New Labour's 'new' look at mental health policy has some nasty surprises for those who believed that May 1st 1997 heralded a new dawn of tolerance, understanding and social inclusion for those suffering from mental health problems. The government is proposing changes that have serious implications for the human rights of people who use psychiatric services. Although the National Service Frameworks contain positive developments like home treatment, the government's priority appears to be increasing coercion and control for those using mental health services. The green paper reforming the 1983 mental health act includes proposals for compulsory treatment in the community, and is accompanied by a joint Home Office and Department of Health initiative on the management of people with so-called dangerously severe personality disorders (DSPD). If enacted, this would enable psychiatrists to detain such people indefinitely, even though they had committed no offence. We would be the only democracy in the World in which you could be locked up for life without having committed an offence. Compulsory treatment in the community and reviewable detention represent serious challenges to human rights, and this has fuelled concern inside the profession. In January 1999 the Critical Psychiatry Network first met in Bradford to discuss these concerns, and has since made clear its opposition to compulsory treatment in the community and reviewable detention for people with DSPD. To understand critical psychiatry we must consider the recent context in which medicine and psychiatry have been practiced.
In the last fifty years there has been growing disaffection with the medical profession. Until recently, the public was happy to defer to what was seen as the knowledge and experience of experts like doctors. What might loosely be called post-modernism has changed that, questioning the role of experts by challenging the authority of their knowledge. The assumption that science and technology can answer society's most complex problems has been thrown open to doubt. Science is no longer regarded as the saviour of mankind, but as the bringer of even greater problems. As medicine has become more influenced by technology and science, it has lost contact with basic human values of respect for the other person's beliefs and preferences. This is particularly so in psychiatry, where clinical neuroscience has driven a political agenda inflamed by distorted media coverage of high profile 'failures' of community care, in which risk reduction is of paramount importance. The result is legislation that attaches more importance to forcing people to take medication. Psychiatry has always been deeply split between care and healing on the one hand, and coercion and social control on the other. Government legislation, in shifting the balance away from care towards control, is making this split even clearer. No other medical speciality has the equivalent of the psychiatric survivors movement, confirmation of the coercive nature of psychiatry.
Critical psychiatry is part academic, part practical. Theoretically it is influenced by critical philosophical and political theories, and it has three elements. It challenges the dominance of clinical neuroscience in psychiatry (but does not exclude it); it introduces a strong ethical perspective on psychiatric knowledge and practice; it politicizes mental health issues. Critical psychiatry is deeply sceptical about the reductionist claims of neuroscience to explain psychosis and other forms of emotional distress. It follows that we are sceptical about the claims of the pharmaceutical industry for the role psychotropic drugs in the 'treatment' of psychiatric conditions. Like other psychiatrists we use drugs, but we see them as having a minor role in the resolution of psychosis or depression. We attach greater importance to dealing with social factors, such as unemployment, bad housing, poverty, stigma and social isolation. Most people who use psychiatric services regard these factors as more important than drugs. We reject the medical model in psychiatry and prefer a social model, which we find more appropriate in a multi-cultural society characterised by deep inequalities.
The practice of critical psychiatry has important ethical implications. It is often difficult to work in the biomedical model in a way that really respects and engages with the patient's beliefs and preferences. What point is there respecting the patient's view if you believe that the main objective is to rectify a neurochemical imbalance in someone's brain? The social model, on the other hand, recognizes that the meaning of distress is culturally contingent, and so engaging with the person's belief systems and values is of paramount importance. This can only be achieved by listening carefully and respecting the person's beliefs. Critical psychiatry also brings a political perspective on mental health issues. The biomedical model locates distress in the disordered function of the individual's mind/brain, which relegates social contexts to a secondary role. This is problematic because it completely overlooks the role of poverty and social exclusion in psychosis. One of critical psychiatry’s most important tasks is the creation of a new dialogue between survivors, mental health service users and psychiatrists, a dialogue that recognizes the value of different types of expertise. Psychiatrists are experts by profession, but service users are experts by experience. The best outcomes will only be achieved when these two types of expertise can work in alliance, something that critical psychiatry argues must happen now. The government already recognizes the importance of alliance between patient experts and health professionals in the area of chronic physical illness, by establishing an Expert Patients' Task Force to consider how professionals can work in partnership with expert patients. We believe that this model must be applied to the field of mental health, and we hope the government will not waste an excellent opportunity to act on this.
The Critical Psychiatry Network can be contacted on http://www.critpsynet.freeuk.com/
Co-chairs, Critical Psychiatry Network
Dr. Phil Thomas
Bradford Home Treatment Service
26 Edmund Street
Bradford BD5 0BJ