IMPLEMENTING CRITICAL PSYCHIATRY IN PRACTICE: POSITIVE AND NEGATIVE ASPECTS D B Double

Critical psychiatry website psychiatry.co.uk psychiatry.co.uk

Critical psychiatry website psychiatry.co.uk psychiatry.co.uk

Critical psychiatry website psychiatry.co.uk psychiatry.co.uk Critical Psychiatry Network co.uk co.uk

Reservations about teaching critical psychiatry to medical students Asked to take down webpages from my personal webspace

Reservations about teaching critical psychiatry to medical students Asked to take down webpages from my personal webspace Consultant colleagues concerned I may mislead students

Reservations about teaching critical psychiatry to medical students Asked to take down webpages from my personal webspace Consultant colleagues concerned I may mislead students Suggested university should not be seen as linked with critical psychiatry

Critical psychiatry is a legitimate academic and clinical activity University encourages both staff and students to use their personal webspace

Critical psychiatry is a legitimate academic and clinical activity University encourages both staff and students to use their personal webspace Academic freedom is essential for the development of unorthodox or new opinions

Critical psychiatry is a legitimate academic and clinical activity University encourages both staff and students to use their personal webspace Academic freedom is essential for the development of unorthodox or new opinions Doctors should be encouraged to think about their professional role

Critical Psychiatry Network Formed in 1999

Critical Psychiatry Network Formed in 1999 Small group of psychiatrists

Critical Psychiatry Network Formed in 1999 Small group of psychiatrists Develop a critique of the contemporary psychiatric system.

Promoting the critical mental health movement Ranges from reform to revolution

Promoting the critical mental health movement Ranges from reform to revolution Psychiatry can be practised without the justification of postulating brain pathology as the basis for mental illness

Promoting the critical mental health movement Ranges from reform to revolution Psychiatry can be practised without the justification of postulating brain pathology as the basis for mental illness Mental disorders must show through the brain but not always in the brain

Criticism of psychiatry Crisis of confidence created in the 1960s and 70s

Criticism of psychiatry Crisis of confidence created in the 1960s and 70s Particularly about its vague diagnostic categories

Criticism of psychiatry Crisis of confidence created in the 1960s and 70s, Particularly about its vague diagnostic categories Rosenhan - psychiatric diagnosis is subjective and does not reflect inherent patient characteristics

Mainstream response Psychiatrists do not detect pseudopatients simulating signs of mental illness – Spitzer

Mainstream response Psychiatrists do not detect pseudopatients simulating signs of mental illness – Spitzer “…assuredly an unreliable system must be invalid”

Mainstream response Psychiatrists do not detect pseudopatients simulating signs of mental illness – Spitzer “…assuredly an unreliable system must be invalid” Operational diagnostic criteria for psychiatric disorders, initially for research, and then for psychiatric classifications, such as DSM-III

Neo-Kraepelinian approach Psychiatry could again be assured about the validity of its diagnostic categories, which had now been much better defined

Neo-Kraepelinian approach Psychiatry could again be assured about the validity of its diagnostic categories, which had now been much better defined Associated with reaffirmation of implicit “medical model” with focus on brain mechanisms

Neo-Kraepelinian approach Psychiatry could again be assured about the validity of its diagnostic categories, which had now been much better defined Associated with reaffirmation of implicit “medical model” with focus on brain mechanisms and positivistic approach to science

Rotten reputation of anti-psychiatry International movement against psychiatry which is “anti-medical, anti-therapeutic, anti-institutional and anti-scientific” (Roth 1973)

Rotten reputation of anti-psychiatry International movement against psychiatry which is “anti-medical, anti-therapeutic, anti-institutional and anti-scientific” (Roth 1973) Anti-psychiatry defined more by mainstream psychiatry than the identified protagonists themselves

Rotten reputation of anti-psychiatry International movement against psychiatry which is “anti-medical, anti-therapeutic, anti-institutional and anti-scientific” (Roth 1973) Anti-psychiatry defined more by mainstream psychiatry than the identified protagonists themselves Generally seen as a passing phase in the history of psychiatry

Proponents of “anti-psychiatry” David Cooper - “[P]sychiatry … has aligned itself far too closely with the alienated needs of society”

Proponents of “anti-psychiatry” David Cooper - “[P]sychiatry … has aligned itself far too closely with the alienated needs of society” RD Laing - “By and large psychiatry functions to exclude and repress those elements society wants excluded and repressed”

Proponents of “anti-psychiatry” David Cooper - “[P]sychiatry … has aligned itself far too closely with the alienated needs of society” RD Laing - “By and large psychiatry functions to exclude and repress those elements society wants excluded and repressed” Thomas Szasz - State should not interfere in mental health practice or medicine in general

Biomedical vs interpretive approaches “Mental diseases are brain diseases” – Wilhelm Griesinger 1845

Biomedical vs interpretive approaches “Mental diseases are brain diseases” – Wilhelm Griesinger 1845 “It is only from the neuropathological standpoint that one can try to make sense of the symptomatology of the insane"

Biomedical vs interpretive approaches “Mental diseases are brain diseases” – Wilhelm Griesinger 1845 “It is only from the neuropathological standpoint that one can try to make sense of the symptomatology of the insane" "The notion, mental disease, must be deduced neither from the mind nor from the body, but from the relation of each to the other." Baron von Feuchtersleben 1845

Pluralism in psychiatry ( ) Psychoanalysis – Freud first spoke publicly in USA at Clark University in 1909

Pluralism in psychiatry ( ) Psychoanalysis – Freud first spoke publicly in USA at Clark University in 1909 Pragmatic approach of Adolf Meyer - Psychobiology

Pluralism in psychiatry ( ) Psychoanalysis – Freud first spoke publicly in USA at Clark University in 1909 Pragmatic approach of Adolf Meyer - Psychobiology Interpersonal approach of Harry Stack Sullivan focused on the person

Definition of “critical” Inclined to find fault, or to judge with severity

Definition of “critical” Inclined to find fault, or to judge with severity Characterised by careful, exact evaluation and judgement

Definition of “critical” Inclined to find fault, or to judge with severity Characterised by careful, exact evaluation and judgement Of the greatest importance to the way things might happen

What is acceptable practice? “Incompatible with effective teamwork in a community psychiatric service”

What is acceptable practice? “Incompatible with effective teamwork in a community psychiatric service” Inappropriate defensiveness in mainstream practice

What is acceptable practice? “Incompatible with effective teamwork in a community psychiatric service” Inappropriate defensiveness in mainstream practice Apparent difference may lead to unnecessary polarisation in debate

Promoting critical practice 1. Diagnosis:

Promoting critical practice 1. Diagnosis: assessment is broader than simple diagnostic labels, even if rarely possible to be sure about the origins of personal problems.

Promoting critical practice 1. Diagnosis: assessment is broader than simple diagnostic labels, even if rarely possible to be sure about the origins of personal problems. 2. Treatment:

Promoting critical practice 1. Diagnosis: assessment is broader than simple diagnostic labels, even if rarely possible to be sure about the origins of personal problems. 2. Treatment: social support and personal therapy may be beneficial; medication has its place, but prescribing should not be beyond the evidence.

Psychiatric diagnosis Should be person-centred and not necessarily imply a statement about bodily dysfunction

Psychiatric diagnosis Should be person-centred and not necessarily imply a statement about bodily dysfunction Attempt needs to be made to understand psychiatric presentations in personal and social terms

Psychiatric diagnosis Should be person-centred and not necessarily imply a statement about bodily dysfunction Attempt needs to be made to understand psychiatric presentations in personal and social terms Not only about identifying disease, but also the reasons for human action

Psychiatric diagnosis (Cont) Means of attempting to manage individual clinical complexity

Psychiatric diagnosis (Cont) Means of attempting to manage individual clinical complexity Boundaries between syndromes are ‘fuzzy’

Psychiatric diagnosis (Cont) Means of attempting to manage individual clinical complexity Boundaries between syndromes are ‘fuzzy’ Too easily assume a diagnostic concept is an entity of some kind

Psychiatric diagnosis (Cont) Prototype or ideal type

Psychiatric diagnosis (Cont) Prototype or ideal type Idealised description of those aspects of concrete reality that interest us

Psychiatric diagnosis (Cont) Prototype or ideal type Idealised description of those aspects of concrete reality that interest us Value-laden nature of diagnosis is not a sign of scientific deficiency but of its meaningful nature

Psychiatric treatment Treatment is not an attack on an impersonal ‘disease entity’

Psychiatric treatment Treatment is not an attack on an impersonal ‘disease entity’ Supporting people to recover as much as possible from their mental health problems

Psychiatric treatment Treatment is not an attack on an impersonal ‘disease entity’ Supporting people to recover as much as possible from their mental health problems Rehabilitate to become as independent as they wish, taking into account their difficulties.

Psychiatric treatment (Cont) Medication is often prescribed in life crises reinforcing defensive mechanisms against overwhelming anxiety

Psychiatric treatment (Cont) Medication is often prescribed in life crises reinforcing defensive mechanisms against overwhelming anxiety Power of placebo should be recognised

Psychiatric treatment (Cont) Medication is often prescribed in life crises reinforcing defensive mechanisms against overwhelming anxiety Power of placebo should be recognised We all want a simple, quick, cheap, painless, and complete cure

Psychiatric treatment (Cont) Therapeutic zeal has led to the justification of all sorts of groundless and sometimes damaging, if not lethal, medical interventions

Psychiatric treatment (Cont) Therapeutic zeal has led to the justification of all sorts of groundless and sometimes damaging, if not lethal, medical interventions Doctors need to take advantage of the dynamic relationship between doctor and patient, and not exploit patients

Psychiatric treatment (Cont) Services need to provide a therapeutic atmosphere, even when fulfilling their custodial functions

Psychiatric treatment (Cont) Services need to provide a therapeutic atmosphere, even when fulfilling their custodial functions Critical psychiatry not the same as psychotherapy, which operates outside mental health legislation

Psychiatric treatment (Cont) Medication is merely used pragmatically

Psychiatric treatment (Cont) Medication is merely used pragmatically Questioning the specific effectiveness of medication is legitimate

Psychiatric treatment (Cont) Medication is merely used pragmatically Questioning the specific effectiveness of medication is legitimate Clinical trials are biased eg. not as "double-blind" as is commonly assumed

Acceptable limits of psychiatry Not easy to adopt a critical position in psychiatry.

Acceptable limits of psychiatry Not easy to adopt a critical position in psychiatry Despite Good Medical Practice still requiring doctors to respect colleagues and not allow personal views to affect professional relationships unduly

Acceptable limits of psychiatry Not easy to adopt a critical position in psychiatry Despite Good Medical Practice still requiring doctors to respect colleagues and not allow personal views to affect professional relationships unduly Critical psychiatry is merely arguing for more openness in mental health practice.

Biomedical psychiatry's belief system Brain pathology as the basis for mental illness

Biomedical psychiatry's belief system Brain pathology as the basis for mental illness Avoids complicated metaphysics

Biomedical psychiatry's belief system Brain pathology as the basis for mental illness Avoids complicated metaphysics Provides professional respectability

Biomedical psychiatry's belief system Brain pathology as the basis for mental illness Avoids complicated metaphysics Provides professional respectability Scientific ambition of elucidating the cause of mental illness

Synthesis of critical psychiatry Biomedical hypotheis based on faith, desire and wish fulfilment rather than logic

Synthesis of critical psychiatry Biomedical hypotheis based on faith, desire and wish fulfilment rather than logic Threat of anti-psychiatry taints restatement of critical psychiatry

Synthesis of critical psychiatry Biomedical hypotheis based on faith, desire and wish fulfilment rather than logic Threat of anti-psychiatry taints restatement of critical psychiatry Critical psychiatry is acceptable

Conclusion "Psychiatry is naked," the child said. Psychiatry could not admit to that. It thought it better to continue the procession under the illusion that anyone who couldn't see its clothes was either stupid or incompetent