Download implementing critical psychiatry in practice: positive and negative

IMPLEMENTING CRITICAL
PSYCHIATRY IN PRACTICE:
POSITIVE AND NEGATIVE ASPECTS
D B Double
Critical psychiatry website

www.antipsychiatry.co.uk
Critical psychiatry website


www.antipsychiatry.co.uk
www.uea.ac.uk/~wp276
Critical psychiatry website



www.antipsychiatry.co.uk
www.uea.ac.uk/~wp276
Critical Psychiatry
Network
www.criticalpsychiatry.
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 (1900-1970)

Psychoanalysis – Freud first
spoke publicly in USA at
Clark University in 1909
Pluralism in psychiatry (1900-1970)


Psychoanalysis – Freud first
spoke publicly in USA at
Clark University in 1909
Pragmatic approach of Adolf
Meyer - Psychobiology
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
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.
2.
Diagnosis: assessment is broader than
simple diagnostic labels, even if rarely
possible to be sure about the origins of
personal problems.
Treatment:
Promoting critical practice
1.
2.
Diagnosis: assessment is broader than
simple diagnostic labels, even if rarely
possible to be sure about the origins of
personal problems.
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