"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
Rapid Response:
not postpsychiatry,but politics
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