Postpsychiatry: Mental Health in a Postmodern World

by Patrick Bracken

How are we to make sense of madness and psychosis? For most of us the words conjure up images from television and newspapers of seemingly random, meaningless violence. It is something to be feared, something to be left to the experts. But is madness best thought of as a medical condition? Psychiatrists and the drug industry maintain that psychoses are brain disorders amenable to treatment with drugs, but is this actually so? There is no convincing evidence that the brain is disordered in psychosis, yet governments across the world are investing huge sums of money on mental health services that take for granted the idea that psychosis is an illness to be treated with medication. Although some people who use mental health services find medication helpful, many do not, and resist the idea that their experiences are symptoms of illnesses like schizophrenia. Consequently they are forced into having treatment against their wishes. So, how do we make sense of this situation? Postpsychiatry addresses these questions.It involves an attempt to rethink some of the fundamental assumptions of mental health work, showing how recent developments in philosophy and ethics can help us to clarify some of the dilemmas and conflicts around different understandings of madness. Throughout, the authors examine the conflicting ways in which politicians, academics, and mental health professionals appear to understand madness, and contrast this with voices and experiences that are usually excluded - those of the people who use mental health services. They then examine the power of psychiatry to shape how we understand ourselves and our emotions, before considering some of the basic limitations of psychiatry as science to make madness meaningful. In the final section of the book they draw on evidence from service users and survivors, the humanities and anthropology, to point out a new direction for mental health practice. This new direction emp

Genres: Psychology, Mental Health

312 pages, Paperback

First published February 1, 2006

Reviews

[Tomás Narvaja · Rating 2 out of 5]

Honestly, do yourself a favor a read Gut Feminism by Elizabeth Wilson instead. This book mainly points out the binary of biology/psycho-social with biology being prioritized currently in psychiatry and argues for simply flipping it. Wilson actually addresses the problem of the binary itself and the problem with taking either the approach currently being taken which prioritizes biology, or the approach Bracken and Thomas take in the book. She's significantly more nuanced and critical, and her work is more up to date.

[Matthew O'Sullivan · Rating 4 out of 5]

To call psychiatry pseudo-medicine and social control can easily get one labelled a crackpot, a Scientologist or thrown in a mental hospital but an institution with psychiatry's power (to arrest, force medicate, indoctrinate) deserves unremitting scrutiny and here we have some through the postmodern lens.

The text starts off by defining institutions as a symptom of the Enlightenment, in particular of August Comte's Positivism, which draws meaning from the scientific rather than religious or esoteric. The post-modern approach is not a rejection of reason, science and technology but a challenge to its socially ascribed supremacy.

Chapter 1 is an investigation into institutional (WHO, NHS) responses to madness, in particular the move from "beneficent paternalism" to new approaches under Blair's Labour government. Chapter 2 examines some of service users' experiences with psychiatry and highlights the need for ULR (User Led Research) and PAR (Participatory Action Research). Chapter 3 analyses critical responses to Psychiatry, including Mad Pride and the Hearing Voices Network, groups who embrace "madness as a fundamental feature of human life" asking us to move beyond the "blackmail of being for or against the enlightenment" and look to shift societal attitudes towards acceptance rather than control in what Foucault calls the "move towards the social exclusion of unreason". Chapter 4 contrasts the form of the illness, the professionals' diagnosis, with the actual content of their delusions, voices or visions. Bracken and Thomas get quite technical here, arguing for a move away from "methodological individualism"; the tendency to view psychiatric diagnosis in isolation. They see this as a result of the influence of Karl Jaspers' "General Psychopharmacology" on Psychiatry which dictates a "static phenomenology" which, in turn, amounts to a dismissal of the lesson in Descartes' cogito ergo sum. They argue though that Jaspers' thought is still Cartesian as he is a student of Husserl's, who, though centuries later, mirrors Descartes' cogito, still classifying mind/body as distinct, but with different phraseology; Descartes' calls body "res extensa" and mind "res cognitans" while Husserl refers to the thinking subject as a "monad with windows". Thus we have a tension between Jaspersian phenomenology and psychoanalytic hermeneutics. The authors, therefore, turn to Heidegger, who finds a sort of synthesis to dualism; being-in-the-world rather than merely being in the world, is a sort of creative act, being human is an active phenomenon and "we are the illumination that brings a world to light." They recommend the term "embodiment" as a way to move away from Cartesian dualism. Similarly, with time, Heidegger argues past, present and future are inextricable features of time, this is called a "hermeneutic phenomenology." In this way, Postpsychiatry reverses the static Jaspersian phenomenology, preferring a hermeneutics of distress, believing the "psychological world of suffering patients are structured through past experiences and future expectations." Chapter 5 begins by recognising that psychosis is necessarily mediated by language and analyses, arguing for a cognitivist approach which sees the content of psychotic experiences as, not meaningless, as Psychiatry does, but simply wrong. The authors begin with Chomsky's conception of language as deriving from a generative grammar, growing "like a seed in a pot... language is innate." From here they reference Chris Frith, insisting that the role and structure of language are crucial to an understanding of psychosis. Using driving as an analogy, they define language and subsequently speech and actions as either "stimulus driven" or "intentional." In this light, schizophrenia is therefore seen as a "disorder of self-awareness," a breakdown of the mind's self monitoring confuses "stimulus driven" thoughts with "intentional" resulting in delusions or voice-hearing. Wittgenstein's investigations into language are here mentioned, his development from the Tractatus Logico-Philosophicus to the Philosophical Investigations, of language as a picture, then as a tool. Reference is also made of his beetle thought experiment and the impossibility of knowing what's in another's box, of knowing another's thoughts, epistemologically. This is crucial to more recent analyses of language's role in meaning production like Button et al. who ask if meaning is located inside the speaker's head or in the external environment. Chapter 6 discusses the ethics of treatment; drug treatment, therapy and ECT. On therapy, the authors state that "therapy works... through the generation of hope, establishing relationships and by working on meanings. They reference Jerome Frank's essential elements to therapy; "a helping relationship with a thoughtful and concerned listener, a clearly defined space in which healing can take place and some form of ritual." Drug treatment on the other hand depends on the "social milieu" of the biological understanding of mental illness and the "therapeutic milieu" where doctors present drug treatment without other forms of help. It is claimed that "anti-depressants work however little if any of the improvement seen is due to specific chemical effects." Referring back to Heidegger, the authors do not completely dismiss the biological elements of mental illness rather saying we are "embodied" beings, thus "sadness, distress and despair have a biological dimension." To further this argument, the authors even proffer evidence that the biological effects of anti-depressants might be a result of placebo, drawing on research into stomach ulcers. The chapter moves on to a comparison between the severe treatment of King George III and the enlightened York retreat, (a stick vs carrot argument that has implications for contemporary psychiatry, recognising, as it does, a harshly Pavlovian aspect to certain treatments,) and similar to the York Retreat's approach, the post-revolution reforms in France's twin asylums the Salpêtrière and Bicêtre under Phillipe Pinel, termed "traitement morale." These are mentioned as examples of the history of the mental hospital where care is a moral issue rather than medicalised yet in Foucault's analysis, ever wary of institutions, they are "an instrument of moral uniformity and social denunciation," an example of Enlightenment values, but the authors admit that not everything Foucault said should be canonised. Chapter 7 is a move away from academic critique to raise questions about the, seemingly neutral, activity of writing in psychiatry and medicine, in particular, the case history which is "much more than an illness, it is also a way of constructing a person," in this way, "narratives are the means through which the institution exercises its power" and "although superficially they appear to be active participants in generating a written account of themselves, the real power lies with the clinician." The authors make the distinction between evidence-based medicine (EBM) and narrative-based medicine (NBM) stating EBM "statistical and mathematical processes in randomised trials and meta-analyses, strip away the particular and render the individual without identity and human uniqueness." Chapter 8 considers the role of narrative in recovery, first in doctors' accounts, then in service users'. More explanation of the way the placebo effect works, depending on shared cultural understandings about healing, powerful non-pharmacological factors at play that influence people when taking medication, "that crepuscular region between the all-revealing light of science and the dark, ambiguous realms of human experience," indeed the history of treatment for various ailments has been by witch-doctors healing as often through divination and exorcism as drugs and bandages. It is worth remembering the Hippocratic oath begins with invocation of the Gods Apollo, Asklepios and Hygeia. "Abandon hope all ye who enter" are the words above the entrance to hell in Dante's inferno but, the authors claim, should be on the NICE guidelines for schizophrenia but survivor narratives can give hope to other sufferers from what seems like a futile position. Chapter 9 looks at alternative services offered in two locations in the UK; Sharing Voices Bradford which helps Bradford's BME community, who are disproportionately represented in mental health services, to define their experiences outside of the confines of the medical setting and Hebdon Bridge's Evolving Minds group which emphasizes non-technological ways of understanding experience and subjective wisdom. Both groups "propose that we have a collective responsibility to engage with madness and distress... a range of understandable responses to conflict, abuse and trauma." These services promote what is called "citizenship" in mental health spaces. Active citizenship is a concept that begins with Ancient Greece but is here analysed in the language of Foucault, stating that "what we understand as citizenship, the right to be autonomous self-determining beings" is a function of governmentality, necessary so the "state can divest itself of the burden of control over the individual." The authors call for greater community understanding of mental health issues as a way to de-medicalise distress yet also calling on psychiatric services to take on greater responsibility like Home Secretary Jack Straw did in 1998 when he criticised the NHS redundancy in failing to deal with double-murderer Michael Stone who was diagnosed as having a "psychopathic disorder." (I can sympathise with perceived failings here, I don't want to get into a dystopian world of Psychiatry as Minority Report but I do think community outreach is important). The authors then move on discuss Mad Pride and its reclaiming of the word "mad" in much the same way gay and black groups have reclaimed supposed slurs. The authors claim "madness is a mirror to us all. It reflects back to us ourselves through art, poetry, literature, humour and political action, the madness of the world we have created." Chapter 10 takes a look at funding in the NHS, the timeline begins with the Labour government's promises of funding over and above inflation in 1997 which are evidently not sustainable. Onto a 2004 report by Derek Wanless which states "the NHS needs to shift its focus from a national sickness service which treats disease, to a national health service, which prevents it." Insight is given into Loren Mosher's work with the Soteria project, a suburban retreat for psychosis sufferers that favours no medical interventions and staff with personal skills over professional training; he finds these less restrictive methods have better outcomes than the control group while costing 44% less. Although medication was not totally rejected, they enacted a kind of non-therapy called "interpersonal phenomenology" which is "a non-intrusive, non-controlling but actively empathetic relationship without having to do anything explicitly therapeutic."

All of this is interspersed with illuminating imagined accounts of living with madness.

One criticism I have of the text is the way it uses the term "modernist" to describe the scientific tendencies of Enlightenment thought. To me, Modernism is Joyce, Picasso, Stein even Crowley, thinkers and artists who rejected the stringencies of scientism in place of radical, dynamic models of the future. It's a cultural period that really ends with WWII and the atomic bomb. But this is a distinction for academics, the authors' intentionality is clear.

A further academic concern is that postpsychiatry wants to be viewed as post-modern rather than a Leninist, van-guardist approach to the subject, following Foucault's thought which challenges power and institutions. After a great many dealings with psychiatry, I situate myself as more on the vanguardist side than the post-modern, wanting to be involved in the decision making about my mental health but also expecting there to be intelligent authorities to refer and defer to in the doctors.

Finally, as the authors note, if Postpsychiatry means anything it is an end to what Foucault calls the "monologue of reason about madness," hoping to replace it with new dialogues.