Positivism and psychiatry

First, Ingleby questions the idea that positivist psychiatry is objective, neutral and value-free. Here, Ingleby is influenced by the ideas of Thomas Reference KuhnKuhn (1962) and the Frankfurt school of philosophy, especially Jurgen Reference Habermas and ShapiroHabermas (1972) – see Box 3. He asks whose interests psychiatry serves and whether we want the type of society towards which it leads us. Positivism in psychiatry makes two assumptions: that observations can be made objectively (that they can be defined, that they are valid and can be applied reliably) and that theories in psychiatry can be constructed using causal determinism (Box 2), as in the natural sciences. He argues that the notion of objectivity in psychiatry is a myth. This is because it is not possible for us to talk about our inner psychological worlds in the same way that we talk about the natural world. In this belief Ingleby owes something to the later philosophy of Reference Wittgenstein and AnscombeWittgenstein (1967) and the hermeneutic phenomenology of Reference Heidegger, Macquarrie and RobinsonHeidegger (1962) and Reference Merleau-Ponty and SmithMerleau-Ponty (1962). Consider anger. Most of us have no difficulty in identifying anger; it is the very nature of human experience, grounded in our common sense of what it is to be human, to be able to identify the emotion and the human contexts in which it occurs. In other words, we rely on a taken-for-granted, interpretive competence to recognise anger. The difficulty is that such a common-sense approach does not meet positivism's need for explicit criteria, so science relies on ad hoc definitions that obscure the tacit assumptions necessary for applying them in a given situation. Descriptions of most psychiatric phenomena, such as hearing voices or blunted affect, are of this nature. An alternative approach, adopted by ultra-positivists such as Eysenck, substitutes these problematic phenomena with test scores or physiological measures such as skin conductance. This is circular, because these measures can only be validated against psychiatrists’ subjective judgements. Ingleby argues that decisions as to whether someone is depressed, psychotic or hearing voices are rooted in our common-sense understandings of madness. To claim, as positivism does, that such decisions could be grounded in something that transcends common sense – that is to say, in neutral, value-free science – simply does not make sense.

The censorship of theories

Ingleby's second set of arguments concerns what he calls the censorship of theories, and particularly the claim made by science that the only legitimate forms of explanation are causal. This exists in a ‘strong’ form (the disease model), which maintains that psychosis is caused by disturbances in neurophysiological or neurochemical function. A weaker variant is found in ‘eclectic’ psychiatric practice, which maintains that, although social and psychological factors might be important, to be taken seriously they have to be stripped from background context and regarded as ‘independent variables’. Positivism is simply unable to deal with the complexity of social and cultural environments. In reality, these worlds are rich in meaning and resist linear causal models. The essential point is that contexts provide grounds or reasons for human action, not causes of it. This means that understanding and interpretation should be central to our approach to psychosis.

Again, the influence of Wittgenstein emerges. In Philosophical Investigations, Reference Wittgenstein and AnscombeWittgenstein (1967) argues that the ‘laws’ underlying human agency are simply not of the same logical type as those that govern the physical or natural world. Unlike the laws of nature, they are made by humans and relate only to human agency. For this reason, Ingleby argues that positivism writes human agency out of the frame. In psychiatry, which deals with such issues as individual struggles with meaning, emotion and social position, this neglect of agency imposes severe constraints.

Interpretive psychiatry

Ingleby proposes an interpretive (hermeneutic) psychiatry as an alternative to positivism. Hermeneutics takes for granted that human beings engage in meaningful behaviour that transcends causal explanation and objectivity. If we relinquish positivism, the distinctions between observer and subject, or between describing and explaining, become blurred, and combine in the act of interpretation.

Interpretation has an extensive heritage in philosophy, and its influence can be found particularly in the phenomenology of Heidegger and Merleau-Ponty, all of which is rooted in common-sense ideas of what we believe being human is all about. Reference Csordas and CsordasCsordas (1994) provides an excellent example of such a hermeneutic–phenomenological account, which resists the temptation to move from biological to cultural determinism. A non-philosophical alternative can be found in the work of Oliver Reference SacksSacks (1986), who describes beautifully the inadequacy of biological or psychological accounts of neurological disorders alone in accounting for the complex experiences that occur in these conditions. Sacks points out that we have to place the biological and psychological within the context of a person's narrative or life history.

Ingleby moves away from Heidegger and Merleau-Ponty and looks to a revised form of psychoanalysis to ground a more adequate (in his view) understanding of distress. Superficially, some aspects of Ingleby's ideas resonate with anti-psychiatry. Laing also attached a great deal of importance to understanding psychosis through a revised psychoanalysis. Like Szasz, Ingleby argues that positivism is well suited to psychiatry's role of social control, because it presents matters that are essentially cultural judgements about the nature of health or illness, as empirical facts, but he differs from Szasz over questions of the welfare of the individual. For Szasz, whose moral ideal is that of personal freedom, the problem of psychiatry is that it places the common good, or the values of social institutions (the family, the state, work), above those of the individual. Ingleby argues that social institutions do not necessarily represent the common good. Rather, they represent a group of interests hiding under the banner of economic progress. Here he is influenced by the early writings of Reference Foucault and HowardFoucault (1967), who described the exclusion of the insane as an act of incarceration achieved through the use of high walls, barred doors, chains and padlocks. Ingleby argues that the medical ideology of psychiatry achieves the same objective of social control without physical restraints.

The Power of Psychiatry

The Power of Psychiatry (Reference Miller and RoseMiller & Rose, 1986) was published only 5 years after Ingleby's work, yet the influence of Foucault's later writings is clear. Marx and Freud are no longer the inspirations for a critical approach to psychiatry; they have become part of the problem. The book offers an examination of the origins and social functions of British psychiatry over the previous 100 years. Like Ingleby, Miller and Rose take issue with the epistemological (Box 3) premise of anti-psychiatry – that psychiatric illness does not exist – because it denies the suffering of those who experience emotional distress. In addition, they believe that anti-psychiatry is incapable of illuminating the social and political functions of psychiatry. For this reason, they argue that it is more helpful to accept the reality of psychiatry (as a social practice) rather than engage in empty arguments about the existence or not of mental illness.

Reference Miller, Miller and RoseMiller (1986) points out that anti-psychiatry evolved in a culture preoccupied with personal autonomy and subjectivity, that of the 1960s. The analysis of the power of psychiatry mounted by the anti-psychiatrists is simplistic, because it crudely equates power with the suppression of subjectivity. It says nothing of power and the creation of subjectivity. This idea, taken from Foucault, lies at the heart of Miller & Rose's critique of psychiatry. The power of psychiatry is to be found in the possibilities it creates for us, especially in terms of regulating our behaviour. Such an analysis is necessary because psychiatry operates far beyond the walls of the institution. Today, psychiatry serves as a technology that helps to constitute a radically different set of power relationships in advanced liberal democracies. Mental health confers economic advantage, is seen as a social necessity, and has become an object of personal desire. Psychiatry is found in every corner of our cultural lives. Psychiatrists and psychologist pontificate upon the great events and tragedies of our time. They are called in to interpret and prognosticate in our newspapers, television, radio and magazines. More so than any other branch of medicine, psychiatry has become constitutive of cultural life itself. How are we to understand this?

Miller and Rose see psychiatry as a form of government of the self, in that it makes it possible for us to talk about ourselves, our feelings and our lives, in particular ways. This is what is meant when we speak of psychiatry creating subjectivities. The power of psychiatry is not simply to be found in coercion; it is also to be found in the possibilities it creates for us. For example, in Western societies our experiences of sadness and unhappiness can be talked about within the broad classification of ‘depression’. The experience of hearing voices, on the other hand, is attributed to the ‘narrow’ diagnosis of schizophrenia, which effectively closes down other ways of accounting for the phenomenon (see Reference Leudar and ThomasLeudar & Thomas (2000), particularly Chapters 6 and 7, for a detailed account of this). Thus, there are negative and positive aspects of power in psychiatry. It is not simply a tool for the repression of individual subjectivity; it also generates subjectivities. In other words, it both opens up and closes down possibilities for all of us to understand ourselves.

Technologies of the self

In The History of Sexuality, Reference Foucault and HurleyFoucault (1981) developed the concept of ‘technologies of the self’, arguing that discipline operates most effectively through processes of self-regulation of the person. This implies that we all possess the ability for self-reflection and introspection, and that psychiatry and psychology define this ability. Thus, psychiatry patrols the boundaries between reason and unreason, between sanity and madness. Foucault argued that unreason, or madness, have become constituted as Other, knowable only through the language of reason. Thus we have a monologue of reason about unreason, which excludes the voices of the insane. This, Foucauldian analysis is vitally important in understanding why many service users are disaffected with psychiatry. It also points the way forward.

The influence of government

Reference Rose, Miller and RoseRose (1986) examines in detail the social and political circumstances in which British psychiatry became so influential (i.e. the genealogy of psychiatry: see Box 4). Although his argument is developed in relation to a British context, it is arguable that it is internationally relevant, at least to most Western nations.

At the start of the 20th century, when it was at the height of its success in establishing the causes of diseases, medicine became involved in a new social concern: environmental health. The First World War drew attention to the poor state of health of working-class soldiers, many of whom were rejected for military service. There was a growing awareness that disease and health were not simply matters affecting individuals, but were closely related to the living conditions of the population as a whole. As a result, government power extended to the political regulation of the habits of the population through the management of domestic life, in the interests of health and well-being. This had implications for psychiatry. In the UK, the Royal Commission on Lunacy and Mental Disorder of 1926 declared that:

Psychiatry also cast its gaze on antisocial and immoral behaviours, providing medical explanations for them. It came to be seen as an authority on all aspects of the human situation, including family structure and child-rearing practices. It advocated eugenic campaigns to control the ‘morally insane’, criminals and the ‘mentally defective’, through compulsory sterilisation. Increasingly, the ideal of mental health became a personal responsibility and a national objective for government. According to Rose, these processes changed the nature of madness as a social phenomenon. Mental illness was no longer limited to psychosis as a fundamental otherness that challenged the moral order, but expanded to include personal unhappiness and social inefficiency. This happened partly through the role of psychiatry and psychology during the Second World War in the management of the human factor in social life.

Thus, the Second World War opened up a new domain of social reality for psychiatry, which assumed the task of dealing with those suffering from neuroses that impaired their productivity and employability. This, together with the foundation of the NHS and the welfare state, established a new context for psychiatry, which was legitimised by social policy such as the Mental Health Act 1959. Although this granted doctors specific powers in respect of involuntary admission and compulsory treatment, Rose argues that it would be wrong to interpret this as an extension of the medicalisation of social control. This is because the strategy sought to minimise the role of incarceration by improving the links between medical and social care agencies, making it easier for people to move between them.

Reference Rose, Miller and RoseRose (1986) argues that by positing a simple dichotomy between the (bad) medical model and (good) psychotherapies, anti-psychiatry obscured the problematic features of both. After the Second World War there was a growth in physical and pharmacological treatments, social therapies, psychoanalysis and behaviour therapy. These ‘therapies of normality’ were aimed not at curing intellectual or emotional deficits, but at moulding subjectivity in desired directions. The point here is that these new ‘technologies of the self’ (Box 4) transformed the difficulties of everyday living into psychological problems:

Technologies of the self make it possible to transform a long-term personal relationship such as marriage from an ethical obligation to a matter of personal fulfilment, or allow us to free ourselves from the dread we experience at the thought of our mortality. Death itself becomes a manageable psychological problem.

Postpsychiatry

Elsewhere, we have argued that the advent of the ‘postmodern condition’ and the emergence of postmodern philosophy have opened up new ways of thinking about mental health practice (Reference Bracken and ThomasBracken & Thomas, 2001). Some service users have asked for a move to ‘postpsychiatry’ (Reference Campbell, Read and ReynoldsCampbell, 1996), and we have used this term as an organising principle for our own work. Postpsychiatry is not yet another model to compete with the ‘medical’ and ‘social’ models of psychiatry; instead, it points to the possibility (and the growing reality) of a new direction for mental health work, which moves beyond the theories of the 20th century. This move originates in our conceptual critique of psychiatry (Reference Bracken and ThomasBracken & Thomas, 2001), and in the work of service user groups such as Survivors Speak Out, the National Self-Harm Network, the Hearing Voices Network, Mad Pride and Mad Women, all of which reject medical accounts of their experiences and look elsewhere for their explanatory models. They also highlight the potential for harm caused by psychiatry.

Postpsychiatry seeks to understand why psychiatry is in this position, and to use this understanding to find theoretical and practical ways forward. While remaining part of the broad church of critical psychiatry, postpsychiatry makes the central claim that many of the problems of psychiatry arise from its identity as an enterprise of modernity. The Enlightenment focus on the individual self and the value of reason charted the course followed by psychiatry for 200 years, with the assumption that all its efforts were transparently for the good. Postpsychiatry holds that our discipline is blind to the limitations of its theoretical frameworks, and has overlooked the pain and suffering it can cause.

This has practical and theoretical dimensions if we are to move forward. On a practical level, we try to work with service users and carers to find new ways of doing mental health work. This happens at macro- and micro-levels. At the macro-level we are attempting to set up statutory services that genuinely involve collaboration between service user and carer groups, communities (especially Black and minority ethnic communities) and the professionals who serve them. We also support the emergence of self-defined support groups in the voluntary sector. At the micro-level our work on trauma (Reference BrackenBracken, 2002), and on hermeneutics and psychosis, especially hearing voices (Reference Davies, Thomas and LeudarDavies et al, 1999; Reference Thomas, Bracken and LeudarThomas et al, 2004), stresses the inherently meaningful nature of these experiences within the context of the person's life history and circumstances. In a limited way, postpsychiatry is trying to chart a new relationship between medicine and the experiential world of madness, alienation and distress.

On a theoretical level, postpsychiatry has a number of key influences, but one of our most important goals is to take seriouslythe challenge posed by Foucault's critique. In the past, psychiatrists (particularly in Britain) have dismissed his position as ‘anti-psychiatry’. We disagree. Few psychiatrists are aware of the true depths of Foucault's critique. Most have chosen to listen to those historians who articulate a ‘progressivist’ reading of the history of psychiatry. They argue that, because Foucault made some historical errors, his work can be dismissed. It is worth noting that Gordon has mounted a powerful defence of Foucault's history (Reference GordonGordon, 1990). For postpsychiatry the most important feature of Foucault's work concerns the question of ethics. He presents ethics as a sensibility to Otherness, not as a system of rules or codes to be followed slavishly. He shows us how the generation of knowledge is not ethically neutral but at every step involves implications for other people. This view resonates strongly with feminist writing about ethics, particularly the work of Carol Reference GilliganGilligan (1982), who contrasts the dominant paradigmatic approach to ethics with feminist, or situated, ethics. Nowhere is this more apparent than in our work as psychiatrists, where we like to believe that our interventions are technical and value-free. Foucault helps us to move beyond this position and thus opens up a space in which we can see some of the harm caused by our interventions.