Critical thinking in psychiatry: A positive agenda for change
D B Double
Lecture for the Mind Conference, November 2002
There were two compelling interviews on radio 4 with two survivors of mental health services in the same week in February 2001. One was with Rufus May, interviewed by Fergal Keane on his programme 'Taking a Stand'. The other was with Kay Sheldon, interviewed on 'Women's Hour' by Jenni Murray .
The edition of 'Taking a Stand' won two of the nine Mental Health Media Awards in October 2001 (www.mhmedia.com/press/awards2001.html). These were for the Factual Radio Award for the programme and for the Survivor Award for Rufus May. A record number of people apparently contacted the BBC after the programme.
Rufus May is a clinical psychologist in Bradford. At the time of the interview he was working in Tower Hamlets in London. When introducing the interview, Fergal Keane suggested that a clinical psychologist that takes a stand against the widespread use of medication in mental illness is not perhaps all that unusual these days. However what was unusual was that Rufus May had taken this stance for his experience of mental health services as a patient. In the programme he told how he had kept quiet about his experience of mental health problems to be able to undertake his clinical psychology training.
He also recounted some of his experience as a survivor. Asked to explain his mental health difficulties, he said:-
I think I'd been struggling for some years with some emotional difficulties. Only a few weeks before admission to hospital I'd just gained a new job. My girlfriend had left me a couple of months before. So I was struggling with a sense of abandonment and just becoming 18, feeling that I had suddenly to achieve something and be somebody. … I think the job was very boring. I was a trainee draughtsman. I was given very little to do and I think rather than seeing myself as being in a dull career, it was easy to move to playing with ideas that I might be really an apprentice spy.
An example would be I turned up at my job one day and they asked me to deliver a parcel at short notice from Kings Cross to Manchester. So they gave me some money for the ticket. I got down to Kings Cross and just before the train was leaving I noticed that I'd lost my ticket. A man had brushed past me and I wondered if he'd pickpocketed me. With no time to think before the train went, I decided impulsively to run round the barrier and jump on to the train. I went into the toilets because I thought I might have been spotted. I thought I needed to change my appearance. I went into the toilet and I got some water and I wet my hair and I took my teeshirt out from underneath my shirt and put it on over my shirt. So I changed my appearance as much as I could to avoid the ticket collector. This was very exciting for me. It reminded me of stories when I was a child reading about spy stories. And I thought "What if I really am a spy? What is this is all set up to see if I have got the ability to deliver a parcel under difficult circumstances?" And this idea really appealed to me.
I really came down to earth when a diligent ticket collector knocked on the toilet door behind which I'd lodged myself to avoid him. He only let me off when I acknowledged that I was just an office junior. I think that was the time when I was gradually beginning to drift more and more into a fantasy world, which had a lot of appeal to it.
Rufus did not minimise the significance of and risk involved in his experiences. He talked about when he once left hospital to go down to the railway:-
I did not have the patience to wait for the train, so I just started walking down the track. The train came up behind me. I heard the hooter. I froze. The train just stopped in front of me. I got onto the train. I was preoccupied with religious ideas at the time. I said, "Do you believe in Jesus?" The train driver said, "I don't know about him, but it is a good job Harry saw you."
Kay Sheldon was also candid in her interview on 'Woman's Hour'. Kay received an out-of-court settlement of £58,000 from Norfolk Health Authority after being wrongly treated for schizophrenia over a period of almost 15 years (www.mind.org.uk/press-room/press_page.asp?ID=96). She was detained several times against her will under the Mental Health Act. Kay knew that she did not have schizophrenia and that her treatment was wrong, but she could not get people to listen. The only course of action she found she could take was a medical negligence claim.
Simon Foster, Mind’s Principal Solicitor when commenting on this case said:
Every year Mind hears of dozens of cases where someone is saddled with treatment which is clearly inappropriate for their needs. Unfortunately, once a psychiatrist has formed a diagnosis, it can be extremely difficult to get it reviewed or changed. I am delighted that the Authority finally took a realistic approach to this case. I hope it will encourage other people to challenge decisions which are plainly wrong.
The fact that both Rufus and Kay were able to talk about their experiences as survivors is inspiring. What they have in common is that they are willing to use their stories as a basis for changing mental health services for the better.
To quote from Rufus:-
The psychosis allowed me to move on emotionally. If you look at the 6 or 7 years before I had a psychotic episode, I was struggling. I was blocked. The actual psychosis allowed me to come out of myself and move on. I very nearly became a long-term mental health patient. … But nevertheless through the struggle that I went through, it has given my life a sense of meaning. I want to create better mental health services that are more enabling. I want to change the way we think about human experience.
Similarly for Kay, in her own words:-
What I am hoping is that doctors will start to think a bit more about what they are saying and doing … and to talk to people a bit more and to listen to what they are actually saying is the problem and to take the lead from there.
Critical thinking in psychiatry
This is the kind of thinking about psychiatry that I want to encourage in this lecture. I have called it "critical thinking". However, I do not want you to misunderstand me. The word "critical" tends to have a negative connotation. It tends to imply being antagonistic. This meaning may be the first one that you will find in dictionaries. In this sense, critical means "inclined to find fault, or to judge with severity."
However, 'critical' also has other meanings, such as being "characterised by careful, exact evaluation and judgement." Also, it may have something to do with a crucial turning point, in this sense meaning "of the greatest importance to the way things might happen."
It is in these later senses that I am using the word 'critical' in relation to psychiatry. Not that I am saying we should not think negatively about psychiatry at times. Psychiatry is not always the solution to mental health pronlems; it may be part of the problem itself. However, critical psychiatry wishes to avoid the polarisation that was encouraged by regarding criticism of psychiatry as "anti-psychiatry". The language of opposition has obscured how much there has always been a strand within psychiatry that has attempted to avoid objectifying the mentally ill.
I am a member of the Critical Psychiatry Network (www.criticalpsychiatry.co.uk) that was formed in Bradford in January 1999. The network exists to provide a forum to develop a critique of the contemporary psychiatric system - critique in the sense I have just defined. Essentially, we believe that it is not necessary to justify psychiatric practice by postulating brain pathology as the basis for mental illness.
The problem is that psychiatry has become so dominated by biomedical thinking that the stance of the Critical Psychiatry Network is seen as almost heretical. The assumption is commonly made that schizophrenia and manic-depressive illness are diseases of the brain, just like Parkinson’s disease and Alzheimer’s disease - without always being absolutely clear what this statement means. It is very widely accepted that mental illness is due to a chemical imbalance in the brain.
For example, the guide for patients and their families on major depressive disorder, called Treatment works (http://www.psych.org/clin_res/MajorDepressive.pdf), produced by the American Psychiatric Association from its practice guidelines, states that:-
Disturbances in brain biochemistry (the chemicals in the brain and how they work) are an important factor in depression. Irregularities in specific brain chemicals, called neurotransmitters, occur in depression as well as in other mental illnesses. Scientists are now examining which of these irregularities may cause depression and which are a result of the illness.
This statement in fact leaves open the possibility that chemical imbalances may be results rather than causes of depression. This subtlety may be lost in the simpler message that chemical imbalances cause depression. Moreover, the guide goes on to make clear that:-
Antidepressant medications remedy chemical imbalances in the brain that are associated with major depressive disorder.
So even if the guide is not going as far as saying that chemical imbalance is the cause of depression, which it may wish it could do, it is sure that correcting the imbalance is what reverses the depression. Nothing could be simpler. This statement is made with the authority of the American Psychiatric Association.
However, it seems that the facts may at least not be as clear and simple as this. Moreover, there are implications for the doctor-client relationship. For example, Kenneth Silk, a psychiatrist speaking at the 2000 annual meeting of the American Psychiatric Association at a symposium led by the outgoing President of the Association (www.psych.org/pnews/00-06-16/tool.html), advised psychiatrists that:-
It is imperative to go beyond establishing a treatment goal that centers around "correcting a chemical imbalance" …. Chemical imbalance is an overused term that limits patients and their potential to affect the course of their illness …. It ignores the role of stressors and patients’ reaction to those stressors. It also promulgates the notion that nothing patients do for themselves will make them feel better …. It is only part of the picture.
So it seems that not all members of the American Psychiatric Association agree with the basic emphasis on chemical imbalance as the cause of mental illness. Personally, I would ask you to consider an alternative hypothesis to brain pathology. The kinds of processes that underlie mental illness at the biological level may be no different from those that produce thoughts, feelings, and behaviour among "normal" people. The explanatory model of mental illness that is used in mental health work is important and does affect the way people are treated.
What I am suggesting is that the biomedical hypothesis is uncritically accepted by too many people. The notion that mental illness is caused by a chemical imbalance which can be corrected by medication needs to be looked at critically.
The process of critical thinking
Over recent years, it has become popular to regard critical thinking as something that can be taught. Critical thinking is seen as the art of taking charge of your own mind. If we can take charge of our own minds, the theory is that we can take charge of our lives; we can improve them, bringing them under our command and direction. Critical thinking involves getting into the habit of reflecting on our inherent and accustomed ways of thinking and leads to action in every dimension of our lives.
There are said to be universal intellectual values in critical thinking. These are clarity, accuracy, precision, consistency, relevance, sound evidence, good reasons, depth, breadth, and fairness. Everyone falls into poor habits of thinking. What matters is finding ways out of them and setting higher standards for our thinking. We need to overcome the obstacles to effective thinking in our lives and direct our thinking towards our most important goals and purposes. The views of experts need to be critically assessed. There are practical techniques for making more intelligent decisions that can be learnt. Furthermore, applying critical thinking to life's key decisions has ethical implications.
How could we go about applying these principles to psychiatry? Let's return to the case of Kay Sheldon to find an example. One of the pieces of advice she was given was the following:-
I was told point blank that I should not have children because I would be passing on defective genes. And also, if I became unwell that the child would be taken away - no doubt about it, which was pretty shocking and a very stressful thing to be told. We decided to go ahead and have a child, but it did put a lot of pressure on us.
Kay now has two healthy children and lives with her husband. She ignored medical advice. She started from the first principle of critical thinking, which is to critically assess what the experts are saying.
Wherever does the advice come from that she was given? It is commonly believed that schizophrenia, which was the diagnosis that Kay was given, is a genetic condition. This is because schizophrenia runs in families. By this is meant that schizophrenia occurs more commonly than average in families of people who have a diagnosis of schizophrenia.
We need to use our critical faculties to realise there may be a common logical fallacy here. A widespread mistake is to implicate genetic transmission merely because mental illness runs in families. Genetic transmission is not the only way in which traits are passed on from one generation to the next. We learn in families and imitate others. How we are now is determined by experiences we have had in the past. Environmental factors are important, not just genetic influences.
So there is no necessity that Kay would have defective children, even if she was correctly diagnosed as schizophrenic. Children who are presumed to have a genetic tendency for schizophrenia because one of their parents had the diagnosis, may well be alright if brought up in an undisturbed family. In fact there is evidence for this state of affairs from adoption studies.
The example of the advice given to Kay Sheldon also highlights that the application of critical thinking has ethical implications. Uncritical dogmatic statements have led to the association of research into the genetics of schizophrenia with eugenic campaigns to prevent the propagation of the apparent genetic predisposition to schizophrenia. The advance of political correctness has obviously not led to such views being too far from the surface. I know that Kay Sheldon is not the only user of mental health services who has had similar advice from psychiatrists over recent years.
I want to take our analysis of critical thinking one stage further. We need a theoretical approach. We need to ask why people are so ready to adopt the biomedical model in psychiatry. We need to see how that system of collective beliefs legitimates various power structures.
Critical theory has distinguished itself through its critique of science as positivism. What I mean by this is that there is a tendency to believe that natural science is the only valid mode of knowledge. Psychiatry is said to have advanced over recent years in its understanding of the mind and mental illness. It suits people's expectations to think that psychiatry has found the solution to mental illness.
Scientific abstractions have been enormously successful in producing technological advances, so it may not be surprising that a prominence is placed on the scientific scheme of objective fact. However, verifiable knowledge about the mind is as essential as natural facts. The importance of human self-knowledge should not be undermined in tyrannical thinking about the brain.
The primary aim of psychiatric assessment should be to understand the user of mental health services as a person. The danger of saying that mental illness is a brain disease is that it reduces people to brains that need their biology cured. Critical theory promotes an approach to personal and social analysis that recognises personal and social problems and promotes personal and social change.
Let us return to the case of Rufus May for an example. Rufus is very keen to make sense of people's psychotic experiences. This is how he works as a clinical psychologist. As far as he is concerned it may be possible to make sense of the most disturbed of experiences.
Psychotic experiences may seem meaningless and incomprehensible. This is why we are inclined to regard them in an impersonal way. We tend to attribute them to a disturbed brain, as they seem 'other' and separate from the person. To avoid engaging with someone, who it seems could not possibly be so mad and crazy, we impute a chemical imbalance or some other brain abnormality.
Rufus' attempt to deal with problems at a personal level leads to him looking for alternatives to medication to help people. In the radio interview he talked about when he managed to come off medication himself.
The first two attempts to come off medication were failures. I got very high. I was living at home, and my parents got very anxious. We got into a battle. I ended up back in hospital. … When you come off the medication, … if anything stressful or exciting happens, it's very easy to experience a sense of mania, a sense of excitement that keeps you awake, and your thoughts race. … Those states … were qualitatively different from the original confusion I experienced.
Anyway, it seemed that this was a relapse of illness. I almost became convinced of that myself and felt that maybe I shouldn't try coming off the medication.
But, eight months later I'd managed to get myself into art college. I couldn't paint in a straight line because of the tremors I was experiencing. I wrote to my psychiatrist asking to be withdrawn from my medication. The answer was 'no'. So I felt I had no choice. I had to try to come off again … I think the difference this time was that I'd left home. I was able to manage some of the withdrawal symptoms by smoking cannabis which helped me stay calm. Also these withdrawal effects lasted for many months. I ended up squatting with friends. There seemed to be a tolerance for unusual behaviour. People allowed me to go out walking late at night. … I do not blame my parents for being very worried when I was living at home. In this different environment, I was for example able, for example, to walk down in the night in the rain, with a bin liner to keep me dry, to the non-stop picket outside the South African Embassy and talk at length with the protestors there with zest and passion. And then walk home in the morning. And nothing happened. I could pass through the high. … It was crazy, but it was OK. It did not lead to any major problems.
We all want to have easy answers to our problems. Expectations that medication will help are understandable. I do not think Rufus would necessarily recommend his way of coming through his psychosis and coming off medication to other people.
A critical frame of mind is required to question the evidence of clinical trials and to take on the forces of the medical establishment and the pharmaceutical industry. Challenges to the orthodoxy of mainstream psychiatry are suppressed. A critical stance in psychiatry demands going to the root of the foundations of its practice. Such an approach may be seen as a threat, but it is also an opportunity for growth and a recognition of the potential for change.
Conclusion: A positive agenda for change
What I am arguing in this lecture is that psychiatry needs to be self-conscious, self-critical and non-objectifying. Psychiatry needs to be open to the uncertainty of human action, rather than seeking to fix it in its biological substrate. I am trying to release psychiatry from its institutional constraints, so that free of the power strongholds currently vested in biological psychiatry, opportunities for improvements in the treatment of psychiatric clients can be provided.
This may sound like an idealistic agenda. And I think there is a sense it which it could be seen as naïve. Psychiatry has always had a biological bias. Historically there has always been this tendency. However, I think the ideological basis of psychiatry has swung even more strongly towards the biological side over recent years. This imbalance does need to be redressed.
We need a renaissance of what I call a biopsychosocial, rather than a biomedical, understanding of mental illness and its treatment. This approach looks at the whole person, their life and circumstances, and not simply into their brain. Surely it is not such a radical agenda to propose a more complete assessment of people's mental health problems and more recognition of the social and psychological aspects of those problems in the treatments we offer. Of course there is a biological component to mental illness, as there is in all behaviour, whether ‘normal’ or ‘abnormal’. The point is that the kinds of processes that underlie mental illness at the biological level may be no different from those that produce ‘normal’ thoughts, feelings and behaviour among people without a diagnosed mental health problem. That is a very different working hypothesis than mainstream psychiatry's reductionism and has implications for mental health practice.
The implications for clients are that services should become more personal and more attempt should be made to understand their problems. Treatments should become less reliant on physical approaches, such as ECT and medication. The expertise of users and survivors of mental health services will be acknowledged. There will be more awareness of how a biomedical orthodoxy imposes a particular worldview.
Anti-psychiatry came to have a poor reputation. Critical psychiatry needs to recognise its roots in ant-psychiatry but to move on to its positive agenda.
One of the ways in which there may be a shift in the directions I have described is to recognise the value of critical thinking. I have tried to make this case in this lecture. Critical thinking should be seen as a positive force. We can learn how to think critically, and as a theory we can rethink the basis of psychiatric practice. I hope I have managed to encourage you in your critical thinking about psychiatry.