Tuesday, August 22, 2017

Pledge support for changes in understanding of psychosis

The International Society for Psychological and Social Approaches to Psychosis (ISPS) has produced a 'Liverpool Declaration' before its upcoming 20th International Congress. As the declaration says, psychosis needs to be understood as largely a response to life experiences. For too long, social and psychological experiences have been "viewed as simply ‘triggering’ underlying disease processes, a perspective no longer supported by research". Social and cultural psychiatry should not merely be a diluted form of biomedical psychiatry (see previous post).

Monday, August 14, 2017

Differences within critical psychiatry

I have uploaded a video of my talk 'Critical psychiatry: Its definition and differences' given at the AAPP conference in San Diego in May this year. Critical psychiatrists don't always agree. I suggested in the talk that there are three main areas of disagreement, although these issues may not be totally distinct:-

  1. Whether psychiatry should be seen as a medical discipline. Where there is agreement is that psychiatry is different from medicine. The disagreement arises because of how much is made of that difference. Some want to go a far as saying that psychiatry should be non-medical. Others emphasise that medicine covers both physical and mental aspects. The reality is that many patients do complain of physical symptoms which have psychosocial origins and any view on this issue has to take note of psychosomatic medicine.
  2. Whether the Mental Health Act should be abolished. Where there is agreement is that critical psychiatry emphasises the rights of people with mental health problems. This emphasis leads some to argue for abolishing all forced treatment and others to accept that detention can be justified by the loss of mental capacity in mental illness. All would accept that psychiatric abuse is not justified and coercion needs to be minimised.
  3. Whether it is suitable to see mental disorder as illness and disease. Where there is agreement is that all identify there is a problem with seeing mental disorder as brain disease. But the questions are: should it be seen as illness; and is psychiatric diagnosis valid? Some conclude that mental disorder is not illness and alternatives are required to psychiatric diagnosis and others accept that psychological dysfunction can be understood as illness and that diagnostic concepts should be understood for what they are. Diagnoses should not be reified, and seen as ‘things’. Instead they are merely idealised, hypothetical constructs and if they have any value should be understood as such.

In summary, the essential critical psychiatry position of challenging the claim that mental disorders have been established to be brain diseases can lead to some differing perspectives within critical psychiatry. As I have said several times, critical psychiatry is a 'broad church', but it does coalesce round the view that the biomedical hypothesis that functional mental illness is due to brain disease is based on faith, desire and wish fulfilment rather than logic (eg. see previous post).


(with thanks to Kermit Cole for making the video)

Wednesday, August 02, 2017

Why fetishise outcome measurement in IAPT?

Jay Watts has a chapter 'IAPT and the ideal image' in The future of psychological therapy in which she describes the chasm between the image and actuality of Improving Access to Psychological Therapies (IAPT). She concludes that "IAPT operates in a virtuality focussing on performativity and surveillance rather than real encounters between clinician and patient".

In particular, she describes the "pernicious pressure on IAPT workers to gain outcome measures for each session". I've mentioned before talks given by David Clark (eg. see previous post) in which he makes much of the fact that IAPT is collecting this data. As Jay says, "During training, workers are sold into the excitement of producing the largest database on wellbeing in history". It would be nice to know what those promoting IAPT think all this effort has achieved, because I can't see much gain. Data accumulates on a monthly basis without much being done to it (see Reports from IAPT). In fact, this process may well be hindering IAPT from really helping people.

I've mentioned before (see previous post), the perversion of care, as Rosemary Rizq called it, of turning away from the realities of managing distressed people. As Rizq says, society has traditionally allocated to mental health practitioners an "unconscious anxiety-containing function". Mental health practitioners experience enormous emotional difficulties in working with mentally distressed and disordered patients. Focusing on outcomes, as Jay says, "stops pain being listened to and the meaning of symptoms heard".

Monday, July 24, 2017

Wider measures of IAPT outcomes needed

Oliver James has posted references on his website, which he mentioned in his talk given at the Limbus Critical Psychotherapy conference on 'Challenging the Cognitive Behavioural Therapies: The Overselling of CBT's Evidence Base'. The essential point he was making is that CBT outcomes over the long-term may not be as good as they appear in clinical trials over the short-term.

I've mentioned before the overstatement about the effectiveness of the Improving Access to Psychological Therapies (IAPT) programme (eg. How do we know that IAPT outcomes are not just due to expectancy effects? and Need to be realistic about value and effectiveness of psychological therapy). As pointed out by Hepgul et at (2015), even if recovery rates for IAPT are 50%, this means "approximately half of patients are not meeting standard definitions of recovery at the end of their treatments". As they go on to say, "Furthermore, it is likely that a substantial proportion of those who do recover may go on to relapse in due course".

One of James' references is Weston et al (2004). This article does not argue that brief, focal treatment cannot produce apparent powerful results over the short-term but recognises that relapse rates are high. Rates can be as high as 85% over 10-15 years (Mueller et al, 1999). The reality is that many psychiatric disorders are characterised by multiple periods of remission and relapse or symptom exacerbation over many years. Some people do seek further treatment after a course of IAPT or other psychological therapy. Weston et al (2004) found that roughly half of the patients in the active condition of clinical trials of empirical supported therapy for depression, panic and generalised anxiety had sought further treatment by 2 years post-treatment. Of those treated for depression, only third of those who improved remained so after two years. The figure for panic was slightly better at roughly half. Controlled data over the longer term is rare but one such study, the NIMH Treatment of Collaborative Depression Research program (Shea et al, 1992), found that 78-88% of those who entered treatment completely relapsed or sought further treatment by 18 months and that this was a no better an outcome than the controls. Uncontrolled data does suggest that the effects of psychotherapy are longer lasting at 6 months post-randomisation, at least for depression, although effects significantly decrease with longer follow-up periods (Karyotaki et al, 2016).

Clinical improvement is not the same as social recovery and there may be residual symptoms even for those classed as recovered with IAPT. In essence, we don't know how many of the so-called recoveries in the IAPT programme are due to the placebo effect or spontaneous improvement. People tend to get better anyway over the shorter term whether they go for IAPT or not. Saying that IAPT is a 'marvellous treatment', and misleading people about how effective it is, has to stop. This is no different from misleading people about how effective medication is (see previous post). I'm not saying that short-term therapy can't be helpful, but we do need to be honest about the limits of therapy. It may be tempting to overstate the case to obtain political funding for services but it's not scientific.

Sunday, July 23, 2017

Critical psychiatry is part of medicine

I mentioned on my personal blog (see post) that I am going back to Cambridge University in the autumn to do a PhD in Psychology on "The foundations of critical psychiatry". I'm glad I did a psychology degree when I was younger, otherwise I wouldn't have been able to do this. I have been accepted by the Psychology department, whereas Psychiatry and Clinical Medicine wouldn't have been interested.

It's a pity that mainstream psychiatry sees critical psychiatry as too threatening. I suppose it's understandable when it's questioning the biomedical faith that mental illness is due to brain disease (see previous post). But psychiatry and medicine should be patient-centred (see another previous post).

These differences shouldn't divorce psychiatry from medicine, although some critical practitioners have suggested that mental health services should be non-medical (eg. see previous post). I don't agree with them, as critical psychiatry is part of medicine (see another previous post). Psychiatry should be broad and open enough to welcome my PhD.

Friday, July 21, 2017

Overemphasis on disease entities in psychosis

I have mentioned in a previous post that Jim van Os wants to abandon the term 'schizophrenia'. In a follow up article, Guloksuz and he essentially argue for a unitary model of psychosis.

However, in a way, this is missing the point. They acknowledge the "lack of diagnostic markers in psychiatry" but seem to express surprise that this "impedes an objective classification". They seem to think it was a good idea that RDoC (eg. see previous post) was set up to create a so-called objective classification, whereas what they need to do is recognise that classification is inevitable subjective, at least to some extent (eg. see my article).

They still think that there is a likelihood of "distinct diseases" in the broad psychosis spectrum disorder. This is where they are wrong and they need to give up the wish to discover such entities (eg. see previous post), whether it's schizophrenia or a more unitary psychosis.

Thursday, July 13, 2017

Giving up the disease model of mental disorder

I mentioned in my Lancet Psychiatry letter that doctors, because of their medical training, have difficulty in giving up the disease model of mental disorder. Yet this is what the Division of Clinical Psychology (DCP) would encourage them to do (see position statement). This is not a controversial argument. It fits with the WHO QualityRights initiative (see recent Lancet Psychiatry article). As the article says, "A movement to profoundly transform the way mental health care is delivered and to change attitudes towards people with psychosocial, intellectual, and cognitive disabilities is gaining momentum globally".

DCP does not totally dismiss the value of psychiatric classification if only because "these systems provide seemingly ‘tangible’ entities for use in administrative, benefits, and insurance systems". But it does argue for "an approach that is multi-factorial, contextualises distress and behaviour, and acknowledges the complexity of the interactions involved in all human experience". Read how balanced the perspective is. It is relevant to the teaching of doctors as well as clinical psychologists and others working in the mental health field.

Tuesday, June 13, 2017

Rights-based reform of the Mental Health Act

At the recent General Election, the Conservative Party said that it would replace the 1983 Mental Health Act in England and Wales with new laws tackling "unnecessary detention" (see BBC News story). Their manifesto said:-
We will ... reform outdated laws to ensure that those with mental illness are treated fairly and employers fulfill their responsibilities effectively.
The current Mental Health Act does not operate as it should: if you are put on a community treatment order it is very difficult to be discharged; sectioning is too often used to detain rather than treat; families’ information about their loved ones is severely curtailed – parents can be the last to learn that their son or daughter has been sectioned. So we will introduce the first new Mental Health Bill for thirty-five years, putting parity of esteem at the heart of treatment.

Part of the motivation for this change was probably coming from the mental health charities, which formed a Mental Health Policy Group to produce A Manifesto for Better Mental Health. One of these charities, Mind, had a 2017 election manifesto, which had 6 points, of which one was:-
Change outdated and discriminatory legislation like the Mental Health Act and the definition of disability to ensure everyone with mental health problems gets support and respect.

Of course the 1983 Mental Health Act was amended in 2007 to introduce community treatment orders, amongst other changes. There was a several year debate/protest before this amendment and I had a Mental Health Policy website at the time (now essentially defunct). It was the reform of the Mental Health Act then that led to the formation of the Critical Psychiatry Network in 1999. I think changing the Mental Health Act again in the way suggested by the Conservative party is less likely to lead to as much controversy as previously.

If the Conservative Party has enough support to manage to get replacing the current Mental Health Act into a Queen's Speech, the Mental Health Bill needs to take account of the Convention on the Rights of Persons with Disabilities (CRPD). This is what the UN Special Rapporteur on the right to health has proposed (see previous post) and the rest of this blog uses quotes or amended quotes from his report.

The disability framework should radically reduce medical coercion. It starts from the principle that a disability shall in no case justify a deprivation of liberty. There is shared agreement about the unacceptably high prevalence of human rights violations within mental health settings and that change is necessary. Persons with psychosocial disabilities are generally falsely viewed as dangerous, despite commonly being victims rather than perpetrators of violence.

Change has taken place over recent years to challenge the disability stereotype, as many can live independently when empowered through appropriate legal protection and support. There are limitations to focusing on individual pathology.

Similarly, failure to secure the right to health and other freedoms is a primary driver of coercion and confinement in mental health. Mental health problems and disability are not exactly the same and this does need to be teased out in any new Mental Health Bill. In fact, it is still not clear how non-consensual treatment in mental health should be taken forward following the Convention on the Rights of Persons with Disabilities. This should be a government priority, even for a minority government. It needs to make use of appropriate indicators and benchmarks to monitor progress in respect of reducing medical coercion. The active involvement of mental health professionals in the shift towards rights-compliant mental health services is a crucial element for its success.

Mental health as a global health priority

I have mentioned previously (see post) the value of implicating mental health as one of the United Nations sustainable development goals. As pointed out by the UN Special Rapporteur (see previous post)The 2030 Agenda for Sustainable Development includes Goal 3, which "seeks to ensure healthy lives and promote well-being at all ages", and target 3.4, which "includes the promotion of mental health and well-being in reducing mortality from non-communicable diseases". As he also points out, this 2030 Agenda and other influences from WHO, the Movement for Global Mental Health and the World Bank mean that "mental health is emerging at the international level as a human development imperative".

I have tweeted relevant quotes or amended quotes for global mental health from the Special Rapporteur's report (see my responses to my tweet with the link to the report). I'll try and condense them in this blog.

The report emphasises the importance of parity with physical health in national policies and budgets or in medical education and practice, but suggests nowhere in the world has this been achieved. It does not want to forget that the political abuse of psychiatry remains an issue of serious concern in some countries (see previous post).

I have also previously mentioned the critique of The Movement for Global Mental Health by critical psychiatry (see post). The Special Rapporteur agrees with this critique. As he points out, it's all very well to note that millions of people round the world are grossly underserved by mental health services, but quoting alarming statistics about the scale and economic burden of "mental disorders" must not root the global mental health crisis within a biomedical model, as this approach is too narrow to be proactive and responsive. The scaling-up of mental health care must not involve the scaling-up of inappropriate care. He prefers to talk about actions to "scale across", by which he means embracing "a broad package of integrated and coordinated services for promotion, prevention, treatment, rehabilitation, care and recovery", including "mental health services integrated into primary and general health care, which support early identification and intervention, with services designed to support a diverse community". Furthermore:-
Evidence-based psychosocial interventions and trained community health workers to deliver them must be enhanced. Services must support the rights of people with intellectual, cognitive and psychosocial disabilities and with autism to live independently and be included in the community, rather than being segregated in inappropriate care facilities.

As he does in the rest of the report, the Special Rapporteur is encouraging all countries, including lower and middle-income countries, to develop rights-based mental health care.

Critical psychiatry position adopted by United Nations

The United Nations Special Rapporteur on the right to health, Dainius Pūras, has produced a report which focuses on the right of everyone to mental health (see press release). It is the result of extensive consultations among a wide range of stakeholders, including representatives of the disability community and users and former users of mental health services.

It essentially argues for a rights-based mental health service, as has been recognised by the World Health Organisation, to promote and protect the mental health of entire populations. The Special Rapporteur believes that the crisis in mental health should not be managed as a crisis of individual conditions but as a crisis of social obstacles which hinders individual rights. He calls for mental health leadership to confront the global burden of obstacles and embed right-based mental health innovation in public policy.

I have been merrily tweeting quotes or mostly amended quotes from the report, as it very much comes from a critical psychiatry perspective. For example:-

Mental health services governed by reductionist biomedical paradigm that has contributed to exclusion, neglect, coercion and abuse of people
10 Jun 2017, 10:59

Preoccupation with biomedical interventions, including psychotropic medications and non-consensual measures, is no longer defensible
10 Jun 2017, 11:06

Reductive biomedical approaches that do not adequately address context and relationships cannot be considered compliant with right to health
11 Jun 2017, 18:10

While biomedical component important, its dominance has become counter-productive, disempowering rights and reinforcing stigma and exclusion
11 Jun 2017, 18:11

Medicine, in particular mental health, is to a large extent a social science and this understanding should be used to guide its practice
11 Jun 2017, 18:03

Mental health policies should address the “power imbalance” rather than “chemical imbalance”
11 Jun 2017, 22:43

The Special Rapporteur proposes, as would critical psychiatry, that there are three major obstacles to a rights-based mental health for all: (1) dominance of the biomedical model (2) power asymmetries and (3) the biased use of evidence.

As far as the dominance of the biomedical model is concerned, he concludes that:-

We have been sold a myth that the best solutions for addressing mental health challenges are medications and other biomedical interventions
10 Jun 2017, 11:40

The balance between the psychosocial model and interventions and the biomedical model and interventions should be more appropriate
12 Jun 2017, 10:54

For the rest of this blog, I'll try and condense what Lucy Johnstone called my twitter-friendly summary of the report.
ClinpsychLucy
Thanks to @DBDouble for the Twitter-friendly summary. Special Rapporteur who authored the UN report is also a psychiatrist.
12 Jun 2017, 21:42
Anyone who does want to see the list of tweets, though, see my responses to:-
DBDouble
UN Report on right of everyone to enjoyment of highest attainable standard of physical and mental health documents-dds-ny.un.org/doc/UNDOC/GEN/…
10 Jun 2017, 10:44

As far as power asymmetries are concerned, the report goes on to note that biomedical gatekeepers, in particular biological psychiatry backed by the pharmaceutical industry, are the dominant influence. National mental health strategies tend to reflect biomedical agendas and obscure the views and meaningful participation of civil society. Such biomedical bias leads to the mistrust of many users and threatens and undermines the reputation of the psychiatric profession. It dominates services, even when not supported by the evidence. In summary, biomedical power undermines the principles of holistic care, governance for mental health, innovative and independent interdisciplinary research and the formulation of rights-based priorities in mental health policy.

The individual relationship between psychiatric professional and user can also be exploited. Power imbalance reinforces paternalism and even patriarchal approaches. The asymmetry between professionals and users disempowers users and undermines their right to make decisions about their health and creates an environment where human rights violations can and do occur. This misuse of power asymmetries thrives, in part, because legal statutes often compel the profession and obligates the State to take coercive action.

As far as biased use of evidence is concerned, the report notes that the evidence base for the efficacy of certain psychotropic medications is increasingly challenged from both a scientific and experiential perspective. Similarly, research is accumulating in support of psychosocial, recovery-oriented services and non-coercive alternatives. There are increasing concerns about overprescription and overuse of psychotropic medications in cases where they are not needed. Because of the biomedical bias in mental health, there exists a worrying lag between emerging evidence and how it is used to inform practice.

There are various reasons for this research bias, some of which are mentioned in the report. There is a long history of pharmaceutical companies not disclosing negative results of drug trials, which has obscured the evidence base. Scientific research in mental health continues to suffer from lack of diversified funding and remains focused on the neurobiological model. Academic psychiatry has outsize influence, informing policymakers on resource allocation and guiding principles for mental health services. It has mostly confined its research agenda to the biological determinants of mental health. There are also implications for teaching in that the biomedical bias in mental health dominates teaching in medical schools, restricting knowledge transfer to the next generation of professionals.

How can all this be changed? There needs to be a strong ethical focus. Mental health services must respect ethics and rights (including “first, do no harm”), choice, control, autonomy, will, preference and dignity. The overreliance on pharmacology, coercive approaches and in-patient treatment is inconsistent with doing no harm, as well as human rights. Abuse of biomedical interventions compromises the right to quality care in mental health services.

The report does make some specific comments about treatment. Psychosocial interventions and support, not medications, should be the first-line treatment option for the majority of people who experience mental health issues. Sadly, such interventions tend to be viewed as luxuries, rather than essential, and therefore lack sustainable investment. In most cases of mild and moderate depression “watchful waiting”, psychosocial support and psychotherapy should be the frontline treatments. It is not a right to health to prescribe psychotropic medication merely because effective psychosocial and public health interventions are unavailable. There are compelling arguments that forced treatment, including with psychotropic medications, is not effective, despite its widespread use. Peer support, when not compromised, is an integral part of recovery-based services. The right to health requires that mental health care comes closer to primary care and general medicine, integrating mental with physical health.

The report does emphasise that people can and do recover from even the most severe mental health conditions and go on to live full and rich lives. It considers that whether the global community has actually learned from the painful past of rights violations in mental health remains an open question.

I worry that this report will just "collect dust". As the Special Rapporteur himself says there is now unequivocal evidence of failures of a system that relies too heavily on the biomedical model of mental health, and yet this model persists despite the critique. I do think critical psychiatry does need to do more to expose the self-interest of modern psychiatry (see previous post). Still, it's very welcome to have United Nations support in this aim.

Thursday, May 25, 2017

"Deconstructing" American psychiatry

My previous post mentioned the recent AAPP conference on critical psychiatry. At this conference, Nev Jones proposed Derridean deconstruction as a starting point for an American critical psychiatry. As I mentioned, the American Psychiatric Association (APA) Annual Meeting was taking place at the same time. I wonder whether the guide to the APA Annual Meeting could be a text to "deconstruct". 

The welcome from the APA president in the guide mentions that the "field of psychiatry is rapidly evolving with new science, new technologies, new systems of care, and new collaborations and partnerships". In a conference of this sort, it is what she wants you to believe. But has there really been such progress? Perhaps it is just said to hide the real lack of progress. 

Apart from the programme of sessions, courses, lectures, case conferences, talks, symposia, workshops and new research poster sessions, exhibitors display information about products and services related to psychiatry. The meeting would apparently not be possible without the sponsorship of exhibitors. Some provide extra sponsorship of the meeting and pay for advertisements. There are also promotional programmes supported by pharmaceutical companies. 

There is no attempt to hide the commercialism of APA. In fact, the financial relationships with any commercial interest of presenters are listed, although there are a significant number who say they have nothing to disclose. The irony is that APA seems to think that by being so open about its commercial interests it has purified the scientific content of its meeting programme. In fact it does the reverse.

Monday, May 22, 2017

Exposing the self-interest of modern psychiatry

I have mused before about the lack of impact of critical psychiatry (eg. see previous post). Having just been to a conference on critical psychiatry in San Diego organised by the Association for the Advancement of Philosophy and Psychiatry (AAPP) (see programme and abstracts), I have been thinking about how critical psychiatry can be more effective. 

A paper by Peter Zachar, current AAPP President, suggested that what he called "populist uprisings against the establishment" are propelled by recognition of corruption within the system (see previous post about Modern psychiatry's disgrace). I have commented before about how even biomedical psychiatrists have expressed concern about the influence of the drug industry on psychiatry (see previous post), but merely doing this seems to be insufficient for change (see another previous post). 

Adjacent to where our conference took place, the American Psychiatric Association (APA) Annual Meeting was in the Convention Center (see guide). The advertisements in the guide to the meeting portray the interests of APA as much as the content of the meeting. As was said at our conference, the economically successful model of APA is apparent.

Yet there should be disquiet about this situation. Another paper at our meeting by Katherine Larose-Hébert described how the power dynamics in psychiatry act as a "total institution", transforming patients' identities, subjecting them to receive services in the way they have been designed. Biomedical psychiatry is primarily organised for its own interests leaving patients docile and marginalised.

I have always tended to concentrate on conceptual issues within critical psychiatry (see my previous post on the call for abstracts for the AAPP conference). Critical psychiatry needs to do more to expose the corrupting self-interests of modern psychiatry to support the wider acceptance of its ideas.

Wednesday, April 26, 2017

Making mental health services more therapeutic

Rex Haigh (GreenShrink) has a post on his "STRUGGLING TO BE HUMAN: what we're up against" blog about the Critical Psychiatry Network conference, which I also attended yesterday. The conference theme was Recovery in a Time of Austerity. I just wanted to pick up what he says about feeling a bit more at home in the therapeutic community world. As I mentioned in my article, there are links between critical psychiatry and the therapeutic community approach.

GreenShrink also has a post of a talk he gave about therapeutic communities last year. I agree with him about their relevance for the NHS. Although numbers of beds have been reduced, inpatient facilities need to be more therapeutic rather than so custodial. Although we don't have the same degree of total institutions in psychiatry, as the asylums have been closed, inpatient facilities still suffer from such institutionalising practice. And, community services are not immune and need to become less bureaucratic.

I also agree about the relevance of Laing (see previous post about Mad to be Normal film, which I also saw yesterday) and Basaglia (e.g. see another previous post), both for therapeutic communities and critical psychiatry. And, as was said yesterday at the conference by Jo Moncrieff, the 'elephant in the room' when talking about 'recovery' is that mental health problems tend to be seen as brain disease. Such objectification of people may make psychiatry part of the problem rather than necessarily the solution to their problems. Part of the motivation of Laing and Basaglia was to counter this trend.

Friday, April 07, 2017

An experiment in unstructured living for people with mental health problems

The film Mad to be normal was released yesterday. Almost my first post on this blog was about the plans for this film. As Bob Mullan explains (see iNews article), it has been a "long-gestating project". I first heard about it from him in 2006.

I haven't seen the film yet, but I thought it may be worth saying something about Kingsley Hall (see Guardian article), on which the film focuses. Kingsley Hall was the first of several therapeutic community households established by the Philadelphia Association, a charity founded in 1965 by R.D. Laing, David Cooper (although Cooper had nothing more to do with the project after it started) and others. (See extracts on Laing and Cooper from my book chapter 'Historical perspectives on anti-psychiatry'). Laing lived at Kingsley Hall for 18 months in 1965/6. It was an experiment in unstructured living and sought to allow psychotic people the space to explore their madness and internal chaos. It did not attempt to ‘cure’ but provided a place where "some may encounter selves long forgotten or distorted" (Morton Schatzman in Laing and anti-psychiatry).

The local community was mostly hostile to the project. Windows were regularly smashed, faeces pushed through the letter box and residents harassed at local shops. After five years, Kingsley Hall was largely trashed and uninhabitable. Even for Laing, Kingsley Hall was "not a roaring success" (Mullan, 1995). Laing’s dream of a place "without those features of psychiatric practice that seemed to belong to the sphere of social power and structure rather than to medical therapeutics" was only partially successful, even from his own perspective (Laing, 1985).

Kingsley Hall was designed to give people freedom from the social control of psychiatry. As I wrote in my chapter in Liberatory psychiatry, its association
with the counterculture of the 1960s and 1970s may have helped to propel anti-psychiatry into the limelight. It may also have contributed to its demise. Without this cultural support, anti-psychiatry seemed to lose its popular appeal. Also, some of its major proponents, such as Laing, were more obviously interested in personal authenticity than changing psychiatry practically. After Kingsley Hall, Laing went on retreat to Ceylon and India to pursue his interests in meditation, Buddhism and Hinduism. Later in life, Laing (1987) regarded his main achievement as being in the area of social phenomenology in philosophy, not psychiatry. Generally, anti-psychiatry is seen as having had no lasting influence on psychiatry and its practice (Tantam, 1991). For all its calls for liberation, these aspirations were largely sidelined into promoting personal and spiritual freedom with little interest in redeeming psychiatry itself. This diversion helped to allow mainstream psychiatry to marginalise anti-psychiatry’s influence.

I have always said that critical psychiatry has its origins in anti-psychiatry (see eg. my letter). The Philadelphia Association has survived over 50 years and still runs two community houses (see my book review of Testimony of experience). Critical psychiatry has sought to avoid the marginalisation that anti-psychiatry experienced and is looking for acceptance of its position from mainstream psychiatry. Even Laing probably ultimately sought the endorsement of the psychiatric profession as demonstrated by his wish to be professor of psychiatry in Glasgow towards the end of his life.

Thursday, March 30, 2017

Genuine interdisciplinarity in neuroscience research

I have been reading Neuro by Nik Rose and Joelle Abi-Rached. Like me (see previous post), they hope that neuroscience can become a genuinely human science. I like their notion of 'critical friendship' between social sciences and neuroscience. Some of the proper motivation for this friendship may be to share the money going into neuroscience research. It may also be important not to minimise the degree to which neuroscience funding is being wasted on the unattainable. However, there is a need for genuine interdisciplinarity to take the neuroscience research agenda forward. As they say:-
[W]e should not be surprised to find, in contemporary neurosciences, all the features of inflated expectations, exaggerated claims, hopeful anticipations, and unwise predictions that have been so well analyzed in other areas of contemporary biotechnologies.

Social sciences have nothing to fear about the 'neuro-turn' in modern culture (see previous post) and polarised attitudes in the debate are unhelpful (see another previous post). Pressures to translate research findings to clinical applications are also creating perverse effects. To quote again from Neuro:-
Neuroscientists might well be advised to be frank about the conceptual and empirical questions that translation entails, rather than suggesting that the outcome of a series of experiments with fruit flies or feral rats has something to tell us about human violence, or that brain scans of individuals when they are exposed to images of differently colored faces in an fMRI machine has something to tell us about the neurobiological basis of racism.

I also agree that the neuro-turn may be affecting how we view ourselves but that it "is too early to diagnose the emergence of a full-blown ‘neurobiological complex,’ or a radical shift from psy- to neuro-". Critical psychiatry has something to offer to the Neuroscience Project at the Royal College of Psychiatrists (see previous post).

Saturday, March 25, 2017

The faith of mainstream psychiatry

As I've said before (eg. see previous post), it seems obvious to most people that mental illness is due to brain disease. Critical psychiatry doesn't stand a chance! It must be wrong to question this assumption. But, of course, critical psychiatry isn't saying that mind and brain are separate (see previous post). What it is saying is that minds are enabled but not reducible to brains. It's got the weight of philosophy behind it.

Furthermore, it is also saying that the assumption that mental illness is due to brain disease is not based on logic, but rather on faith, desire and wish fulfilment. As I've also said before (see previous post), psychiatry is more like a religion than a science. It's much simpler to believe that brain pathology is the basis for mental illness and that its nature and cause will eventually be discovered. Believing this can be a way of justifying psychiatric treatment.

Actually, there's no need to justify treatment in this way. Mental health problems exist and professional expertise may be beneficial in treatment. The problem is that objectifying people through reducing their problems to brain disease make make psychiatry part of the problem rather than necessarily the solution to these problems.

Tuesday, March 14, 2017

The contested nature of psychiatry

Charles E. Rosenberg has an interesting paper on how psychiatry expanded in the last third of the 19th century to "include an ever-broader variety of emotional pain, idiosyncrasy, and culturally unsettling behaviors". Our modern somatic understanding of illness had to accommodate older "[h]umoral explanations of temperamental peculiarity", such as hypochondriasis, hysteria and melancholy. It began to do this at the beginning of the 19th century, by, for example, Benjamin Rush seeing hypochondria as having a corporeal cause. These "reductionist, mechanism-oriented, and antivitalist" ways of viewing illness created hypothetical disease entities, such as neurasthenia, regarded by George Beard in 1869 as a somatic condition which would eventually be confirmed by postmortem pathology.

As Rosenberg says:-
The dominance of reductionist styles ... has an extraordinarily salient place today. We have never been more infatuated with visions of molecular and neurochemical — ultimately genetic — truth.
As he also says, "yet at the same time we are reflexive [and] critical ... in our approach", even if this is a minority perspective. As discussed in my previous post, psychiatry is polarised about the nature of mental illness. Psychotropic medication has helped legitimate the specific disease entity model of mental illness. This is a "phenomenon that is always in process, always contested, and never completed". With the expansion of the "range of human dilemmas that we ask medicine to address", to quote from Rosenberg:-
[I]t is ... inevitable that the powerful concept of disease specificity has been — and will continue to be — employed as a tool for the ideological management of problematic emotions and behaviors.


(With thanks to a tweet from Richard Hassall)

Monday, March 13, 2017

Polarisation in the debate about mental illness

I have mentioned Mike Owen in a previous post. In a recent blog, he argues for less polarisation in the debate about the nature of mental illness. I couldn't agree more.

However, Mike does need to represent his opponents correctly if there is going to be a rapprochement. He says, "They assume, implausibly, that mind and brain are separate entities rather than different aspects of the same thing". This isn't true. The argument being made is not Cartesian. As Steven Rose says, "That brains enable minds is uncontroversial. That they 'are' the mind is a reductionism too far" (see Lancet article).

Similarly, Mike also says "They also fly in the face of a large body of evidence indicating the importance of genes and altered brain states in contributing to disorders of mental health". Again, not true. The critiques are evidenced-based. Genes, of course, set the boundaries of the possible but environments define the actual. More caution is needed in interpreting so-called altered brain states.

It is important that Mike understands what people are saying who are critical of his view. As Steven Rose says, people like Mike should not "dismiss without a backward glance not only millennia of philosophical debate but also a huge current literature on mind/brain relationships". There is a "conceptual innocence" about his position, although he is, of course, trying to dismiss any criticism. Despite what he may think, modern psychiatry has not solved the mind-brain problem.

Thursday, February 23, 2017

What does it mean to say that antidepressants don't work?

Like Carmine Pariante, I have treated thousands of patients since I started as a trainee psychiatrist in 1985 and became a consultant over 25 years ago (see post on my personal blog). He is convinced that antidepressants work (see article), whereas I am more sceptical. He's correct that I'm in a minority. The trouble with relying on personal experience is that we can delude ourselves.

Pariante does recognise that "about one in three patients with serious clinical depression who takes them doesn't get better". Actually what he means is that about a third of patients do not seem to be helped in clinical trials. These trials are only short-term and people on antidepressants are compared with those taking placebo. About a half of patients in the clinical trials taking placebo also seem to improve. It's, therefore, misleading to imply that two-thirds of patients are getting better because of antidepressants (see post summarising evidence of outcomes with antidepressants). The difference between active and placebo treatment in clinical trials is much smaller than most people realise. In fact it's so small it could be an artefact (see previous post). 

Friday, February 17, 2017

Buying into idea of chemical imbalance causes psychotropic medication discontinuation problems

As mentioned in my previous post, I have been reading The sedated society: The causes and harms of our psychiatric drug epidemic edited by James Davies (2017). The chapter by Luke Montagu, entitled "Desperate for a fix: My story of pharmacetical misadventure", describes the problems he had discontinuing psychotropic medication after "having bought into the idea of a chemical imbalance" when he was taking medication. Luke's father is the Earl of Sandwich, and one of the co-chairs of the All Parliamentary Group for Prescribed Drug Dependence (see previous post). As Luke says:-
[P]sychiatry, in league with the pharmaceutical industry, chooses to perpetuate two fundamental hoaxes. The first ... is that the suffering we call mental illness has a biological basis, like cancer or diabetes, caused by an imbalance of chemicals in the brain ... The second hoax follows on from the first, namely, that today’s drug treatments target and correct this chemical imbalance, just like antibiotics fight infection or insulin treats diabetes.
He goes on:-
One day these beliefs and treatments will seem as misguided as the theory of the four humours, when bloodletting, blistering and purging were believed to restore the correct balance of blood, phlegm and bile
As I said in my previous post, historically it helps to see the chemical imbalance theory as a myth, as it's wrong like humoral theory. I hope Luke's right that it will be found to be misguided, but there are powerful reasons why people do believe it (see eg. previous post). Maybe one of the major reasons for getting rid of it is to prevent people developing discontinuation problems.

Wednesday, February 15, 2017

Social construction of childhood depression

Sami Timimi, in his chapter "Starting young: Children cultured into becoming psycho-pharmaceutical consumers - The example of childood depression" in The sedated society (2017), describes how SSRI antidepressant prescribing for young people has increased, apart from a hiatus around 2004 because of concerns at the time about lack of efficacy and increased suicidality. Despite these concerns, prescribing has continued to increase by arguing in a biased way that the benefits of antidepressants outweigh the risks.

As Sami says:-
It was only relatively recently (in the late 1980s) that our understanding of childhood depression began a far-reaching transformation. Prior to this childhood depression was viewed as a very rare disorder, different to adult depression and not amenable to treatment with antidepressants ...  A shift in theory and consequently practice then took place as influential academics claimed that childhood depression was more common than previously thought (quoting figures such as 8–20% of children and adolescents), resembled adult depression, and was amenable to treatment with antidepressants.

Sami tries to relate this construction of childhood depression to child-rearing practices. I tend to prefer the simpler explanation that it reflects our belief in the chemical cure. I suppose the view in which I was schooled that childhood depression is uncommon and different to adult depression was also socially constructed (see previous post). However, as I said in my BMJ letter, I don't want to get too hung up about whether childhood depression exists. The problem is when it is seen as a biological entity for which antidepressants are indicated.

Monday, January 30, 2017

Meyerian history and examination in psychiatry

I mentioned the article about One hundred years of psychiatry at Johns Hopkins in my previous post. The article focuses on how Adolf Meyer developed an organised approach for history taking and mental state examination in psychiatry, which became standard in the US. It was taken over by the Maudsley Hospital in the UK, again becoming standard (see previous post and my review of most recent edition of The Maudsley handbook of practical psychiatry). However, as the article points out, the "meyerian history and examination ... is little used in the United States today as it is often judged to be too time-consuming".

The clinican comes to a formulation at the end of the history and examination, of which a differential psychiatric diagnosis is merely one element. Some may see formulation as more opposed to psychiatric diagnosis (see previous post), but formulation should, as the article says, summarise "the story focusing on the salience of the problems and context - how has the problem developed, interrupted, and/or distorted the patient's life trajectory".

The article discusses why psychiatry does not focus on the meyerian history and examination in a comprehensive and systematic way, and is, therefore, not as patient-centred as it should be (see previous post). One reason is that too many influential psychiatrists are research-based, rather than being involved in routine clinical care settings. Today's medicine doesn't teach a broad enough basis "for knowing our patients and partnering with them in patient care". Meyer made these methods explicit. This is a "truly personalized medicine, distinct from the ongoing extension of the disease model at a molecular level, which is commonly referred to as individualised or precision medicine" (see eg. previous posts The gap between neural circuits and understanding people and Psychiatric research folly).

Critiquing the neuro-turn

Roger Cooter has an article on why the neuro-turn in popular and academic culture needs to be taken seriously. I tend to regard it as 'neo-phrenological phantasy' (eg. see  previous post), but Roger cautions against being "so lightly dismissive". The neuro-turn may be affecting how we view ourselves. Furthermore, it seems to be beyond criticism, or, as Roger puts it, "the neuro-turn stymies ... its own critique".

As an example, another recent paper I have read is about One hundred years of psychiatry at Johns Hopkins. Whilst discussing the heritage of Adolf Meyer and Paul McHugh for current american psychiatry, it suggests that, "One happy byproduct of current research is that ... the competitive jousting between the 'biological' and psychological' ...[has] dissipated". It goes on:-
It has proven difficult to maintain such debates when research now shows the human brain responding robustly to all manner of psychological, pharmacological, and stimulatory interventions.
So, I've been wasting my time trying to encourage this debate! Studies that literally 'light up the brain' have shut down the argument.

Roger describes the attractions of an ahistorical, posthumanist worldview, which may help to mediate neoliberal politics. At least he concludes that critique is even more "vital and urgent". So, maybe I need to keep going.