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
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There is also a need to respond appropriately to patient interest in
alternative forms of psychiatry and psychotherapy: like One Brain Therapy,
Bach Flowers,various forms of Meditation, Creative Imagination, etc.
Anecdotal reports of success with these methods may be sufficient to
warrant serious efforts to develop appropriate scientific methods for
clinical trials.
Competing interests: No competing interests
Bracken and Thomas propose that current psychiatric practice remains
based largely on the medical model which asserts that the causes of mental
distress are located within the individual and are largely a consequence
of deranged biochemistry or 'neurological dysfunction'. This certainly is
not the position in psychiatry of learning disabilities, where a bio-
psycho-social model has been the preferred overarching model for a number
of years. This model recognises the various contributions to different
forms of mental distress from the organic/biochemical through to the
social/environmental and incorporates the disease, psychodynamic,
cognitive/behavioural and social learning theory models.
Different models
have varying validity depending on the condition in question but all may
be employed in devising interventions and treatments. The evidence base
remains inadequate but the bio-psycho-social model has enabled us to begin
to overcome the damaging split between medical and social models which
dogged services for people with learning disabilities for so long. Perhaps
we are also practicing postpsychiatry.
Competing interests: No competing interests
Postpsychiatry and DSM as a Penal Code
Editor - Bracken and Thomas' excellent article1 is plenty of
enlightening concepts, like Porter's cite: "The rise of psychological
medicine was more the consequence than the cause of the rise of the insane
asylum. Psychiatry could flourish once, but not before, large numbers of
inmates were crowded into asylums,"2 -or jails for inmates.
Indeed, the categories created for Diagnostic and Statistical Manual
of Mental Disorder (DSM), as it was said by Kutchins and Kirk "...reorient
our thinking about important social matters and affect our social
institutions."3
In accord with Webster's Dictionary, law is "a binding custom or
practice of a community: a rule of conduct or action prescribed or
formally recognized as binding or enforced by a controlling authority." In
which case, DSM can be -and frequently is- seen as a Penal Code of mental
behaviour -as it is presumably seen in medicine. A medical Penal Code with
its jurisdiction within the realms of psychiatry, with well defined
procedural rules and judicial proceedings, and well trained psychiatrist
who, like judges, are mainly dedicated to settle the best way of
administering medical "justice," and not just for treatment of "...over
300 mental illnesses, most of which have been 'identified' in the past 20
years."1
When lost of liberty -confinement- is a result of a professional
judgment, we are talking about Criminal Law, not about medicine; of
physicians acting like lawyers and, just in case, with their DSM-Penal
Code at hand.
Alejandro Cuevas-Sosa, M. D.
Chairman of the Centro de Prevención y Tratamiento de la Violencia Sexual
e Intrafamiliar, Apartado Postal 44-212, Col. Del Valle 03101, México, DF
1. Bracken P, Thomas, P. Postpsychiatry: a new direction for mental
health. BMJ 2001; 322: 724-727.
2. Porter R. A social history of madness: stories of the insane. London:
Weidenfeld and Nicolson, 1987 (cited by: Bracken and Thomas).
3. Kutchins H, Kirk S. Making us crazy. DSM: the psychiatric Bible and the
creation of mental disorders. London: Constable, 1999 (cited by: Bracken
and Thomas).
Competing interests: No competing interests
What we may lose sight of is that
not everything can be explained by social circumstances. Attempts by ‘modernist
sociological psychiatry’ in the Sixties to go down that path led to the
mismanagement and undue suffering of a vast number of core psychiatric
patients. The speculations of the R D Laing era that mothers of schizophrenics
and society at large were entirely to blame for their children’s illness is the
most pertinent example of this. Modernist psychiatry, throughout the last
century, was bound to unproven psychological and sociological theories.
Biological psychiatry rose out of the failure of the previous approach to bring
around any significant improvement in people’s care.
In a wider context, a similar
issue of being unable to deal with the social context of a person’s problems
may be one of the reasons why so few junior doctors are willing to become General
Practitioners in run-down, inner city areas. After all, if your patient’s aches
and (mental) pains are mainly due to their chronic deprivation (little changed
since the Black report in 1978, which, together with much work since, showed
that only global change of the surrounding environment can usefully improve a
population’s health i.e. people living with damp and peeling wallpaper will
never, as a group, improve, no matter how many health checks and targets the
government imposes), then whatever you do may, after many years, seem, at the
very least, disappointing.
On the philosophical issue, the use of the term
post-modern by the authors is clearly mistaken. The description of the
characteristics of post-modernist society is not supported by the context in
which the whole post-modernist debate has taken place. The only evidence that
the authors are putting forward is a quote by Muir Gray. We argue that this is
a gross misrepresentation of what post-modernism is about, a common occurrence
when using this word in the Anglo-Saxon world. For anybody interested, we refer
to ‘The Post Modern Condition’ by the recently deceased J.F. Lyotard. We resent
the use of the word post-modern willy-nilly or as yet another wonderful
buzzword.
But, rather than losing ourselves
in a philosophical discussion, we prefer to see the faults and failings in a
grossly under-resourced service. Perhaps we should all be clamouring for more
investment and, once this is in place, see what needs changing and improving.
We prefer to leave our intellectual power struggles outside of the day-to-day
care of the patients.
Jan K Melichar MRCPsych &
Spilios Argyropoulos MRCPsych
Competing interests: The authors, in their article,seem to believe that the whole of modern biological psychiatry is uncaring,unfeeling and only willing to see the patient (or, as the National ServiceFramework so beautifully puts it, ‘service-user’) outside of any socialcontext. As junior psychiatrists who are biologically minded, we would arguethat this is a fundamentally flawed view. What the authors may bemisinterpreting is that, given limited resources and almost no ability toinfluence social circumstances (how many letters supporting rehousing requestshave been successful?), psychiatrists aim to diagnose/treat those elements of apatient’s / service-user’s problems and conditions that they are able to. Ofcourse, the social context plays a great part, but it is a part we have hadvery little influence over – suggestions can be made, but there is often little,if any, funding for these to be implemented. Perhaps a better description of‘Postpsychiatry’ would be ‘Properly Funded Psychiatry’. After all, the authors’own example of ‘Postpsychiatry’ – of the 53 year old Sikh woman – could also beinterpreted as an example of well funded transcultural psychiatry i.e. byputting her concerns/symptoms into the context of her own upbringing, asatisfactory outcome occurred. This could merely be due to enough resourcesbeing present to fund appropriate specialist staff and not because of anyseismic shift in the thinking of the Bradford Home Treatment Service away frompsychiatry as it is practised today.
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psychiatry in the real world
I applaud the opening gambit of Bracken and Thomas in what
needs to become a vigorous debate about future directions in
psychiatry, but disagree with their arguments. They claim
that "20th century psychiatry was based on an uncritical
acceptance of this modernist focus on reason and the
individual subject". It is as if the major influence on the
20th century of Freud and his insistence on the role of
desire, and not reason, as the wellspring of human action
had never been and psychoanalysis had not been a major
component in the practice of 20th century psychiatry. Their
focus appears to be narrowly Anglo-Saxon, as they fail to
acknowledge European developments in psychiatry such as the
influence of Lacan, Kristeva and Deleuze in France and
Bassaglia in Italy. Indeed, they portray modern psychiatry
as predominantly concerned with detaining people, and cite
no references to studies of actual current psychiatric
practice. The psychiatry I was taught and now practice in
Scotland is all about working with patients in their social
and cultural contexts and helping them manage complex social
systems, including their families, employment, education and
the law.
Furthermore, they consistently and inappropriately assign
agency to abstract concepts such as ‘psychiatry’.
Psychiatry does not have agency, but individual
psychiatrists, in their daily practice, do. Such misplaced
concreteness is particularly unfortunate in an article
opposing instrumental rationality, and hides the great
variety of practice between individual psychiatrists. More
fundamentally, they are unclear about their ontological and
epistemological position, and fail to explicate their schema
for uniting empirical causality with hermeneutics. Lastly,
sceptical caution is in order when placing service users
centre stage. Clarke and Newman, for instance, argued that
managers, wedded to a rightwing capitalist ideology, use the
‘need of the consumer’ to break up state monopolies
(1997:107-122).
Bracken and Thomas raise important points. In particular,
far more attention needs to be placed on a sound
understanding of ethics and the philosophy of science in the
training of psychiatrists. This would allow practising
psychiatrists to have the conceptual apparatus to engage in
a moral science of action appropriate to a multicultural
Britain of the 21st century.
References
Bracken P and Thomas P. Postpsychiatry: a new direction for
mental health. BMJ, 2001; 32: 724-7 (24 March).
Clarke, J. and Newman J. The managerial state; power,
politics and ideology in the remaking of social welfare. London, Sage, 1997.
Competing interests: No competing interests