Postpsychiatry: a new direction for mental health
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7288.724 (Published 24 March 2001) Cite this as: BMJ 2001;322:724
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests