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.
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.
Rapid Response:
Authors' response
Editor,
In a brief reply such as this, we cannot hope individually to address
all the points raised in response to our recent article(1). We have
therefore put down a few thoughts, which we hope will clarify some areas
of misunderstanding. We hope to produce a book on the theme in the near
future.
Let us be clear from the start, the concept of 'postpsychiatry' is
meant as a rhetorical device: a way of challenging current thinking, an
invitation to imagine future possibilities, an indicator that radical
change is already underway. In short, the aim has been to provoke a
serious discussion about the theoretical underpinnings of mental health
work in the 21st century.
We are aware that the concept of the 'postmodern' is somewhat
nebulous. However, like it or not, it is all around us. For our part, we
believe it important to make the following distinction. The term
"postmodernity" is often used to refer to a contemporary social, cultural
and political condition, something we simply find ourselves in the midst
of; the result, perhaps of an economic shift towards a 'more flexible mode
of capital accumulation' (2). The concept of postpsychiatry emerges, not
only from a recognition of this economic and cultural shift, but also from
a more positive sense of the postmodern as a way of reflecting upon the
world and our place in it. This relates to the 'postmodern environment'
highlighted by Muir Gray (3).
The last quarter of the 20th century witnessed a serious
interrogation of the legacy of Enlightenment and an increasing realisation
that science and technology would not solve all the problems we face as
human beings. This was not, as some of our critics appear to believe, an
attack on science or Enlightenment but a clearer realisation of their
assumptions and limits. We agree with Foucault's contention that there is
a need to get beyond 'the intellectual blackmail of "being for or against
the Enlightenment" (4). For us, postmodernism is about facing the
contradictions and difficulties of our situation as human beings without
recourse to a belief that there will always be true and false ways of
understanding and correct and incorrect ways of acting and behaving. In
many ways postmodernism raises more problems than answers, but it can
claim a greater degree of honesty than positions which continue
dogmatically assert that they have the truth or the right path to the
truth.
The result of this is not 'therapeutic cowardice' (as Collinson
asserts) but an openness to different frameworks and perspectives. Hence
we welcome the emerging service user movement, and possibilities generated
by groups such as the 'Hearing Voices Network'. We take particular
exception to the comments made by Collinson. The position she adopts
appears to be one of, 'I'm all right, so there's no need for any fuss'.
She may have had a helpful encounter with a psychiatrist but unfortunately
the same cannot be said for many others. In Rogers, Pilgrim and Lacey's
large study of service user's response to the care they received, less
than 50% found the attitude of their psychiatrist helpful (n=463) (5).
'Knowing Our Own Minds', the user-led research undertaken by the Mental
Health Foundation (6), shows that most service users find a wide range of
explanatory frameworks helpful in coping with mental health problems, and
want more than psychiatry. In recent years many courageous users have
spoken out about their experiences and organised to develop alternatives
and to campaign for better statutory care. We find Collinson's
characterisation of such people as those who 'can shout loudest' frankly
offensive.
A critical analysis of psychiatry from a historic-cultural
perspective leads us away from the security of empirical science, with
which most psychiatrists are at home, to the shifting sands of
interpretation, opinion and values. This has a number of consequences.
First, it introduces an interdisciplinary perspective that some of our
respondents find deeply uncomfortable (Melichar and Argyropoulos; Cabrera-
Abreu and Milev; Ranjith and Mohan; Collinson). Why is it that so often
those who purport to defend reason do so in such unreasonable terms? Their
assertions (unsubstantiated) that they are right and we are wrong confirm
the point that we were trying to make. In particular, they highlight the
need to introduce a much wider base for the education of psychiatrists,
which over the last 25 years has become increasingly dominated by
neuroscience (7). Those who accuse us of peddling 'antipsychiatry' have
clearly been so aroused in their invective that they have not understood
our paper. Developing a critique of something is not the same as simply
opposing it. Our critique is meant to open up for discussion the
assumptions and values inherent in psychiatric thinking. Those who claim
that we are 'wrong' to hold the views expressed in this paper imply that
there is a 'right' way to talk about madness (which expression
incidentally, we consider to be less stigmatising than schizophrenia),
that excludes or even forbids other perspectives. However they propose no
justification for this position, which is simply asserted.
If psychiatry is to have a positive future it will require those of
us involved in the speciality to be open to a radical questioning of our
own theories and practice. The positivism, which underscores traditional
psychiatry, is only one philosophical doctrine alongside others. Surely a
truly scientific attitude is one characterised by questioning and doubt,
not by dogma and dismissiveness. We believe that the shift to
postmodernity raises challenges but also important opportunities for
doctors to redefine their roles. This in turn requires openness to the
voices of those for whom psychiatry exists: service users.
P. Bracken
P. Thomas
1 Bracken P, Thomas P. Postpsychiatry: a new direction for mental
health. BMJ 2001; 322:724-7. (24 March.)
2 Harvey D. The condition of postmodernity. Oxford: Basil Blackwell,
1989.
3 Muir Gray JA. Postmodern medicine. Lancet 1999;354: 1550-3.
4 Foucault M. What is Enlightenment? In: Rabinow P, ed. The Foucault
reader. London : Penguin, 1984.
5 Rogers A, Pilgrim D, Lacey R. Experiencing psychiatry: users' views
of services. London: Mind Publications, 1993.
6 Mental Health Foundation. Knowing our own minds: a survey of how
people in emotional distress take control of their lives. London: Mental
Health Foundation, 1997.
7 Pincus H, Henderson B, Blackwood D, Dial T. Trends in research in
two psychiatric journals in 1969-1990: research on research. Am J
Psychiatry 1993; 150: 135-42.
Competing interests: No competing interests