IMPLEMENTING CRITICAL PSYCHIATRY IN PRACTICE: POSITIVE AND NEGATIVE ASPECTS

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IMPLEMENTING CRITICAL PSYCHIATRY IN PRACTICE
POSITIVE AND NEGATIVE ASPECTS

• D B Double

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Critical psychiatry website

• www.anti-psychiatry.co.uk

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Critical psychiatry website

• www.anti-psychiatry.co.uk
• www.uea.ac.uk/wp276

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Critical psychiatry website

• www.anti-psychiatry.co.uk
• www.uea.ac.uk/wp276
• Critical Psychiatry Network www.criticalpsychiatry
  .co.uk

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Reservations about teaching critical psychiatry
to medical students

• Asked to take down webpages from my personal
  webspace

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Reservations about teaching critical psychiatry
to medical students

• Asked to take down webpages from my personal
  webspace
• Consultant colleagues concerned I may mislead
  students

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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

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Critical psychiatry is a legitimate academic and
clinical activity

• University encourages both staff and students to
  use their personal webspace

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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

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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

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Critical Psychiatry Network

• Formed in 1999

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Critical Psychiatry Network

• Formed in 1999
• Small group of psychiatrists

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Critical Psychiatry Network

• Formed in 1999
• Small group of psychiatrists
• Develop a critique of the contemporary
  psychiatric system.

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Promoting the critical mental health movement

• Ranges from reform to revolution

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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

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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

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Criticism of psychiatry

• Crisis of confidence created in the 1960s and 70s

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Criticism of psychiatry

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

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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

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Mainstream response

• Psychiatrists do not detect pseudopatients
  simulating signs of mental illness Spitzer

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Mainstream response

• Psychiatrists do not detect pseudopatients
  simulating signs of mental illness Spitzer
• assuredly an unreliable system must be invalid

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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

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Neo-Kraepelinian approach

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

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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

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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

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Rotten reputation of anti-psychiatry

• International movement against psychiatry which
  is anti-medical, anti-therapeutic,
  anti-institutional and anti-scientific (Roth
  1973)

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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

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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

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Proponents of anti-psychiatry

• David Cooper - Psychiatry has aligned itself
  far too closely with the alienated needs of
  society

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Proponents of anti-psychiatry

• David Cooper - Psychiatry 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

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Proponents of anti-psychiatry

• David Cooper - Psychiatry 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

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Biomedical vs interpretive approaches

• Mental diseases are brain diseases Wilhelm
  Griesinger 1845

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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"

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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

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Pluralism in psychiatry (1900-1970)

• Psychoanalysis Freud first spoke publicly in
  USA at Clark University in 1909

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Pluralism in psychiatry (1900-1970)

• Psychoanalysis Freud first spoke publicly in
  USA at Clark University in 1909
• Pragmatic approach of Adolf Meyer - Psychobiology

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Pluralism in psychiatry (1900-1970)

• 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

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Definition of critical

• Inclined to find fault, or to judge with severity
  

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Definition of critical

• Inclined to find fault, or to judge with severity
  
• Characterised by careful, exact evaluation and
  judgement

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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

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What is acceptable practice?

• Incompatible with effective teamwork in a
  community psychiatric service

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What is acceptable practice?

• Incompatible with effective teamwork in a
  community psychiatric service
• Inappropriate defensiveness in mainstream practice

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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

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Promoting critical practice

1. Diagnosis

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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.

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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

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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.

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Psychiatric diagnosis

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

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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

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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

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Psychiatric diagnosis (Cont)

• Means of attempting to manage individual clinical
  complexity

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Psychiatric diagnosis (Cont)

• Means of attempting to manage individual clinical
  complexity
• Boundaries between syndromes are fuzzy

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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

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Psychiatric diagnosis (Cont)

• Prototype or ideal type

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Psychiatric diagnosis (Cont)

• Prototype or ideal type
• Idealised description of those aspects of
  concrete reality that interest us

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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

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Psychiatric treatment

• Treatment is not an attack on an impersonal
  disease entity

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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

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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.

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Psychiatric treatment (Cont)

• Medication is often prescribed in life crises
  reinforcing defensive mechanisms against
  overwhelming anxiety

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Psychiatric treatment (Cont)

• Medication is often prescribed in life crises
  reinforcing defensive mechanisms against
  overwhelming anxiety
• Power of placebo should be recognised

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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

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Psychiatric treatment (Cont)

• Therapeutic zeal has led to the justification of
  all sorts of groundless and sometimes damaging,
  if not lethal, medical interventions

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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

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Psychiatric treatment (Cont)

• Services need to provide a therapeutic
  atmosphere, even when fulfilling their custodial
  functions

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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

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Psychiatric treatment (Cont)

• Medication is merely used pragmatically

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Psychiatric treatment (Cont)

• Medication is merely used pragmatically
• Questioning the specific effectiveness of
  medication is legitimate

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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

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Acceptable limits of psychiatry

• Not easy to adopt a critical position in
  psychiatry
• .

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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

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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.

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Biomedical psychiatry's belief system

• Brain pathology as the basis for mental illness

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Biomedical psychiatry's belief system

• Brain pathology as the basis for mental illness
• Avoids complicated metaphysics

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Biomedical psychiatry's belief system

• Brain pathology as the basis for mental illness
• Avoids complicated metaphysics
• Provides professional respectability

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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

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Synthesis of critical psychiatry

• Biomedical hypotheis based on faith, desire and
  wish fulfilment rather than logic

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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

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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

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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