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. 2001 Aug 25;323(7310):449.

Postpsychiatry

There is nothing postmodern in what people with schizophrenia want

Christopher Bagley 1
PMCID: PMC1121043  PMID: 11548720

Editor—As a social scientist, and as one of a growing number of professionals who can say publicly that they have been treated for schizophrenia, I found the adoption of the term “postpsychiatry” by Bracken and Thomas unsatisfactory.1 They have fallen under the spell of a current fad, which in psychiatry—as in other disciplines—amounts to the dressing of an emperor in non-existent clothes.

Bracken and Thomas imply that in postpsychiatry's new age the person with mental illness is part of a complex, interacting matrix of social influences in which the mind cannot be abstracted or studied as an independent phenomenon. The individual, it seems, is a creature of his or her social environment. Jaspers's phenomenology of mind is rejected as isolating the individual from this social matrix. But in my experience, the mind is an independent phenomenon—not merely a system of neuropsychological complexes but the seat of emotion, will, and creativity that transcends the environment.

The most important advances in psychiatry in the modern age are the development of pharmacological treatments that, helping the mind to operate efficiently, can release self reflective energy. Social factors of course are important in the emergence and relapse of illness, but it is our brain that is the author of progress in the network of social relationships.

It is not accidental that many user groups have adopted biological models of schizophrenia. The social psychiatrist Querido reported that patients eagerly accepted his view that voices were caused by a malfunction in brain circuitry, just as we sometimes hear voices on a crossed telephone line. This idea, of symptoms as alien and controllable, is of great comfort for patients and forms the basis of much successful cognitive behaviour therapy. Schizophrenia is not caused by relatives, or by cruel environments. It is an illness like epilepsy that is the subject of misunderstanding and prejudice; an illness of the brain, best treated in ways that allow patients to control symptoms.

Of course, patients and their allies need to address the widespread stigma and prejudice concerning schizophrenia. Active programmes to do this owe nothing to postmodern faddism. Their approach is conceptually similar to that of other campaigns against prejudice concerning minority groups.

What do people with schizophrenia want? They want non-coercive treatments (including pharmotherapy, cognitive behaviour therapies, and supportive psychotherapy); rapid access to treatments when they experience the onset of symptoms; voluntary admission to hospital when requested; and social work support for housing and employment programmes. There is nothing postmodern in this. True, as Bracken and Thomas assert, community care is failing. It is failing because of government underfunding, not because of a failed model of science. We ask for bread, and you offer us postmodernism.

References

  • 1.Bracken P, Thomas P. Postpsychiatry: a new direction for mental health. BMJ. 2001;322:724–727. doi: 10.1136/bmj.322.7288.724. . (24 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2001 Aug 25;323(7310):449.

Current psychiatric practice has been exposed

Mark Rapley 1,2, Alec McHoul 1,2, Susan Hansen 1,2

Editor—Bracken and Thomas have given a name to the dehumanising biological shibboleth of contemporary psychiatry.”1-1 Electronic responses serve more to make their case than to refute it: the biologically minded provide no evidence to support their rejection but simply state that Bracken and Thomas are wrong, and recycle misleading simplifications of earlier challenges to biopsychiatry (the misreading of Laing being a case in point).1-2 To argue that sensitive cross cultural practice is “properly funded” psychiatry1-2 is, similarly, a form of intellectual appropriation analogous to the hijacking of Tuke's “moral treatment” by the mad doctors of the 19th century.

To suggest that, in learning disability, postpsychiatry is the norm1-3 overlooks the sudden emergence of “dual diagnosis,” when psychiatry's power was threatened by clinical psychology. To believe that non-verbal people with IQs of 45-50 were displaying symptoms of psychosis strains credulity. These are familiar tactics to critics of psychiatry.

That contemporary biopsychiatry, rather than modernist psychiatry, is “bound to unproved . . . theories” that fail to “bring around any significant improvement in people's care”1-2 is shown by the failure of biomedical research to identify any unambiguous sign of psychiatric (as opposed to neurological) disorder in the current Diagnostic and Statistical Manual of Mental Disorders, and also by the routine infliction of brain damage on the recipients of psychiatric “care.”1-4 Why do neurologists attempt to control epilepsy? Because seizures inflict brain damage. Why do psychiatrists routinely recommend doctor-induced seizures for depressed people?

Bracken and Thomas have exposed current psychiatric practice. They are prepared to acknowledge that those who hear voices are not necessarily biologically disordered but, rather, are essentially indistinguishable from the “normal” population1-5; that the evidence for supposed brain diseases such as schizophrenia is so self evidently unscientific as to be worthless1-5; that the toxic effects of neuroleptics are widespread and devastating; and that self proclaimed medical texts such as the Diagnostic and Statistical Manual of Mental Disorders are driven more by sociopolitical concerns than by medicine. The manual is more a reflection of contemporary prejudice than it is a psychiatric analogue for Gray's Anatomy.

Critical psychology also questions the pathologisation of misery that biopsychiatry proselytises.1-4 Bracken and Thomas's article represents a possibility for change. The biological substrate of human conduct is necessary for both ordinariness and madness, but it can never be sufficient explanation for either.1-4

References

  • 1-1.Bracken P, Thomas P. Postpsychiatry: a new direction for mental health. BMJ. 2001;322:724–727. doi: 10.1136/bmj.322.7288.724. . (24 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Melichar JK, Argyropoulos SV. “Postpsychiatry”—or merely “properly funded psychiatry” [electronic response to Bracken et al. Postpsychiatry: a new direction for mental health]. BMJ 2001. bmj.com/cgi/eletters/322/7288/724#EL1 (accessed 28 March).
  • 1-3.Barron P. “Postpsychiatry” is psychiatry in learning disabilities [electronic response to Bracken et al. Postpsychiatry: a new direction for mental health]. BMJ 2001. bmj.com/cgi/eletters/322/7288/724#EL4 (accessed 28 March).
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BMJ. 2001 Aug 25;323(7310):449.

Solution is possible within existing biopsychosocial framework of psychiatry

Gopinath Ranjith 1,2, Rajesh Mohan 1,2

Editor—Bracken and Thomas offer a critique of the practice of modern psychiatry and promise a brave new world called postpsychiatry. But their criticisms of psychiatry are no more than recycled arguments of the antipsychiatry movement; their vision is high on ideals and low on practical utility.

They assume that the legitimacy of modern psychiatry is questionable and that community care has failed, necessitating a new theoretical framework in the post-asylum era. In support of the first notion they quote a book by one of the authors. They ignore evidence against their second argument.2-1

Jaspers's emphasis on the importance of form over the content of psychopathology provokes the authors' ire. Large crosscultural studies such as the international pilot study of schizophrenia,2-2 concentrating on the form of symptoms, led to an understanding not only of the universal experience of psychotic symptoms but of social and contextual factors as well. By polarising biological and psychosocial factors, they ignore the rapprochement that has happened recently, as seen in articles by Kandel2-3 and Holmes.2-4 In their eagerness to portray psychiatrists as social controllers Bracken and Thomas ignore the recent efforts of prominent psychiatrists to defend patients' rights.2-5

The stated goals of postpsychiatry are alarming. The undue importance of interpretations of subjective experience will divert the focus from the distress and pain experienced by patients. Wrong assumptions may be made in the case of people from immigrant communities, depriving them of effective treatments. It is obvious that all psychiatrists need to be competent in dealing with patients from other cultures. But this is possible within the existing biopsychosocial framework of psychiatry without our resorting to fanciful thinking and recycled ideas.

References

  • 2-1.Marshall M, Lockwood A. Assertive community treatment for people with severe mental disorders. Cochrane Database Syst Rev 2000;2:CD001089. [DOI] [PubMed]
  • 2-2.Leff J, Sartorius N, Jablensky A, Korten A, Ernberg G. The international pilot study of schizophrenia: five-year follow-up findings. Psychol Med. 1992;22:131–145. doi: 10.1017/s0033291700032797. [DOI] [PubMed] [Google Scholar]
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BMJ. 2001 Aug 25;323(7310):449.

Net of exclusion and control is being extended

David Morgan 1

Editor—Bracken and Thomas's programme for postmodern psychiatry comes at a critical moment of transition in British psychiatry.3-1 But the direction is being moved not by a liberating epistemological shift in approaches to mental disorder but by powerful countervailing voices from a sceptical public and the state. Postmodern perspectives are liable to leave psychiatrists even more vulnerable to a political agenda that is primarily concerned with closure and risk.

The changes driving this transition affect medicine in general. They stem from the disintegration of a previously stable relation between medicine, society, and the state, in which the state supported the right to medical care, medicine delivered treatments to professionally agreed standards, and both gained the respect of an approving society, which secured the political legitimacy of the NHS. The success of this arrangement was underpinned by unquestioned trust in the integrity of the medical profession.

That trust has now begun to unravel, not only among the public but within the government. Complaints about the quality of medical provision, the rise of articulate user groups, and intense media interest in events such as those at Bristol Royal Infirmary have eroded public confidence and politicised standards of medical care. The trend is now away from therapeutic diversity and autonomy towards an unprecedented system of clinical governance “extending into the clinical community at all levels” and open to public scrutiny.3-2

This applies to psychiatry as well, whose relation to the state is currently the subject of statutory reform. In the case of disorders posing a possible danger to society, a white paper categorically asserts that “concerns of risk will always take precedence” over the patient's “best interests” (para 2.16).3-3

Control of risk warrants the “move away from the narrow concept of 'treatability'” (para 3.5), which the home secretary believes has allowed psychiatrists too much discretion over whom to detain. In a statement quoted by the Central Office of Information the home secretary said that the white paper changes “this wholly unacceptable position and moves beyond the rather artificial criterion of ‘treatability’ in determining who should be detained.”3-4

The quasilegal category “dangerously severe personality disorder” has been introduced to identify potentially dangerous people who are seldom seen as treatable or detained under the Mental Health Act. General practitioners, social workers, local government officers, and criminal justice agencies will have a statutory obligation to share information with the psychiatric services about such people (para 5.1-3) with a view to detaining those assessed as potentially dangerous, whether they are medically treatable or not (para 3.3).

The postmodern values that Bracken and Thomas advocate are barely acknowledged in this programme of surveillance that extends the net of exclusion, coercion, and control beyond people who are mentally ill and beyond the hospital to the community itself. These moves are opposed by most psychiatrists3-5 and are an outrage to professionals and user groups who share a humanitarian vision of psychiatric care.

Yet, to those who do not share this view, defence of clinical diversity, tolerance, and patient autonomy can easily appear as an equivocation, if not a wholesale collapse of intellectual and political nerve. Ironically, a more robust assertion of psychiatry's commitment to therapeutic values is needed to contest the gradual assimilation of psychiatry within the criminal justice system. Sadly, the postmodern aversion to fixed ideas and beliefs is no match for a determined agenda of the state.

References

  • 3-1.Bracken P, Thomas P. Postpsychiatry: a new direction for mental health. BMJ. 2001;322:724–727. doi: 10.1136/bmj.322.7288.724. . (24 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3-2.Department of Health. A first class service: quality in the new NHS. London: DoH; 1998. : para 3.12. [Google Scholar]
  • 3-3.Secretary of State for Health and Home Secretary. Reforming the Mental Health Act. London: Stationery Office; 2000. . (Cm 5016-I.) [Google Scholar]
  • 3-4.Central Office of Information. Managing dangerous people with severe personality disorder: consultation document. London: COI; 1999. . (221/99.) [Google Scholar]
  • 3-5.Crawford MJ, Hopkins W, Thomas P, Moncreiff J, Bindman J, Gray AJ. Most psychiatrists oppose plans for new mental health act. BMJ. 2001;322:866. . (7 April.) [PMC free article] [PubMed] [Google Scholar]
BMJ. 2001 Aug 25;323(7310):449.

Notions of “mad” and “madness” are stigmatising

Sue Collinson 1

Editor—A little learning is a dangerous thing; this is certainly borne out by the embarrassing spectacle of psychiatrists dabbling in the history of ideas.4-1 Bracken and Thomas's trawl of European thought from the 18th to the 21st century, used as a framework for beating up their own profession via their impoverished historical understanding of the development of attitudes towards those who are “mad,” left me both disturbed and angry. Disturbed because as a patient I found much of what they said unsettling; and angry because I felt that the evidence used to justify something called postpsychiatry was dangerously flawed.

The Enlightenment philosopher John Locke wrote about the mad that they “do not appear to me to have lost the faculty of reasoning, but having joined together some ideas very wrongly, they mistake them for truths, and they err as men do that argue right from wrong principles.” I would say that this is a fair summary of Bracken and Thomas themselves.

Bracken and Thomas state that the Enlightenment (which apparently only ended at the onset of the recent “decade of the brain”) somehow promised that rationality and science would overcome human suffering, almost as if this was a bad thing. It seems to me that there is something wonderful and optimistic in this, worth remembering in these more cynical times.

More disturbing to me was the authors' persistent use, in a 21st century context, of the term “madness,” as in the “relation between medicine and madness” and “psychiatry's promise to control madness.” I have had a mental illness for over two years, but I am not, and have never been, mad. It is my (perhaps deluded?) understanding that mental illness and madness are not the same thing, and that modern psychiatry is interested in treating mental illnesses. Notions of mad and madness are highly stigmatising. It is sad to see these terms still being used in the psychiatric profession.

The World Health Organisation has identified just one mental illness, depression, as a social and economic time bomb; it is responsible for 4.2% of the world's total burden of disease and the fifth leading cause of disability globally.4-2 This is not the time for the psychiatric profession to show therapeutic cowardice, self indulgence, and self doubt. It would seem that Bracken and Thomas are chasing the tail of their argument around the hermeneutic circle of meaning and thus are going nowhere.

To let the Enlightenment have the last word: the 18th century surgeon, William Cullen, proposed that all pathology originated in a disordered “spasm” of the nervous system. It is my sincere hope that this proposed postpsychiatric project is no more than a tic.

References

  • 4-1.Bracken P, Thomas P. Postpsychiatry: a new direction for mental health. BMJ. 2001;322:724–727. doi: 10.1136/bmj.322.7288.724. . (24 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4-2.Dawson A, Tylee A. Depression: social and economic timebomb. London: BMJ Publishing Group; 2001. [Google Scholar]
BMJ. 2001 Aug 25;323(7310):449.

Might “properly funded psychiatry” be better description than postpsychiatry?

Jan K Melichar 1,2, Spilios V Argyropoulos 1,2

Editor—Bracken and Thomas seem to believe that the whole of modern biological psychiatry is uncaring, unfeeling, and only willing to see the patient (or, as the national service framework so beautifully puts it, “service user”) outside of any social context.5-1 We believe that this is a fundamentally flawed view.

Given limited resources and almost no ability to influence social circumstances (how many letters supporting rehousing are successful?), psychiatrists aim to diagnose and treat those elements of a patient's problems that they are able to. The social context plays a great part, but it is a part we unfortunately have very little influence over.

The authors' own example of postpsychiatry (a 53 year old Sikh woman being helped when her psychotic behaviour was explained in cultural terms) could be an example of well funded transcultural psychiatry. A satisfactory outcome occurred when her concerns and symptoms were put into the context of her own upbringing. This could merely be due to there being enough resources to fund appropriate specialist staff and not because of any seismic shift in thinking away from today's psychiatry. Perhaps a better description of postpsychiatry would be “properly funded psychiatry.”

It is also important to remember that not everything can be explained by social circumstances. Attempts by modernist sociological psychiatry in the 1960s to do this led to the mismanagement and undue suffering of large numbers of core psychiatric patients. Speculations from R D Laing's era that mothers of people with schizophrenia and society at large were entirely to blame for their children's illness is a pertinent example. Modernist psychiatry, throughout the last century, was bound to unproved psychological and sociological theories. Biological psychiatry arose out of its failure to greatly improve people's care.

The authors' use of the term postmodern is mistaken, and the only evidence that they put forward to support this is by Muir Gray. We argue that this is a gross misrepresentation of postmodernism, a common occurrence when this word is used. We resent the use of the word as yet another buzz word.

Rather than losing ourselves in a philosophical discussion, however, we prefer to see the faults and failings in a grossly under-resourced service. Perhaps we should all be clamouring for more investment and, once this in place, see what needs changing and improving. We prefer to leave our intellectual power struggles outside the day to day care of the patients.

References

  • 5-1.Bracken P, Thomas P. Postpsychiatry: a new direction for mental health. BMJ. 2001;322:724–727. doi: 10.1136/bmj.322.7288.724. . (24 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2001 Aug 25;323(7310):449.

Psychiatrists need different training for 21st century

Michael van Beinum 1

Editor—Bracken and Thomas open what needs to become a vigorous debate about future directions in psychiatry, but I disagree with their arguments.6-1 They claim that “20th century psychiatry was based on an uncritical acceptance of [the] modernist focus on reason and the individual subject.” It is as if the major influence on the 20th century of Freud and his insistence on the role of desire, and not reason, as the wellspring of human action had never been and psychoanalysis had not been a major component in the practice of 20th century psychiatry.

The authors' focus seems to be narrowly Anglo-Saxon, as they fail to acknowledge developments in psychiatry elsewhere in Europe, such as the influence of Lacan, Kristeva, and Deleuze in France and Bassaglia in Italy. Indeed, they portray modern psychiatry as predominantly concerned with detaining people, and cite no references to studies of current psychiatric practice. The psychiatry I was taught and now practise in Scotland is all about working with patients in their social and cultural contexts and helping them manage complex social systems, including their families, employment, education, and the law.

Furthermore, the authors consistently and inappropriately assign agency to abstract concepts such as “psychiatry.” Psychiatry does not have agency, but individual psychiatrists, in their daily practice, do. Such misplaced concreteness is particularly unfortunate in an article opposing instrumental rationality and hides the great variety of practice between individual psychiatrists. More fundamentally, the authors are unclear about their ontological and epistemological position and fail to explicate their schema for uniting empirical causality with hermeneutics. Lastly, sceptical caution is in order when placing service users centre stage. Clarke and Newman, for instance, argued that managers, wedded to a rightwing capitalist ideology, use the need of the consumer to break up state monopolies.6-2

Bracken and Thomas raise important points. In particular, far more attention needs to be placed on a sound understanding of ethics and the philosophy of science in the training of psychiatrists. This would allow practising psychiatrists to have the conceptual apparatus to engage in a moral science of action appropriate to a multicultural Britain of the 21st century.

References

  • 6-1.Bracken P, Thomas P. Postpsychiatry: a new direction for mental health. BMJ. 2001;322:724–727. doi: 10.1136/bmj.322.7288.724. . (24 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6-2.Clarke J, Newman J. The managerial state; power, politics and ideology in the remaking of social welfare. London: Sage; 1997. [Google Scholar]
BMJ. 2001 Aug 25;323(7310):449.

Authors' reply

P Bracken 1,2, P Thomas 1,2

Editor—Any call for a radical rethinking of an established discipline inevitably invokes a wide range of responses. Some are simply defensive (and sometimes offensive) dismissals, but others offer more considered objections and arguments. We direct our response mainly to the latter. In a brief reply such as this we cannot address individually every point our critics make. We have therefore put down a few thoughts here, which we hope will clarify some areas of misunderstanding, and hope to produce a book on the theme in the future.

“Postpsychiatry” is meant as a rhetorical device: a way of challenging current thinking, an invitation to imagine future possibilities, an indicator that radical change is already under way. In short, our aim is to provoke a serious discussion about the theoretical underpinnings of mental health work in the 21st century.

Having spent many years “dabbling in the history of ideas,” we are well aware that the term “postmodern” is a nebulous concept. It is often used simply to refer to a contemporary social, cultural, and political condition, something we find ourselves in the midst of, the result of an economic shift towards a “more flexible mode of capital accumulation.”7-1

But postpsychiatry also emerges from another, more positive, sense of the postmodern as a way of reflecting on the world and our place in it. The last quarter of the 20th century witnessed a serious interrogation of the legacy of the Enlightenment and an increasing realisation that science and technology would not solve all the problems we face as humans. This was not, as some of our critics seem to believe, an attack on science or the Enlightenment but a clearer realisation of their assumptions and limits. For us, postmodernism is about facing the contradictions and difficulties of our situation as humans without recourse to doctrines that assert that there will always be correct and incorrect ways of understanding, acting, and behaving.

This is not a new theory to replace Marxism, science, or religion but a deeper sensitivity to the ways in which knowledge, power, and values are interwoven. Perhaps postmodernism does raise more questions than answers. But we do not find this a frightening prospect. Rather, it seems a more mature and honest response to the social and moral issues we face than the dogmas that brought so much suffering to the 20th century.

The result of this is not therapeutic cowardice (Collinson and Morgan's view) but an openness to different frameworks and perspectives. Hence we welcome the emerging service user movement, which offers far more exciting and radical possibilities than simply existing as a pawn of consumerism, as van Beinum suggests.

Bagley asserts that service users are generally satisfied with the psychiatric status quo and simply want more of the same. This runs counter to our experience and the available evidence. In Rogers et al's large study of service users' response to the care they received, less than half found the attitude of their psychiatrist helpful (n=463).7-2 Knowing Our Own Minds—user led research undertaken by the Mental Health Foundation—shows that most service users want far more than the traditional answers of psychiatry.7-3

We agree with van Beinum about the need to introduce a much wider curriculum in the training of psychiatrists, which over the past 25 years has become increasingly dominated by neuroscience.7-4 The responses of some of our critics (Ranjith and Mohan, Melichar and Argyropoulos) indicate the importance of this, and the need for a more sophisticated understanding of the relation between biological and social factors, such as that advocated recently by Rose.7-5

Far from leaving us in a position of paralysis with respect to a “determined agenda of the state” (Morgan), postmodernism (or postpsychiatry) actually allows us to see, and therefore to fight, injustice from more than one perspective. We struggle in very practical ways with the ideas that we propose; the home treatment service in Bradford is an example of this.

Another important focus for struggle is against the stifling influence of the pharmaceutical industry in psychiatric education and research. Collinson dismisses such concerns and argues that we should just get on with treating illnesses such as depression, which is said to be a global time bomb. Contrary to her assertion, we believe that this is exactly the sort of issue that requires a debate about knowledge, values, and power.

Should we be trying to frame all the sadness, misery, and demoralisation of different peoples around the world in the technicalised, individualised labels of the Diagnostic and Statistical Manual of Mental Disorders? Will this be an advantage to anyone other than the drug companies, anxious to find new markets for their products? Should we not seek to engage with human distress in ways that put values such as solidarity, mutual support, and human rights centre stage? To echo Bagley, could it be a case of: they ask for social justice and we offer Prozac?

If psychiatry is to have a positive future it will require those of us involved in the specialty to be open to a radical questioning of our own theories and practice. This is not antiscience. Surely a truly scientific attitude is one characterised by questioning and doubt, not by dogma and dismissiveness.

References

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