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Education And Debate

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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Postpsychiatry: a new direction for mental health

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

Competing interests: No competing interests

30 March 2001
Sue Collinson
Not back to the future again, please