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Authors' response. Invited commentary on … Beyond consultation

  • Pat Bracken (a1) and Phil Thomas (a2)
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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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1 McCabe, R, Heath, C, Burns, T, Priebe, S. Engagement of patients with psychosis in the consultation: conversation analytic study. BMJ 2002; 325: 1148–51.
2 Read, J, Reynolds, J (eds). Speaking Our Minds: An Anthology. Macmillan, Open University, 1996.
3 Davidson, L. Living Outside Mental Illness. Qualitative Studies of Recovery in Schizophrenia. New York University Press, 2003.
4 Roe, D, Davidson, L. Self and narrative in schizophrenia: time to author a new story? Med Humanit 2005; 31: 8994.
5 Roberts, GA. Narrative and severe mental illness: what place do stories have in an evidence-based world? Advan Psychiatr Treat 2000; 6: 432–41.
6 Bracken, P, Thomas, P. Post-psychiatry: Mental Health in a Postmodern World. Oxford University Press, 2005.
7 Bracken, P. Trauma: Culture, Meaning and Philosophy. Whurr Publications, 2002.
8 Thomas, P, Bracken, P, Leudar, I. Hearing voices: a phenomenological–hermeneutic approach. In Voices in the Brain: the Cognitive Neuropsychiatry of Auditory Verbal Hallucinations (eds Spence, S, David, A). Psychology Press, 2004.
9 Kuhn, TS. The Structure of Scientific Revolutions (2nd edn): 111. University of Chicago Press, 1962.
10 Tyrer, P, Kendall, T. The spurious advance of antipsychotic drug therapy. Lancet 2009; 373: 45.
11 Bracken, P, Thomas, P. From Szasz to Foucault. on the role of critical psychiatry. Philos Psychiatr Psychol 2009; in press.
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BJPsych Bulletin
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Authors' response. Invited commentary on … Beyond consultation

  • Pat Bracken (a1) and Phil Thomas (a2)
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Author's response

Pat Bracken, Consultant Psychiatrist and Clinical Director
10 September 2009

We would like to thank Philip Cowen, Rob Poole and Robert Higgo for taking the time to comment on our editorial. These correspondents raise many points and we apologise in advance for not responding to them all. However, we will attempt to deal with the main issues in what follows.

Cowen rightly raises the question of coercion and perhaps this shouldhave featured more centrally in our editorial. It is certainly a major issue for service users and their organisations. While many will accept that some sort of control and/or coercion is needed to deal with risky behaviour, many complain that the dominance of a psychopathological framework means that few alternatives are presented to people in times of crisis. Sometimes it is the lack of alternatives that leads to conflict which in turn leads to coercion. People who do not think of themselves as having an illness (even when they are ‘‘well’’) understandably resent the idea that what they are offered in times of crisis is simply hospital and medication. When alternatives to hospital are available they are often used positivelyby service users. In their book Alternatives Beyond Psychiatry - (1) Stastny & Lehmannbring together descriptions of such alternatives from many parts of the world. If coercion does become necessary, we do not believe that psychiatry possesses the sort of predictive science that would justify itsbeing the lead agency. We agree fully with Cowen that this is primarily a political issue and only secondarily a medical one.

We also agree with Cowen that modern science provides not only explanatory models but also ‘‘some degree of mastery over the natural world’’. But the practical utility of a scientific model does not provide proof for the ‘‘truth’’ of that model. The Romans could build magnificent aqueducts but we would now regard many of their ideas about the nature of the natural world as mistaken. In addition “mastery” is not always a positive. In many ways, it is the idea that science could, or should, be about providing us with ‘‘mastery’’ over the world that has given rise to contemporary (postmodern) interrogations of the Enlightenment project.

We do not believe that mental health care can, or should, be centred on a primary discourse which is scientific-technical in nature. However, this does not mean that biomedical science has no role to play in helping people who endure episodes of madness or distress. The sort of neuroscience we value is the sort articulated by Steven Rose, Professor ofBiology and Director of the Brain & Behaviour Research Group at the Open University and one of Britain’s leading scientists. Rose argues for aneuroscience which is non-reductive, humble and able to engage positively with philosophy and the humanities (2). We are also not anti-psychopharmacology but we want a pharmacology that has freed itself from the corruption of Big Pharma, and one that moves away from the notion thatwe can only understand the action of neuroleptic drugs in relation to outdated concepts like schizophrenia (3).

Poole & Higgo are less generous in their response to our paper. Indeed, we find it hard to understand how they have reached some of their conclusions. At no point do we characterise recent moves on the part of the Royal College, or other organisations, to engage with service users as‘‘ inauthentic’’. The kernel of our argument is that this engagement can and should develop from consultation into collaboration. We believe that most psychiatrists actually welcome this. Nor do we, at any point, dismissthe ideas of those users and carers who understand their problems in biomedical terms. However, one does not have to be a critical psychiatrist to know that a very large percentage of service users, and their organisations, are deeply unhappy with what is offered to them by psychiatry and, in particular, the way in which psychiatry frames their difficulties. The Health Editor of the Independent newspaper, Jeremy Laurance, took time away from his usual work to survey the territory of mental health a few years ago. He travelled to different places in Englandand spoke to many service users on his way. He writes: ‘‘The biggest challenge in the last decade has been the growing protest from people withmental health problems who use the services. There is enormous dissatisfaction with the treatment offered, with the emphasis on risk reduction and containment and the narrow focus on medication. They dislikethe heavy doses of anti-psychotic and sedative drugs with their unpleasantside effects, and a growing number reject the biomedical approach which defines their problems as illnesses to be medicated, rather than social orpsychological difficulties to be resolved with other kinds of help’’(4).

It is nonsense to suggest that simply acknowledging this dissatisfaction (while at the same time accepting that a certain number ofservice users are happy with the status quo), amounts to a ‘‘lack of respect for the diversity of opinion within the service user movement’’.

Poole and Higgo also object to our use of the word ‘‘madness’’ and indeed accuse us of embracing ‘‘the language of bigotry’’. We would point out that there is no set of words that will be acceptable to everyone in the mental health field and we certainly do not use the term ‘‘madness’’ in order to offend. The word ‘‘madness’’ is used, and has been used, in many different cultural and academic writings as well as by organisations such as Mad Pride and the Icarus Project. Do the makers of the film‘‘The Madness of King George’’ also stand accused of bigotry? Are Richard Bentall, Roy Porter, Jeremy Laurance, and a host of others, guilty of ‘‘inappropriate modishness” for using ‘‘madness’’ in the titles of their books? On the other hand, we know many service users who feel very stigmatised by terms such as ‘‘schizophrenia’’, ‘‘borderline personality’’and ‘‘treatment resistance’’.

Poole and Higgo seem particularly incensed by our positive engagementwith certain strains of postmodernist thought. Our position is that one can argue for certain ideas, values and ways of life without resorting to the assumption that one has found the ‘‘truth’’ or that one somehow has gained access to ‘‘objectivity that transcends a particular paradigm’’. Wedeny that this amounts to some sort of ‘‘anything goes’’ philosophy. ‘‘Truth’’ and ‘‘facts’’ are indeed important but they have very often beenused by the powerful to silence the voices of the weak. The history of the20th century is littered with disasters wrought by those who agued that they had science, facts and truth on their side.

Poole & Higgo go on to dismiss the role of the Critical Psychiatry Network (CPN). For some reason, they accuse the group of ‘‘selfrighteous separatism’’. This is in spite of the fact that many individualsin the CPN are active members of the Royal College and have participated positively in college meetings, including hosting a day long seminar on critical psychiatry at the AGM in 2005, as well as recent joint events with the Philosophy, Spirituality and Transcultural special interest groups. Our editorial in this journal was written in response to a requestfrom the editor of the Bulletin and one of the authors (PB) gave one of the ‘‘prestigious lectures’’ organised by the president, Dinesh Bhugra, last year.

The critical psychiatry network is made up of ‘‘ordinary mental health professionals’’ who care deeply about their profession and who are committed to establishing connections with the service user movement in all its diversity. Individuals in the network are also working to free ouracademic discourse from its toxic entanglement with Big Pharma. We assert that critical thinking: the ability to think outside the assumptions of one’s profession, to reflect critically upon it’s history and it’s practices, is not a threat to psychiatry, rather it is a tool through which the profession can begin to establish positive relationships with the developing user movement.

References:

(1) Stastny T, Lehmann P. Alternatives Beyond Psychiatry. Peter Lehmann Publishing, 2007.

(2) Rose S. The Future of the Brain. The Promise and Perils of Tomorrow’s Neuroscience. Oxford University Press, 2005.

(3) Moncrieff, J. The Myth of the Chemical Cure. Palgrave Macmillan, 2008.

(4) Laurance J. Pure Madness How Fear Drives the Mental Health System. Routledge, 2003 (p. xix)

Pat BrackenPhil Thomas
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Post-modernism and psychiatry

Rob Poole, Professor of Mental Health
24 August 2009

We have found that ‘post-psychiatry’ (1) tends to challenge our patience more than it does our ontological security. We are pleased that Bracken and Thomas’s recent contribution to the Bulletin contains something we actually agree with: “...an increasing number of psychiatrists are seeking to work with different frameworks and to engage positively with the diversity of the user movement” (2). However, we doubtthat ‘post-psychiatry’ has much to contribute to this effort. Holloway’s commentary (3) is generous with regard to the philosophical basis of the article. We believe that the application of the confused and confusing ideas that are known as ‘post-modernism’ to psychiatric practice is deeplymisguided and counter-productive.

The key contention in Bracken and Thomas’s article is that organised psychiatry’s recent attempts to form an alliance with service users and carers are inauthentic. A true alliance, according to them, requires that we abandon the bio-medical perspective in general and descriptive psychopathology in particular in order to allow us to preferentially engage with radicals within the service user movement.

They briefly mention more conventionally minded service users and carers, but effectively dismiss their point of view. This apparent lack ofrespect for the diversity of opinion within the service user movement is entirely consistent with the post-modernist convention that everything, including ‘facts’ and ‘truth’, is relative. Where all perspectives are equally valid, the post-modernist is free to reject objectivity as an illusion, and to confine dialogue to the likeminded. For those of us who cling on to older humanistic ideas, the challenge in getting alongside patients is to take service users’ experiences and views seriously whetheror not they coincide with our own. Choosing to align ourselves with one particular perspective is patronising and simply repeats the mistakes of the past.

There is an inappropriate modishness (not to mention a lack of self-awareness) in Bracken and Thomas’s free use of the term ‘madness’. The word remains offensive to many service users, despite the fact that a minority choose to reclaim it. It is one thing for service users to definethemselves as ‘mad’. It is quite another matter for mental health professionals to use such terminology. There is a parallel here with the reclamation of racist words by some Black people. There is no degree of alignment with anti-racism that makes it ok for white people to use these terms. Similarly, it is hard to see how the interests of people with mental illness are furthered by urging psychiatrists to embrace the language of bigotry.

Bracken and Thomas sustain their argument by caricaturing the biological-mechanistic and suggesting that it is the primary conceptual framework of psychiatry. They make assumptions as to how the profession might respond to the challenges of the more radical parts of the service user movement, but they do not reference these responses, presumably because no one has made them. Although this type of argument is common in post-modernist writing (the discourse is implicit, so the lack of explicitreference to it is irrelevant), it is hardly likely to be persuasive to anyone with a reasonable level of independent mindedness.

In a fine piece of post-modern doublethink, ‘post-psychiatry’ seems to want to be both part of psychiatry and separate from it. Bracken and Thomas deny being anti-psychiatry, anti-medical or anti-scientific but they reject the existence of any objectivity that transcends a particular paradigm and they regard descriptive psychopathology as oppressive. The logical corollary of their rhetoric is that when we are helpful to patients, it is despite the fact that we are psychiatrists, not because ofit. If this is the case, why involve doctors in the care of people with mental illness at all? It is simply implausible and logically inconsistentto suggest that a Royal College of Post-Psychiatrists would somehow shrug off the encultured baggage of the doctor-patient relationship to lead us to a better place where the biomedical is replaced by something which is unspecified, but nicer.

A significant part of mainstream British psychiatry has long been working to develop a more humanistic, relevant form of practice that seeksto help people to solve problems in their lives rather than simply fixing problems in their minds or their brains (4, 5). Biological research and treatments in psychiatry are necessary in this endeavour, though it would be foolish to deny that there is a problem when they dominate. Indeed, it was the then President of the American Psychiatric Association (not himself a post-psychiatrist, we believe) who complained that too much psychiatry followed a ‘bio-bio-bio model’ (6).

Post-psychiatry is a tendency within the Critical Psychiatry Network,a small group of psychiatrists united mainly by their dissatisfaction withthe status quo. We accept that there is a great deal wrong with the statusquo, but we choose to put our faith in ordinary mental health professionals and service users, who have worked steadily to change attitudes and to try to develop better, more user friendly psychiatric services. This seems more fruitful to us that self-righteous separatism.

Psychiatry is having something of an identity crisis at present (e.g.7): "The crisis consists precisely in the fact that the old is dying and the new cannot be born; in this interregnum a great variety of morbid symptoms appears" (8). Despite its good intentions, there is little chancethat ‘post-psychiatry’ will achieve much by suggesting that a set of inconsistent and logically flawed ideas can renew the profession. Like Sokal (9) we believe that ‘truth’ and ‘facts’ are important because they are one of the few weapons that the weak have against the strong. ‘Post-psychiatry’ is a distracting irrelevance. The real task is to shift the intellectual centre of gravity of the actually existing profession.

Declaration of interests: none

Rob Poole, FRCPsych, Professor of Mental Health, Glyndwr University, Wrexham Academic Dept of Mental Health, Technology Park, Croesnewydd Rd, Wrexham, LL13 7YP. tel 01978-727324. fax 01978-727167

Robert Higgo, FRCPsych, Consultant Psychiatrist, Liverpool Assertive Outreach Team, Arundel House, Smithdown Rd, Liverpool, L15 2HE tel 0151-330 8119.

References:

1.Bracken P, Thomas P. Beyond consultation: the challenge of workingwith user/survivior and carer groups, Psychiatric Bull 2009, 33, 241-243.2.Bracken P, Thomas P. Authors’ response. Invited commentary on ...Beyondconsultation, Psychiatric Bull 2009, 33, 245-246.3.Holloway F. Commonsense, nonsense and the new culture wars within psychiatry. Invited commentary on...Beyond consultation, Psychiatric Bull 2009, 33, 243-244.4.Poole R, Higgo R. Psychiatric interviewing and assessment. Cambridge University Press, 2006.5.Poole R, Higgo R. Clinical skills in psychiatric treatment, Cambridge University Press 2008.6.Sharfstein SS. Big Pharma and American Psychiatry: The Good, the Bad and the Ugly, Psychiatric News 2005, 40, 16, 3.7.Craddock N, Antebi D, Attenburrow M-J, Bailey A, Carson A, Cowen P et al. ‘Wake up call for British psychiatry’, Br J Psychiatry 2008. 193: 6-9.8.Gramsci A. Selections from the prison notebooks Lawrence and Wishart 1971.9.Sokal A. A physicist experiments with cultural studies, Lingua Franca May/June 1996, 62-64.
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A big tent?

Philip J Cowen, MRC Clinical Scientist
10 July 2009

I have carried out neurobiological research in academic psychiatry for thirty years and find much to endorse in the editorial by Bracken and Thomas. Being trusted with the life experiences of others is a privilege and participating in the construction of shared narratives is a key psychiatric skill. My reservation is how far Bracken and Thomas relish diversity when it comes to views that aren’t in agreement with their own. For example, while Holloway’s balanced and well-reasoned response is castigated for reducing “complex issues to simple binaries, ‘heroes… [and]… villains’”, the authors seem to me rather binary themselves (“sickened by the corruption of academic psychiatry”) and also curiously disengaged from a central problem - that of coercion.

The notion that people with bipolar disorder have “a dangerous gift to be cultivated and taken care of” makes a lot of narrative sense to me and anyway how could I possibly object if that’s how a person wants to seeit? However, if that person’s behaviour threatens the well-being and safety of others there may well be irreconcilable conflicts of understanding which could lead to compulsory hospitalisation and treatment, no matter how expert a psychiatric team might be in engaging with diverse perspectives. I don’t know what the answer to this problem is, or even whether psychiatrists should be involved in it, but it seems to me an overwhelmingly political issue that marks psychiatry off from other medical specialities much more clearly than the social construction of diagnosis, which after all is as much the case for heart disease as it is for psychiatric disorder (1). On the other hand if someone wishes to see their heart disease as a spiritual problem and reject biomedical treatment, even if it puts their life in jeopardy, they run no risk of being compulsorily admitted to hospital and forcibly administered aspirin and statins.

I think that Bracken and Thomas might also be more open-minded about what biomedical science can do for us. I say this with trepidation (and the near-certainty of betraying “serious misunderstanding”) because the authors obviously have a healthy respect for their expertise in continental philosophy and the philosophy of science. Nevertheless, how far our culturally based scientific practices can give us access to a realexternal world is a complex and contested issue (2). What does seem to be the case is that modern science not only provides explanatory models (innumerable discourses do that) but uniquely, for better or worse, gives us some degree of mastery over the natural world. The ability of vaccination to eradicate smallpox was not culturally contextual even though the germ theory might be.

Of course it may be that the tools of biomedical science are simply inappropriate for helping people with what we currently call psychiatric problems. This is a perfectly coherent intellectual view and ultimately itis up to a democratic society to decide if it wants to pay for medical doctors and medical science to be involved. Bracken and Thomas seem to believe that there is a role for medicine and science in psychiatry but I just don’t know if their “authentic science of human beings” accommodates,for example, cognitive neuroscience. If it does, we have an exciting project.

References1.Searle JR. The Construction of Social Reality. Penguin books, 1995. 2.Dreyfus HL. How Heidegger defends the possibility of a correspondence theory of truth with respect to the entities of natural science. http://socrates.berkeley.edu/~hdreyfus/rtf/Heidegger-Realism_5_95.rtf
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