Lecture given at Mind Annual conference 2001
Critical Psychiatry: Seeing Psychiatry as it Really is.
For some years I have maintained the Critical Psychiatry website. Recently a colleague asked me to produce a webguide on critical psychiatry for the Royal College of Psychiatrists’ website. He stressed that I should try and explain why a psychiatrist would be interested in critical psychiatry.
Why should a psychiatrist like myself be prepared to be critical of his own profession? At first glance, it may not seem appropriate that a psychiatrist should be prepared to apparently undermine the authority of his own practice.
I do not want to mislead you. I am not proposing abolishing mental health services. I am trying to improve the services that are on offer. All I am seeking to do is ensure that mental health services have a firm foundation. It seems to me that psychiatry can be remarkably defensive about its practice. How much faith should we have in a psychiatry that is so easily threatened by any challenge to its basis?
To me, it is not surprising that I have concerns about being associated with some of the practices of psychiatry. For example, the conditions of patients in a privately-run mental asylum in Ervadi, in South India, were investigated after 28 people died in a fire in August this year (BBC News online report). Many of those killed had been chained to their beds, leaving them no means of escape. In several hostels nearby, people were found to be fettered round the ankle by heavy iron chains, coupled together convict style. The authorities had to announce a ban on chaining the mentally ill.
All too often psychiatric practice can become inhumane. We cannot always be proud of the history of the treatment of the mentally ill. It is only since the 1950s that psychiatric hospitals have been unlocked in this country.
It would be wrong to think that there are not problems in current mental health practice. Failings are not only in the past or in other countries. For example, Diana Rose, spent most of 1999 in acute psychiatric care. She described the story of that year in an article in Openmind. As she herself admits, what she described is the sharp end of psychiatry: control and restraint, forced injections, ECT, close observations and seclusion.
The main point she makes is primarily about communication. For example, she explained what it was like relating to staff in the secure unit of the hospital.
The main task of the nurses, of whom there were plenty, seemed to be to check, every 30 minutes, the whereabouts of everyone on the ward. They had a chart on which to record people's locations. The rest of the time they spent either in the office, in the pool-room, or walking about swinging bunches of keys. Patients who liked playing pool had some interaction from the nurses; the rest of us had none.
The atmosphere was not much better on the acute ward. As Diana says:
There was hardly any interaction between staff and patients. The interaction that did exist revolved around trouble. As long as there was something up, I got attention. When things were calmer and I was causing no trouble, I was ignored to the point of neglect. In the last few weeks, as I got ready for discharge, the boredom was crushing, even threatening to bring on another 'relapse'. The bureaucracy of the section 17 form did not help. Nurses communicated, as in other aspects, only to tell you what you could not do.
Diana does not particularly seek to apportion blame for this state of affairs. She writes:
I do not mean to imply that the staff were nasty people. As individuals, they were kind and personable. But in their role as nurses they seemed to forget their communicative abilities and turn into beings 'too busy' to extend the hand of help to people who really were in need of it. The acute ward was peopled by lost souls pacing the ward, holding cups of coffee and smoking continuously. There was not even much interaction between patients, because we came from such different backgrounds and had such different interests. Having said that, there was still more communication between fellow patients than between patients and staff.
Her conclusion is this:
The culture of psychiatry has to change so that people are not treated as 'cases' or instances of categories, but as people with hopes, fears and aspirations, which need to be dealt with on a human level. Surely it should not be up to patients to say that psychiatric staff need to learn some communication skills?
How does it happen that psychiatry leads to this objectification of people? This is what I want to look at in this lecture. I think reducing persons to things is an aspect of practice to which psychiatry must be continually alert. Psychiatry needs to be critical of itself in this sense. There needs to be time to reflect on what we are doing in psychiatry. We need to be open to seeing psychiatry as it really is.
The biomedical model of mental disorder
The dominant model of mental disorder is biomedical. I do not make this statement to encourage controversy but merely to point out that there has been a minority position in psychiatry, which adopts what I will call a biopsychological model of mental disorder.
It is very common for psychiatrists to believe that patients diagnosed as having a mental illness have a chemical imbalance in the brain. This view is transmitted to the public so that there is widespread acceptance of this hypothesis.
For example, GlaxoSmithKline are the manufacturers of Seroxat or paroxetine, which is its generic name. In the USA it is known as Paxil, where it is marketed for generalised anxiety disorder (GAD), social anxiety disorder, panic disorder, depression and obsessive-compulsive disorder (OCD). Although direct to consumer advertising is prohibited in the UK, patients in this country do have access to information on prescription medicines through the internet on overseas websites, notably from the USA where direct to consumer advertising is permitted.
Paroxetine is a newer class of antidepressant medication known as selective serotonin reuptake inhibitors (SSRIs). Paxil is the first SSRI drug approved in the USA for treatment of generalised anxiety disorder (GAD). On the GlaxoSmithKline website, there is an explanantion that:-
Disorders like GAD may be caused by an imbalance of chemical messengers in the brain. One of these chemical messengers is serotonin. Serotonin helps send electrical signals from one nerve cell to another. In the process, serotonin is released from one nerve cell (the sender) and travels to the next (the receiver), where it is either absorbed or returns back to the original sender cell. When a person suffers from GAD, there may be a problem with the balance of the serotonin system that affects the cell to cell communication. Paxil blocks serotonin from being reabsorbed back into the sender nerve cell. This process increases the amount of serotonin available to be absorbed by the next cell and may help message transmission return to normal.
To give the drug manufacturers their due, they are careful enough to admit that the theory that mental disorders are caused by chemical imbalance is a hypothesis. They suggest that "disorders like GAD may be caused by an imbalance of chemical messengers in the brain" and "there may be a problem [in GAD] with the balance of the serotonin system that affects the cell to cell communication" (my emphasis). Many people go further by acting on this hypothesis.
GlaxoSmithKline make a clearer statement about chemical imbalance elsewhere on the website:-
Antidepressant medication is believed to relieve the symptoms of depression by correcting the chemical imbalance of the neurotransmitters in the brain.
In other words, theories about chemical imbalance come from research on the effects of psychotropic medication. Although the drug companies may be taking advantage of the belief that medication corrects chemical imbalance, there is an obvious widespread wish to think that it is true. It is not solely propagated by the drug companies.
I do not want you to misunderstand me. I am not suggesting that mental disorder has nothing to do with the brain. Of course it has its origins in the brain. However, making such a statement does not provide any understanding of the reasons for mental health problems. In fact, reducing mental disorder to a causal statement about brain pathology avoids ascribing any meaning to such action.
It may be very difficult to make sense of some people with mental disorder, particularly people diagnosed as having a psychotic illness. Such people may have symptoms, including bizarre beliefs or delusions, unusual experiences such as hallucinations and their thought may be difficult to follow and disordered. The temptation may then be to say that this is because of an abnormality in the brain. Actually what might really be needed is even more effort to try and understand why they are expressing themselves in such a way.
The biopsychological model of mental disorder
Adolf Meyer was the foremost American psychiatrist in the first half of the twentieth century. He was sceptical of biomedical hypotheses. Specific theories have changed since his time. The speculation then was that there were circulating toxins which caused schizophrenia. Meyer regarded such explanations as artificial. He appreciated the wish to find underlying causes, but did not see the need. As far as he was concerned, mental illness was the result of faulty mental adjustment.
Meyer's emphasis was on understanding the patient as a person. His advice in assessment was to concentrate on what he called "the facts of the case". This relates to personal and social details in the psychiatric presentation. It was important not to foreclose an understanding of a person's problems by moving on too soon to a single-word medical diagnosis.
As Meyer maintained, it may not be possible to move on to the stage of diagnosis. In which case, the person's problems still needed to be managed, whatever the diagnosis. Thus, in a way, medical diagnosis may be unimportant. Certainly the danger is that it oversimplifies the nature of a patient's problems. For Meyer, too much emphasis was placed on diagnosis in everyday psychiatric practice. This meant that psychiatrists did not make enough effort to produce a commonsense understanding of why patients had reacted in the way that they had to the situation in which they found themselves.
Psychiatry has always had a bias towards biomedical understanding. It thereby avoids the uncertainty of human action. It justifies its practices by making the metaphor of mental illness literal.
Psychiatry needs to be more open to the potential of human possibilities. Such a view may be dismissed as vague and uncertain. Meyer's position has been dismissed by mainstream psychiatry as "almost entirely sterile". What psychiatrists feel they need is progress based on clear scientific foundations. However, it is important not to oversimplify matters so that they become nonsensical. There is a distinction between persons as social beings and bodies as physical objects. This difference should not be denied. There are consequences of treating people as though they are physical objects rather than social beings. The relationship between professional and patient is important in psychiatry as it is in the rest of medicine.
The efficacy of psychiatric medication
In everyday practice, there is considerable evidence of overprescribing, and irrational prescribing, in the sense that more than one drug is prescribed when it is not needed.
So why is psychiatric practice not evidenced-based? After all, almost all psychiatrists say that the efficacy of psychiatric medication has been proven.
Evidence for the efficacy of medication comes from randomised controlled trials. Yet these trials are biased. One of the particular methods of introducing bias is through what is called unblinding. The benefits of randomisation in a trial need to be preserved by ensuring that allocation to both subjects and experimenters is blind. However, the blind may be broken in a variety of ways. Participants in trials are keen to establish whether they are receiving active or placebo drugs. The assessors who are doing the ratings of trial outcomes cannot be uninfluenced by indications of whether participants have been taking active or placebo drugs.
Triallists will generally accept on reflection that double-blinding is not infallible. Yet because there is a sense that nothing can be done about it, there is no serious attempt to accommodate the implications. Unblinding means that randomised controlled trials are not as objective or unbiased as we might like - even the best designed and well executed studies.
If bias is introduced through unblinding, does this matter? The evidence seems to be that it does. Few trials measure whether the blind has been maintained. Those that do, generally confirm that there has been significant unblinding and that the degree of unblinding correlates positively with efficacy ratings.
The role of expectations in the doctor-patient relationship is well recognised. In other words placebo effects can be powerful. If blinding is not eliminated in trials, the results may be no more than the amplification of a placebo effect.
If expectations can be powerful in treatment, they can also be powerful in discontinuing treatment. People may form attachments to their medications more because of what they mean to them than what they do. Psychiatric patients often stay on medications, maybe several at once, even though their actual benefit is questionable. Any change threatens an equilibrium related to a complex set of meanings that their medications have acquired. These issues of dependence should not be minimised, yet commonly treatment compliance is reinforced by emphasising that it is not addictive.
To be an effective healer, it may be thought that psychiatrists should have as much faith in their medications as their patients. Yet one history of medicine is of doctors prescribing medication which is subsequently regarded as useless and often dangerous. Prescribing trends follow fashions rather that necessarily objective data.
People may find it surprising that as a psychiatrist I am not preoccupied with medication in my management of patients. I again appeal for my authority to Adolf Meyer. Although trained as a neuroanatomist, and maintaining an interest in the subject, biological considerations hardly ever arose in his consideration of mental conditions. In management what prevailed was a humane psychological interest. For example, he was sceptical about the enthusiasms of his time for insulin coma therapy. Although we have moved on from this fad, it is important to see the history of psychiatric treatment in perspective. It is vital that we do not repeat the exploitation of the mentally ill, which has always been the historical tendency.
Criticisms of psychiatry have been collected together as "anti-psychiatry". Two names particularly associated with this movement are RD Laing and Thomas Szasz. Both of them disapproved of the term "anti-psychiatrist" used of themselves.
Critical psychiatry has its origins in anti-psychiatry. It has become commonplace to see anti-psychiatry as a passing phase in the history of psychiatry. However, it may be more constructive to place anti-psychiatry in its broader cultural context and sees it in terms of its continuities rather than discontinuities.
Moreover, it is important to recognise that anti-psychiatry contains several different strands. It is not commonly appreciated how much the positions of RD Laing and Thomas Szasz differ. They have both been very rude about each other. Szasz does not think that psychiatry can ever be justified as an intervention by society. Laing was more concerned with making psychotic experience understandable.
What these critiques have in common is the recognition that the tendency to objectify those diagnosed as mentally ill can make psychiatry part of the problem rather than necessarily the solution to mental health problems. Critical psychiatry remains within psychiatry and yet recognises its excesses. In particular, it does not seek to justify psychiatric practice by postulating brain pathology as the basis for mental illness.
The Critical Psychiatry Network
The Critical Psychiatry Network was formed in Bradford in January 1999. The group provides a network to develop a critique of the contemporary psychiatric system. We have organised two annual conferences and our third will be held next April 2002. The theme of next year’s conference will be "Beyond drugs and custody: Renewing mental health practice".
This year's conference was entitled "Reducing the biomedical dominance of psychiatry". We are trying to get more of a voice for a biopsychological model in psychiatry. It can be very difficult to get this point of view heard. People who are critical of the biomedical model can arouse tremendous hostility.
For example, two of the speakers at this year's conference have experienced opposition in psychiatry. The keynote speaker was Jan Foudraine from Holland, who, if you like, was the Dutch equivalent of Ronnie Laing for critical psychiatry. He wrote a bestseller in the 1970s which was translated in English as Not made of Wood, in which he expressed his disappointment with the lack of human dignity that he found in traditional psychiatric practice. He was also frustrated with psychotherapeutic approaches when he went to America and worked there for a few years, trying to transform his psychotherapy based ward there into what he called a school for life. Even though this book had popular appeal, he could not make sense of the professional hostility he received and he became the personal ambassador in Holland of Baghwan Shree Rajneesh.
Similarly, Lucy Johnstone, another of the speakers, who last year published a second edition of her excellent book Users and abusers of psychiatry had to leave clinical work as a clinical psychologist to become an academic because of the hostility she experienced. A few years ago in Clinical Psychology Forum she described how she was once harangued for forty five minutes after a clinical presentation by three medically minded psychiatrists trying to get her to change her views. She only managed to stop being pestered by getting into her car and driving away!
Reform of the Mental Health Act
Part of the initial focus for the Critical Psychiatry Network was the new government's plans for reform of the Mental Health Act. We have been much concerned about treatment with consent and a reduction of compulsion - the themes of this day of the conference.
Some of us had hoped that the new government may herald a new dawn of tolerance, understanding and social inclusion for those suffering from mental health problems. However, we had not yet got used to New Labour's emphasis on "spin" and presentation. Although the Government must respond to legitimate concerns about public safety, it also has a duty to prevent discrimination against people diagnosed as having mental health problems.
We made responses as a group at each stage of the consultation about the Mental Health Act reform. We were concerned about the way in which evidence was being used from suicide and homicide inquiries to imply that more coercion would lead to a reduction in deaths. In fact increasing coercion could potentially lead to an increase in deaths. Mental health intervention can precipitate someone into acting out their aggression. Treatment is not necessarily a panacea for mental health problems.
The new Act could potentially lead to an increase in coercion for which there are inadequate safeguards. In particular, extension of compulsory treatment powers to the community seems difficult to justify.
The potential for a root and branch reform of the Mental Health Act was welcomed. After all, I have been saying in this lecture that services tend to reduce people to objects and rely too much on physical treatments. Mental health services have far more than a custodial role. The point is being missed, however, that it was the increase in voluntary, not compulsory, care and treatment in the 20th century which has made the traditional psychiatric hospital less relevant to modern psychiatric practice. Services have expanded dramatically, so that what is on offer is not just within the asylum. It would be wrong to deny the history of psychiatry in the asylum, but any new Act has to take account of the need for voluntary treatment.
It may be expecting too much to see the reform of the Mental Health Act as an opportunity to challenge the biomedical view of mental health. However, it is important to restrict any potential abuse of medical power.
Summary and conclusion
Approaches which emphasise medical diagnosis and the use of physical treatments currently dominate mental health practice. Critical psychiatry instead encourages a more complete assessment of people's mental health problems and more recognition of social and psychological aspects in treatment. There is a potential for exploitation of people with mental health problems. It is not good treatment to fail to offer understanding of people's difficulties.
The biomedical basis of psychiatry seems remarkably fragile. There is a resistance to seeing psychiatry as it really is. The dominant biomedical view has been very good at marginalising any critique. I think this is particularly obvious in the way that it has undermined any criticism by suggesting that it is an attack on the seriousness of mental distress itself. Critics of psychiatry have all been lumped together as anti-psychiatrists.
The issue is about accountability and the direction of mental health services needs to be user-led. The aim is a radical shift in power towards users and an acknowledgment of the expertise of survivors of psychiatry. The case for an extensive programme of training and supervision in order to disseminate a critical perspective on psychiatry is overwhelming.