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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