Postpsychiatry: a new direction for mental health

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

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.

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

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.