such diagnoses are so easily and widely given: the doctor is generous in giving this “prescription” of disease, thinking that this is the least they can do to help, to acknowledge that their patient is suffering due to a medical condition. There is not too much wrong with doctors’ well-meaning generosity. A diagnosis is welcomed by most patients after all. However, simply acknowledging that their patient is suffering, without doing the extra step of blaming it all to “a medical condition”, might be better. It is not often encountered, because doctors feel they are expected to have all the answers, and they do not want to let the patient down. They are also very keen to blame a disease, in order to take all the responsibility off the patient. The problem lies in that, by so doing, doctors frequently leave the patients feeling like victims of that “disease”, totally disempowered and helpless creatures. Also, the rights often outweigh the responsibilities in the sick role that the patients adopt. This tool, which a doctor may use out of compassion in a genuine attempt to help, even has a potential for abuse. Finally, I do not want to be misunderstood as claiming that mental illness does not exist. On the other hand, I believe that we should be watchful not to encourage “too much medicine” or rather “too much illness”. A more effective and fair way of supporting patients has proved many times to be not the “medicine” that we give them, but the empowerment, optimism and hope we instil into them, so that they feel they are their own masters, and not the victims of a “disease” that only “medicine” can cure. |
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Chris L. Manning, Chair Depression Alliance. Ce PriMHE. Member of Mental Health Taskforce
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Dear Sir If we abandon the concept of free will, is that the exercise of free will or the inevitable deterministic outcome occasioned through the (if grudging) acceptance of the current understanding of how the brain struts its stuff? Surely, the point is that, whether free will exists in fact or not, we feel as though we are exercising it; although most of us experience times at which we are tested to our limits, or, if experiencing a profound cerebral dysfunction that itself affects the more even balance of such functions, the complete annihalation of any sense of control, although control usually remains. You are, after all, more likely to be attacked by someone with no diagnosis who is drunk, by virtue of disinhibition of self-control, than by anyone with a formal diagnosis of mental ill-health (unless that person is a miserable soul with a diagnosis of substance misuse?). I can certainly be glad to be mad, but only when I choose to be. When the jockey riding my hippocampus gets thrown, all hell breaks loose. Faithfully Chris Manning |
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Robert H Chaplin, Consultant Psychiatrist Springfield Hospital, 61 Glenburnie Road, London SW17 7DJ
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Double (2002) in exploring the limits of psychiatry stops short of examining the implications of the reform of the Mental Health Act. This is unfortunate as one of the most controversial non-diseases in psychiatry would have been scrutinized: dangerous severe personalitiy disorder (DSPD). In common with many non-diseases (Smith 2002), it is not welcomed by many doctors (Mullen 1999). However it is unlike many of the so called non- diseases referred to in the text. These seem to be mainly conditions that doctors view as trivial complaints although patients nevertheless find distressing and seek help. However DSPD is just as unlikely to confer benefit to the patient as it is to the doctor. It may lead to indefinite incarceration for a patient who has not comitted an offence, for which there is yet no treatment. DSPD, in my view, is a political non-disease. It exists in no internationally recognised classification, no psychiatric text book and is not being campaigned for by any user group. It benefits neither doctor nor patient. An extra axis for the international classification of non- diseases is therefore suggested: aetiology of the non-disease. This could include self-diagnosis (allergy to the 21st century, self diagnosed adult attention defecit disorder, etc) iatrogenic non-disease (tranquilisers for bereavement) commercial non-disease (antidepressants for normal shyness) and political non-disease. References: Double D. The limits of psychiatry. BMJ 2002;324:900-4. Mullen P. Dangerous people with severe personality disorder BMJ 1999;319:1146-7. Smith R. In search of "non-disease" BMJ 2002;324:883-5. |
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Tom McGlynn, Director (Tasmania) ME/CFS Society of Australia
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To highlight the medical insight and empathy with patients reflected in your 'non-diseases ballot' it would be instructive, alongside the eventual results, to publish lists of the likeliest 'top 10 non-diseases' such a ballot would have elicited from medicine's best and finest in 1852, 1902 and 1952 respectively. Such lists would not only be chastening for the profession to scan, even today, but could serve as predictors of the embarrassment that some, at least, of those involved in today's exercise may yet experience when their recent responses are republished a few years hence, before their likely mean life expectancy expires - say about 2022 A.D. Unlike the benighted quacks of yore, they may then suffer a deserved discomfort on being reminded, after 20 years further research, of the ignorance and/or bumptiousness so many have displayed in 2002, not least if their talents (or whatever it takes...) have by 2022 elevated a few to some pinnacle of the profession. Most alarming is that votes cast for certain of the more serious alleged non-diseases you have listed expose medical ignorance of much peer -reviewed research, some of it decades old and thus very likely pre-dating the training - even the births - of some of your correspondents. As one would expect, the disclaimer "We are...not suggesting the suffering of people with these "non-diseases" is not genuine" has already been ignored by some in the media who have seized on this public version of a boozy (but doubtless wholly tax-deductible) post- prandial medi- conference party game. It is hard enough already for patients to expose the educational limitations of many journalists but, when doctors parade perceptions of disease more defective than those of some of those journalists, we are forced to accept the inevitability of medical ignorance inflicting further harm on millions of people for many more decades to come. Patients worldwide (particularly those suffering as I do from more than one of the 40+ often wholly disabling conditions so wittily juxtaposed with 'gap teeth, 'big ears' and 'dandruff') therefore request BMJ to publish the names of the initiator(s) i.e. the "we" in your introductory sentence: "On 13 April we...publish a theme issue on...non- diseases." Tom R McGlynn, Director (Tasmania) ME/CFS Society of Australia |
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Riadh T. Abed, Consultant Psychiatrist Rotherham District General Hospital, Rotherham S60 2UD
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Duncan Double is right to point to the shortcomings of current psychiatric classification and to the narrow biological view of mental disorder which dominates current psychiatric thinking. This erroneous model which essentially reduces psychiatry to a sterile form of molecular biology is incapable of advancing our understanding of psychological dysfunction. However, while Double's cogent arguments against current psychiatric thought and practice are well received the alternative suggested is equally flawed. It is particularly worrying that the author should call for a diminished role for science in the understanding of human psychology and psychiatry (or for that matter, sociology and culture) and replace this with the confusion of post-modernism. This is likely to increase the conceptual pluralism that already plagues psychiatry. I share Double's concern about the neglect of social and cultural contexts in current psychiatric thought but the answer to this is the integration of sociology and culture into an expanded discipline of psychology which itself is part of the biological sciences. Thus,unlike Double, I would advocate a new psychiatry that is broader and more (not less) rigourously scientific. |
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Shahid H Zaman, SHO psychiatry Southmead Hospital, Bristol, Avon, BS10 5NB
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Quite often in mental health services circles, the concept of the “biomedical model” is misunderstood. Although it takes a reductionist (but not absolute reductionist) stance, it approaches the study of the phenomenon of health function/dysfunction from both a “bottom-up” and a “top-down” approach. The dimensions of culture, sociology and indeed psychology as causation factors are certainly not ignored or over-ruled as perhaps suggested by the Double article, but are integral in this approach. Observation through quantitative and qualitative measuring or analysis tools is at the heart of scientific enquiry. A shortcoming of such tools will be reflected in the present day theories and explanations of phenomena. Just because we at present have a less thorough understanding of psychological or sociological phenomenon than e.g. molecular biological ones, it is seems unwise to abandon the present scientific (i.e. biomedical) approach in the practice of psychiatry, to replace it with more conjecture instead of search for better measures. As far as the label of disease versus non-disease is concerned, this concept has always been value-laded in all clinical sciences from cardiology to psychiatry. It is here that the biomedical model will not necessarily give the “right answer” and so leads to most of the confusion in both practice and an understanding of the biomedical model. |
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Duncan B Double, Consultant Psychiatrist and Honorary Senior Lecturer Norfolk Mental Health Care NHS Trust and University of East Anglia,, Carrobreck, Norwich NR6 5BE
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I appreciate the support for my article from Sylvia Caras, as she is someone who has experienced mental health problems. The Critical Psychiatry Network believes that a combination of two types of expertise: expertise by experience, and by profession is a prerequisite for the highest quality mental health services. Arthur Rifkin is right that no information about the presumed aetiology of functional mental disorder is generally included in DSM III/IV - an exception is post-traumatic stress disorder. The neo-Kraepelinian approach focuses on biological aspects of illness and promotes the operational criteria of DSM III/IV. There is therefore only an association between DSM III/IV and biological aetiology, not a logical link. A classificatory system in itself is not necessarily biomedical. The fact that DSM-I was influenced by the reaction types proposed by Adolf Meyer illustrates this. However, a biomedical approach is opposed to the views of Adolf Meyer on psychiatric diagnosis.1 The aim of increasing diagnostic reliability in DSM III/IV contrasts with Meyer's recognition of the inevitable uncertainty of diagnosis.2 Meyer argued that the first aim of the psychiatrist should be to obtain an understanding of the person rather than to make a diagnosis. He was seen as undermining the value of psychiatric diagnosis. As far as he was concerned, one-word diagnoses may give the false impression that psychiatric disorders are easily defined and that their origins are well established. A biomedical approach, by comparison, has an explicit and intentional concern with diagnosis and classification, as does DSM III/IV. Making a biomedical diagnosis identifies a medical disorder, often implying a physical pathology, at least for the major mental illnesses. Inasmuch as DSM III/IV is associated with an approach which hypothesises an underlying somatic disorder, it contributes to the process of objectifying patients so that they become merely bodies needing treatment. Like Constantinos Paschalides, I would not say that disorders such as depression and chronic fatigue are outside the rightful province of medicine. I hope Tom McGlynn appreciates this clear statement. The point is that diagnosis of mental illness implies psychological dysfunction. Mental health problems may be helped in the doctor-patient relationship, for example, by counteracting demoralisation, as suggested by Paschalides. The problem with the biomedical model is that it implies somatic dysfunction. It diverts attention from the importance of the therapeutic relationship. As noted by Robert Chaplin, the invention of a diagnosis of dangerous severely personality disordered (DSPD) highlights the political nature of psychiatric diagnosis. As he implies, such a diagnosis needs more justification than social non-conformity and needs to be made on the basis of psychological difficulties and dysfunction. Dangerousness may be independent of mental disorder. The combination of risk and mental disorder has always been the justification for detention in psychiatric hospital. The Government should not introduce preventive detention in the new Mental Health Act by the backdoor in the mental health system because they want to avoid justifying it in the criminal system. Despite the statements of Riadh Abed and Arthur Rifkin, critical psychiatry is not against science. It does have concerns about a positivistic view of science. It is a form of hermeneutics in that it recognises the importance of interpretation in establishing "facts". Psychiatry is part of the human sciences, not natural sciences. Rifkin may want to make psychiatry a natural science by eliminating free will. However, the application of science should not be mindless and nonsensical - as recognised by Chris Manning. Although the brain is the substrate for personal action, understanding the meaning of people's distress and the psychological and social origins of their difficulties is still required. Critical psychiatry is not necessarily tied to postmodernism. It covers a range of views. What is crucial is that psychiatric practice is not taken for granted. It needs to be self-conscious, self-critical and non-objectifying. Its world-view, collective beliefs and attitudes need to be examined. In particular critical psychiatry does not seek to justify psychiatric practice by postulating brain pathology as the basis for mental illness. I agree with Shahid Zaman that in practice the biomedical model tends to be more eclectic than absolutely reductionist. However, modern psychiatry has always claimed that the key to progress is greater research into the biological basis of mental illness. The "solution" has not been forthcoming. Doctors have been trained in biological methods and are fearful of abandoning this tradition when approaching psychiatry.3,4 Psychiatry does need to be open to the uncertainty of human action, rather than seeking to fix humanity in its biological substrate. References 1. Double DB. The overemphasis on biomedical diagnosis in psychiatry. Journal of Critical Psychology, Counselling and Psychotherapy 2002; 2: 40-47 2. Double DB. What would Adolf Meyer have thought of the neo-Kraepelinian approach? Psychiatric Bulletin 1990; 14: 472-4 3. Double DB. Training in "anti-psychiatry". Clinical Psychology Forum 1992; 46: 12-4 4. Double DB. Integrating critical psychiatry into psychiatric training. In: Newnes C, Holmes G and Dunn C (eds). (2001) This is madness too. Ross-on-Wye: PCCS Books.
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Larry Culliford, Consultant Psychiatrist Brighton CMHC, 79 Buckingham Rd, Brighton, BN1 3RJ
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This a good, thought-provoking paper. Duncan Double (and others) may like to know of comparable initiatives aimed, at least in part, at bringing about a synthesis of psychiatry and anti-psychiatry. This is in terms of human spirituality. Within the Royal College of Psychiatrists, for 2 years now, there has been a 'Spirituality and Psychiatry' Special Interest Group (www.rcpsych.ac.uk/college/SIG/spirit) whose membership now stands at close to 500. Spirituality is 'The Forgotten Dimension',not only of mental health care(1)(2)(3), but also of general health care (4). We seek to clarify the meaning of 'spirituality', defined for example by Murray & Zentner as: 'a quality that goes beyond religious affiliation, that strives for inspiration, reverence, awe, meaning and purpose, even in those who do not believe in God. The spiritual dimension tries to be in harmony with the universe, strives for answers about the infinite, and comes essentially into focus in times of emotional stress, physical (and mental) illness, loss, bereavement and death’ (5). Whereas there are obvious overlaps, we are also at pains distinguish spirituality, which is universal and unifying, from religion(s), which are essentially socio-cultural phenomena and potentially divisive. We are looking closely at the relevance of spirituality in mental health care, supported by an extensive and growing evidence base. We are interested in 'new paradigm' research methods [see (1), (3)& (4)]. We seek to promote spirituality in terms of skills and attitudes, as well as knowledge, and are increasingly aware of the benefits for healthcare practitioners - in terms of reduced stress levels, improved work satisfaction, protective effects against burnout, alcohol and substance misuse, marital and family breakdown - of acquiring and developing spiritual skills (3). I am grateful to Double, and pleased that he has taken this step in opening up the debate. References: (1)Swinton, J. (2001) Spirituality and Mental Health Care: Rediscovering a Forgotten Dimension. London: Jessica Kingsley. (2)Larson, D.B., Larson, S. & Koenig, H.G. (2001) The patient’s spiritual/religious dimension: a forgotten factor in mental health. Directions in Psychiatry. 21,307-334. (3)Culliford. L.D. (2002) Spiritual Care and Psychiatric Treatment – An Introduction. Advances in Psychiatric Treatment, 8 (4)July: In press. (4)Koenig, H.K., McCullough, M.E. & Larson, D.B. (2001) Handbook of Religion and Health. Oxford: Oxford University Press. (5)Murray, R.B. & Zentner, J.P. (1989) Nursing Concepts for Health Promotion. London: Prentice Hall. |
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Riadh T. Abed, Consultant Psychiatrist Rotherham District General Hospital, Rotherham S60 2UD
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I am grateful to Duncan Double for making it clear in his response that post-psychiatry is part of hermeneutics. I would whole-heartedly agree that this is so and therefore, its claim to also somehow be part of science must be viewed with great suspicion. Hermeneutics(1) is based on the dualistic idea that human behaviour and experience is governed by 'meaningful resons' unique to the subject entirely separate from the physical laws of causality. According to this view sceince is excluded from the area of personal meaning and by implication from whole areas of human psychology. While the post-psychiatrists may wish to present these ideas in a new garb, they were, in reality, the dominant force in psychiatry during most of the twentieth century in the form of the intellectual blind-alley of Freudian psychodynamics. The hermenuetic approach unlike sceince has the major weaknesses of lack of predictive efficacy (1) and its being unconstrained by the limitations of the laws of natural science. Therefore, unlike science, it lacks the mechanisms for evaluating the worth of competing hypotheses and approaches ending up with a situation where practically anything goes. Hermenuetics should limit itself to areas such art and literature where it could do no harm. It is unsuited to solving real life problems such as mental illness which require knowledge and understanding of how the world works. References: 1. Bolton D. & Hill, J. (1996) Mind, Meaning and Mental Disorder: The Nature of Causal Explanation in Psychology and Psychiatry. Oxford: OUP |
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Duncan Double, Consultant Psychiatrist and Honorary Senior Lecturer Norfolk Mental Health Care NHS Trust and University of East Anglia,, Carrobrack, Norwich NR6 5BE
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Riadh Abed has given me the opportunity to attempt to clarify the relationship between critical psychiatry and science. He seems to be promoting scientism, in the sense that he believes that the natural sciences are the only valid mode of knowledge. Critical theory seeks to analyse why and how people accept or consent to systems of collective beliefs that legitimate various power structures. Argument about whether critical psychiatry has the authority of science exemplifies the ideological nature of psychiatry and medicine in general. Despite Riadh Abed, critical psychiatry is not dualistic. It seeks an integration of mind and brain. Recognising the ontological connection between mind and brain is not inconsistent with the contention that mind and body are conceptualised under incommensurable systems and that functional mental states cannot be explained in terms of physical causes. Merely because mind and brain are talked about in different terms does not mean they are distinct in essence. Scientific abstractions have been enormously successful in producing technological advances, so it may not be surprising that a prominence is placed on the scientific scheme of objective fact. However, verifiable knowledge about the mind is as essential as natural facts. The importance of human self-knowledge should not be undermined in tyrannical thinking about the brain. It is not weak to challenge a deterministic account of human behaviour. Although Riadh Abed regards Freudian psychoanalysis as an intellectual blind-alley, Freud himself attempted to create a science of the mind in this deterministic sense. He may have failed in this, but I would be loath to exclude all psychoanalytic insights from human knowledge. It may well be difficult to prove causal relationships in human behaviour, but this should not mean that we do not try to understand the reasons for human action. Connections may make sense. I am including everyday understandings, not just the depth interpretations of psychoanalysis. Although Riadh Abed may be exaggerating that "anything goes", we do need to recognise the inevitable uncertainty of psychiatric practice. The primary aim of psychiatric assessment should be to understand the patient as a person. Mainstream psychiatry acts on the somatic hypothesis of mental illness to the detriment of understanding people's problems
I am not surprised that Riadh Abed takes the position he does. Medical training is not a good education for hermeneutics. I, too, was schooled in a blinkered scientism, and can remember jettisoning it, when it was pointed out to me that it was questionable whether an understanding of human behaviour should take a form similar to the laws of natural sciences. Critical psychiatry is asking for a reconsideration of whether psychiatric practice needs to be justified by postulating brain pathology as the basis for mental illness. It may be misleading to tie critical psychiatry to post-psychiatry as this implies acceptance of post-modernism. There is an argument within critical psychiatry, for example, about whether post-modernism retreats into the irrational. This divergence should not detract from the main critical message of the need to avoid determinism by becoming more self-conscious about the unsatisfactory nature of modern psychiatry. |
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Janet L Hutchison, fulltime student student at University of Canberra, Australia, 2615.
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I agree with Tom McGlynn. I recall my atopic sister's reactions to typical food allergens being dismissed as psychosomatic. Health workers' use of the ideas of Illich and Foucault to justify their culturally programmed disbelief in ADHD is laughable. In this context, the oppressive professional hegemony is the oppositional and responsibility avoidant reaction to individuals with ADHD and stimulant drug therapy. The misplaced moral tone with which Ritalin and dexamphetamine are discussed, is incompatible with informed consent, and anti-discrimination and fair trading laws. This provider behaviour, however, is consistent with the judgement deficits that are so prodigiously chronicled by social psychologists. Provider neglect and abuse of individuals with hidden disabilities is bad enough in Australia, but tragically worse in the UK. As a woman, I am particularly concerned by providers' indifference to girls and women with ADHD. It's really surprising. I find current research on gender differences and similarities in ADHD fascinating. Misjudgement has condemned them to silence. It's time they were "allowed" to tell their own stories. The evidence of educational, occupational, financial and social disadvantage associated with ADHD is significant. Acknowledgement of this is no more 'medicalisation' than is acknowledgment of the modern disadvantage of superior storage of energy as fat. Clearly some transformational learning is required. One fair approach may be to gaol the failed health providers of truanting teenagers, instead of their mothers. Janet Hutchison |
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Chris M Bowker, Coordinator Social Alternatives In Mental Health Inc.
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There is much debate about what knowledge disciplines are appropriate in understanding and treating behaviour that falls outside the norm. The thing is that it is psychiatry that dominates and excludes other ways of knowing and understanding. And of course it must be noted that it is not just professional interetsts and psychiatric dominance that is at the heart of the problem. Commercial interests are as significant and continue to exert a major influence on the types of research undertaken and interventions used. Disciplines such as sociology are on the fringes. Social alternatives are too often written off as radical. Usually when psychiatric representatives claim a bio-psycho-social view they are referring to meeting needs in regard to a persons housing, employment status etc. There is no understanding of individual behaviour in a social political philosophical or historical context. And it is not expected that practitioners would take such an approach. They do not have the necessary critical/knowledge skills to do so. It is not part of the psychiatric knowledge package. Double is certainly an exception and demonstrates knowledge beyond the average psychiatrist. So in this sense it is very encouraging to see members of the profession expand their knowledge boundaries, arouse other psychiatrists out of their apathy and open up discussion. Double in his article makes a valid statement in his reference to the anti-psychiatry movement in that its leaders are dissident psychiatrist. I would just like to add that it is a real shame that people such Szas, Laing, Mosher and Breggin, who are demonstrating real courage and integrity in taking a critical approach of psychiatry, are forced to become dissidents and labelled accordingly. While these individuals still make a most valuable contribution through their academic exercises etc, at the local level practitioners such as these are very few and far between. I hope that Double does not become another statistic in this regard and continues to keep the mainstream thinking arguing and debating. Chris Bowker
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Dr. Terry D. Lynch, GP, psychotherapist and author of 'Beyond Prozac: Healing Mental Suffering Without Drugs, 23 Russell Lawn, Ballykeefe, Limerick, Ireland.
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Deart Sir/Madam, I applaud Dr. Double for this article. He raises fundamental questions about the current direction of psychiatry, in particluar psychiatry's pre-occupation with biochemistry at the expense of other, equally valid hypotheses. Psychiatry does not exist in a vacuum. Psychiatry's failure to focus on other hypotheses impacts on health care users, limiting care options and the direction of research.This is very serious, and it time that biopsychiatry was called to account for its extraordinary preoccupation with biochemistry in the absence of scientific proof which might justify such preoccupation. Yours sincerely, Dr. Terry Lynch. |
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Michael J Smith, Consultant Psychiatrist Department of Psychological Medicine, University of Glasgow, G12 0XH, UK
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It is interesting to return to this correspondence after three months, and review the debate. Leaving philosophical discussion about hermeneutics and post-modernism aside, I have simpler criticisms to make about Duncan Double’s paper. Firstly, he creates a false distinction between what we might call “everyday” NHS psychiatry and his proposed “post-psychiatry”. Most of us became psychiatrists because we’re fascinated by people and the complexity of their lives: if we wanted to be purely “biomedical” scientists, we’d have specialised in anaesthetics, or perhaps pathology. The “bio-psycho-social” model we use isn’t just a fancy term: it does describe the kind of skilled “muddling-through” that all good doctors should use in their practice. It’s worth recalling that every psychiatrist in Britain must have formal training in psychotherapy, that a large minority are also trained in CBT and DBT, and that many of us started our careers in General Practice, where the social context of family medicine is obvious. Many psychiatrists who work as psychotherapists won’t have written a prescription for years. It is a caricature to propose that psychiatry is a reductionist, biomedical behemoth, crushing all dissent and interested only in drug treatment. This might be funny, were it not so serious. Psychiatry and psychiatrists are easy scapegoats, and it is a fundamental mistake to imagine that psychiatrists are responsible for the worrying developments Double describes. We are not: he is aiming at the wrong target. Far from seeking to be agents of social control, the Royal College of Psychiatrists vehemently objected to proposals to detain people with “severe and dangerous personality disorder” in the proposed English mental health act. We were simply ignored by the Government. (see http://www.guardian.co.uk/Archive/Article/0,4273,4462123,00.html). Secondly, the medicalisation of everyday life is not restricted to psychiatry, but is creeping in to everything from childbirth to dying (as described elsewhere in this issue of the BMJ). The driver for this change is largely related to “consumer” demand and commercial pressures, rather than professional empire-building. “Psychiatry” is not responsible for the rise in antidepressant prescribing: 90% of depression is managed in primary care, in response to patients seeking help. Psychiatrists did not go looking for people with ADHD: they had to respond to demand from families who could not cope with their childrens’ behaviour. Likewise, psychiatry did not invent chronic fatigue syndrome. In fact, when psychiatrists try to limit the medicalisation of problems like CFS in favour of a more holistic approach, they are vehemently criticised by CFS sufferers themselves. The Critical Psychiatry group’s contribution is welcome, but I hope they will inform a 21st Century debate, not rehash those of the 1960’s and 1970’s. Neuroscience is advancing at a phenomenal rate: but it is not limited to lab-based, reductionist models of disease. Current research is beginning to describe the complex ways in which mind and brain, individual and group, health and illness interact in the real world. The social, cultural and ethical implications of these developments are enormous: “post-post-psychiatry” has already happened. |
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D B Double, Consultant Psychiatrist and Honorary Senior Lecturer Norfolk Mental Health Care NHS Trust and University of East Anglia, Carrobreck, Norwich NR6 5BE
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I agree with Michael Smith that mainstream psychiatry is generally more eclectic than radically reductionistic. On the other hand, I would not like him to undermine the impact of what I am saying by suggesting that everything is alright in psychiatry because we are now all eclectic. The biopsychological model of Adolf Meyer is more thoroughgoing than an eclectic approach. Meyer recognised the role of psychogenesis in the aetiology of psychotic disorders and did not see the biological foundation of such disorders as dissimilar from other mental disorders such as the neuroses and personality disorders. Eclecticism acknowledges that stress may precipitate mental disorders on the basis of a biological vulnerability. It emphasises the biological foundations of psychotic disorders, which may be difficult to understand in personal terms. The role of psychogenesis in neurotic and personality disorders is more easily accepted. Smith apparently does not want psychiatry to be held responsible for overmedicalisation. Despite his concern about repeating debates of the past, critical psychiatry unashamedly recognises its roots in the "anti-psychiatry" of the 1960s and 1970s. The 'anti' element in anti-psychiatry arises because the objectification of the mentally ill can make psychiatry part of the problem rather than necessarily the solution to mental illness.1 The term "anti-psychiatry" has been used to marginalise the critique of the psychiatric system. It is a label used by mainstream psychiatrists of so-called anti-psychiatrists, such as R D Laing and Thomas Szasz, who in fact both disavowed the use of the term of themselves. Eclecticism, such as that propounded by Anthony Clare in his book Psychiatry in Dissent2, attempted to neutralise the conflict with anti-psychiatry. Critical psychiatry is seeking a different consensus from Clare's eclecticism. Critical psychiatry sees itself as an advance over anti-psychiatry in the sense that it accepts the social role of psychiatric practice. Anti-psychiatry tended to reject psychiatric interventions as a form of social control. For example, the Critical Psychiatry Network's concern about the government's proposals for reform of the Mental Health Act are based on ethical reasons and linked to its critique of the explanatory model of mental illness, not a rejection of the need for the Mental Health Act itself.3 In essence, critical psychiatry argues that psychiatric practice does not have to justify itself by postulating brain pathology as the basis for mental illness.
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