Tuesday, May 19, 2020

The Philadelphia Association: Meeting oneself in the other

I’ve previously (eg. see post) mentioned the Philadelphia Association (PA). Its first therapeutic community was the infamous Kingsley Hall (see another previous post). The PA still runs two community houses and provides a full psychotherapy course and other training. I did a review of Bruce Scott's book which presents the testimonies of 14 people who have lived in PA households. I’m very grateful to Miles Clapham for agreeing to do this guest post on the PA. 

“understanding meaning impinges on myself in the other...” Karl Jaspers1

At a Philadelphia Association open evening this May, a participant asked about the different theories favoured by different psychotherapy trainings: Kleinian, Freudian, Lacanian, and so on, wanting to know where the Philadelphia Association stood in relation to these ideas. A colleague replied with elegant simplicity that most psychoanalytic trainings ask you to see the client or patient through the lens of their favoured theory as the way to truly understand the position that person is caught in; in contrast at the Philadelphia Association we want to try and meet the person (of course seeing the person in front of you involves many complexities, and with or without theories we bring all sorts of expectations, prejudices, hopes and desires which may distort or influence the way any meeting may go). My response, not so elegant, was perception is part of the world, language is part of perception, and theories inform or regulate the language used and therefore our way of seeing or perceiving. What we want to do is to find, if there is such a thing, “wild perception”2, untutored perception, astonishment at the world and each other, to break out of captivation by our preformed ways of seeing. And somehow do psychotherapy with or within this way of being.

The Philadelphia Association was founded by R.D. Laing with others. Laing, who was an extraordinary person, wrote some extraordinary books, influenced many doctors to come into psychiatry, including myself, and influenced many to criticise psychiatry, including a number of psychiatrists. Arguably Laing was part of the large scale social critique that resulted in the eventual change in the law from the 1957 Mental Health Act to the 1983 Act, which gave many more rights to psychiatric patients than previously. The 2007 amendments to the Act took some of those rights away again, making it easier to justify detention for a ‘mental disorder’, a change that many psychiatrists opposed but was forced through regardless.

The Philadelphia Association started with the once famous/notorious ‘therapeutic community’ at Kingsley Hall in 1965, which has been much written about. A year or two later, led by Dr John Heaton, originally an ophthalmologist who became interested in perception and philosophy especially phenomenology, and trained as a psychoanalyst, the PA developed a psychotherapy training. The training was and is based in philosophy and psychoanalysis, particularly developing a phenomenological and existential critique of psychoanalytic approaches. The PA is now a locus for a critique of psychiatry and the many and various psychotherapies based in psychoanalysis and academic psychology, such as CBT. The ‘style’ of therapy offered is outside any simplistic divide between objectivity and subjectivity, inner world and outer world, mind and body, strongly opposing a scientistic world view in therapy that sees only the measurable as real.

The Philadelphia Association currently runs two houses in London for people struggling with life, and who may have been (this is not essential) through psychiatric services and therefore in some sense a survivor. These houses require people to self-refer, and then once invited by the residents, to attend at least one and sometimes more meetings with the house residents, along with the house therapists. One has to ‘find one’s way’ to the house, you cannot be referred by your community mental health or social care team, although that said social workers or community mental health teams may be involved in some way to encourage a person to look into the houses. The houses have therapists who conduct group meetings for the residents three times a week, and residents also need to have individual psychotherapy, often at a ‘low cost’ rate. This is mostly paid for through benefits, sometimes disability allowance. Residents may have paid employment, not organised through the house, and pay rent themselves. The houses are therefore not a drain on NHS or social care resources, and are amazingly cheap compared with more formal residential care ‘placements’ or inpatient care.

The house therapists do not participate in the Care Programme Approach (CPA), although some residents remain involved with their community mental health team. Some residents are on medication. When the PA was founded in 1965, there was an idea that residents would not have any psychiatric medication. There is still a debate about this, and certainly it is an option if someone is on medication that they can come off it while living in the house. If the person wanted medical oversight for this reduction or cessation of medication, this would need to be by a doctor outside the PA. Alternatively, the individual can take responsibility her or himself for this.

The houses are not set up to manage serious crises, although back in the day some people came in quite acute psychotic states and lots of those involved in the PA and the psychotherapy training would spend time, sometimes many hours, in the house with the person in crisis, to try and see them through without psychiatric intervention. It is fair to say this did not always work, although for others this was enough to allow them to manage their own journey. One example, the person concerned has written about this, was a young man who spent two years in his room, almost never coming out, at one point almost starving himself to death. There was huge concern in those around him about leaving him. Most psychiatric doctors, nurses and others would think this terrible neglect. Nevertheless, and while the PA would eschew measuring success as a return to social conformity, this young man did subsequently go to University and complete a higher degree.

The houses are therapeutic communities, in perhaps a minimalistic sense. There is no daily programme of activities, no occupational therapy, no particular routine other than the house meetings. The houses provide a safe living space, a community of others who have their own often difficult life journey, and there is no pressure to stay a quick few weeks or even few months and then leave and move on. The houses are a limited resource, as people may sometimes stay for 2-3 years, and movement from the house would be considered slow by other services. That said the houses tend to have vacancies. It is not always easy to find people who want to live in these interesting and quite difficult places. Because of the unstructured ‘referral’ process, and the PA houses being unorthodox and relatively unknown, there is not always a steady stream of applicants to live in them.

Some research has been done on outcomes, but the PA has not been good at organising research, nor has it wanted to particularly. The PA’s philosophical position is to eschew ascientific, objectifying approach, although there are good examples elsewhere of phenomenological research into other approaches to ‘mental illness’, in Europe and in Australia. The PA does not claim to be treating people’s ‘mental illnesses’, nor does it claim anything special, rather emphasising ordinary living. People may choose to come to the houses, live there for a while, and perhaps find a different direction for themselves in their life. Nothing is promised, nor could it be.

The same is true of the psychotherapy the PA tries to show a way towards. Therapy in our privileged society (for many but certainly not for all, and maybe for a lot less now) is often seen as a treatment for ‘mental illness’. With mental illness destigmatised especially for young people, many embrace a diagnosis - bipolar disorder is popular - as some sort of indication of self-awareness. We now expect solutions to life problems, happiness is a commodity we must have, CBT or mindfulness supposedly reshape our minds or thoughts so we are no longer anxious, depressed or in despair. There is perhaps a sense in our society, although this is not unique, that it is your social duty to get ‘sorted’ so you are not a burden – read cost – to others, and you can take your place in a commodity and consumer driven neo-liberal capitalist society, without worrying too much about the climate emergency or even Covid-19. Medication is a huge part of this as we know, many people expect targeted drugs, perhaps tailored to genetic or immunological differences, to rapidly rebalance their neurotransmitters and endorphins.

The PA takes a sceptical view towards theory and practice in psychotherapy. One of the main thinkers behind this scepticism was John Heaton. Heaton was for a long time, from an early member in 1965, until his death in 2017, one of the main intellectual figures in the PA. He was also one of the founders of the Guild of Psychotherapists, with Ben Churchill and Peter Lomas, who also took a critical view of psychoanalytic theory and practice. Laing, although radically criticising the psychiatry of his early years when heavy use of ECT and lobotomy were common, and patients often spent years incarcerated in psychiatric ‘bins’, was not so clear in his critique. Laing brought together the philosophy of Sartre and the existentialists, with psychoanalytic ideas, notably from Winnicott and the “Middle Group” at the Institute of Psychoanalysis. Heaton in contrast took psychoanalysis to task for reification and objectification of ideas such as the unconscious, projection, transference, but vitally our more general ideas about the ‘mind’, the nature of thinking or feeling, and what might count as psychotherapy and training in psychotherapy.

Heaton was a member of the British Phenomenology Society, and a regular attender and contributor to the annual Wittgenstein conference in Austria. He published several books including Wittgenstein and psychotherapy: From paradox to wonder and The talking cure, which explicate his thinking in relation to how we conceptualise and practice psychotherapy, very much influenced by the ‘therapeutic’ move in understanding Wittgenstein’s philosophy. Heaton comes to see therapy not as a rule based activity (not that anything goes) but a relationship in which someone is helped to make sense of her life in new ways perhaps freeing herself from a weight of fixed ideas and ways of perceiving things. Psychotherapy is not a technical process, but an exploration, and language, however at times difficult to find, is ordinary.

Importantly, especially in finding other ways of thinking about symptoms or the ‘unconscious’, Heaton emphasised, following Wittgenstein, that while psychoanalysts as well as neuroscientists might insist that ‘experience’ is private and mediated in the brain, many questions can be asked here. When it comes to making sense of ‘experience’ we depend on language which cannot sensibly be private, or just ‘in my head’. Wittgenstein, well before developments such as systemic family therapy or attachment theory, suggests that we learn to speak of our pain as children surrounded by adults who give us the words to use. Words at first are part of the expression of pain, and not a description, and replace crying or screaming, unless we are in extremis.

This distinction between language as expression, and language as description is missed in psychiatry, leading to deep confusion about the nature of so called ‘mental states’. Psychiatrists tend to assume there is some mental object, a mood, an hallucination, that must be accurately described, although mainly for diagnostic purposes. Currently in psychiatry, there is little attempt to understand what drives the torments, whether thoughts, voices, moods, although psychoanalysis, as well as Jaspers, traditionally has wanted and attempted to do just this. Psychiatry still distinguishes between the form and content of psychiatric symptoms for nosological purposes and orthodox psychiatrists are often very suspicious of the search for meaning in the terrifying experiences of those they are confronted by.

While Jaspers and Freud both set a limit on trying to understand psychosis, a phenomenological approach is exploratory but not dogmatic about what might be found. Interestingly, Roger Boyes, a Times journalist who experienced hallucinations after coming out of intensive care for Covid-19 (see article), apparently a common experience, talked of these as ‘his brain’ trying to make sense of what happens when you are so ill and in an induced coma for some time. Working with young people I have seen, sometimes at least, hallucinations disappear, not when made sense of directly, but when the young person makes sense of their often traumatic or abusive experiences in other ways. Hallucinations may be experienced when things don’t make sense; when language in some way reaches into someone’s experience, the hallucinations might fade away.  

We can ask therefore, what could psychiatry be like if it was recognised that there was no such thing as a ‘mental state’, certainly not the reified object it is taken to be, and that what patients need is to be able to express themselves, in whatever way comes to them? Art and music are vital ways of expression, whether or not they are part of a therapeutic method. Recognising this is important as children who were abused are often not given words by concerned adults to express their pain. The abusing adult more often insists on secrecy and silence. Hence the inchoate nature of someone’s pain that may end up being expressed through illness, of whatever kind. We now know that trauma is non-specific in its effects and can be part of ‘mental illnesses’, ‘physical illnesses’, the rather horribly named ‘medically unexplained symptoms', as well as for some a push to do extraordinary things. Finding expression through speech or in any other way is not necessarily a cure, there is no cure, but may allow some form of liberation.

Wittgenstein said the philosopher seeks to find the liberating word. Liberation itself is a word that leads to many domains, not least questions of race, gender and class. This is the subject for another blog, but having recently, in spite of ‘knowing’ about it before, woken up to the hidden ways racism works even when the protagonists are not overtly or deliberately racist, it needs acknowledgement. It is common knowledge that poverty is linked with poor health outcomes in all domains, it is also common knowledge that BAME people have more mental illness than white people and are imprisoned and hospitalised using the MHA more. That BAME people die more from Covid-19 is also linked. How do we talk about this knowing how painful it is, how difficult it is for BAME people to be constantly the whistleblower (whistleblowers are still more likely to be discriminated against, sacked from their jobs, and further persecuted in some way), how difficult for white people to acknowledge that even without intention our actions, social structures, regulations, stop and search or policing of social distancing can be racist?

Intersectionality3 is a broader way of thinking about people’s position than existentialism, which claims universality from a European context, showing that non-European value systems are equally valid, and making explicit how race, gender, class and sexuality interrelate in the subjectivity and position of people of colour. However the idea of situation in existentialism still has a lot to offer to psychiatry and psychotherapy in thinking about meaning, value and position. Sonia Kruks in Situation and human existence  discusses the social aspects of situation, mutuality and freedom. Alfred Kraus’ idea of a phenomenological-anthropological approach in psychiatry covering all aspects of the personal, social, cultural, meaning world of the subject derives in part from this idea of situation.4 We are not determined by our situation, freedom is fundamental, situation is however our starting point. Situation, and the meanings attached, move between or beyond notions of the inner world and particularly horrible, ‘external reality’. External to what? Another question is whether we can ‘transcend’ our situation by our own efforts, or do we require a revolution, a social movement, politics? Can psychotherapy address all of this? Whether we have the potential for change in relation to the areas considered by intersectionality, whether racism, sexism, ableism, class, not to mention the climate emergency, is at the heart of our current dilemmas.

The PA tries – what does this mean exactly? – to put all this in question: theory, position, situation, subjectivity, power structures. But there is a limit. And we are bodies, as Merleau-Ponty lets us know, and merely human. If we ‘meet’ in some sense, see each other, experience through our limited speech something of the terror we face, the hurt, the loss, our ‘thrownness’ into this world, our despair, our futility, our ravenous desires and destructiveness, our rage at the world and at death … is all this universal, cross cultural, beyond intersectionality? Doubtless not, but there is the necessity that we meet, and find ourselves not in isolation but in the face of, in the presence of the other.

1 Karl Jaspers quoted in Thomas Fuchs, Brain mythologies; Fuchs, Breyer and Mundt (eds) Karl Jaspers’ philosophy and psychopathology, Springer, 2014.
2 Maurice Merleau-Ponty, The Visible and the Invisible, Chapter 4 The Intertwining, the Chiasm. Northwestern University Press, 1968.
3 Patricia Hill Collins Intersectionality as critical social theory. Duke University Press, 2019
4 Alfred Kraus. How can the phenomenological-anthropological approach contribute to diagnosis and classification in psychiatry. Chapter 13 in Nature and narrative, eds Fulford, Morris, Sadler and Stangellini. OUP 2003

Miles Clapham is a phenomenological psychotherapist at private practice in psychotherapy and psychoanalysis, having retired as an NHS consultant child and adolescent psychiatrist. He trained with the Philadelphia Association in psychoanalytic psychotherapy and is a member of its training committee.

Sunday, May 17, 2020

Antidepressants and suicidality

Plöderl et al (2020) have produced the most definitive commentary yet on whether antidepressants are associated with increased suicide risk. Interestingly a twitter conversation (so twitter can be useful after all!) helped to produce this consensus statement. Further analysis of the data would apparently be possible if the FDA made a large dataset publicly available (I’m not sure why it isn’t).

Plöderl et al’s cautious conclusion is that “the analyses consistently hint at an elevated risk for suicide attempts and, less reliably, also for suicides in cohorts of adults”. They suggest this is “remarkable for drugs that are used to treat depressive symptoms”.

I agree that whether antidepressants are associated with increased suicidal risk is an important issue. However, I am perhaps not as surprised if this is the case, as Plöderl et al seem to be.

Doctors do need to be cautious about prescribing antidepressants. It can be an identity-altering experience (see previous post). People react to taking antidepressants in a multitude of ways. For example, some people may feel that a doctor is not taking them seriously by trying to palm them off with antidepressants and this may trigger a suicide attempt. Okay, they may well have been at high risk of suicide anyway, but how the doctor reacts to their presentation may well matter. We may all wish for a simple, quick, cheap, painless and complete cure if we’re feeling desperate, but reality may actually be more complex.

So, I think we do need to be clear, if there is an increased suicidal risk with antidepressants (and the evidence seems to confirm that there is, perhaps particularly in the first few weeks after initiating treatment with antidepressants), that this is probably related to the act of prescribing for people who are feeling desperate. As far as I’m aware, there is no evidence that there is any direct effect of antidepressants on the brain, for example, that increases suicidality.

Thursday, May 07, 2020

Looking back at the birth of postpsychiatry

I'm very grateful to Brad Lewis for this guest post, following that from Pat Bracken and Phil Thomas, also on postpsychiatry (see previous post).

I appreciate Duncan’s request to consider how postpsychiatry has evolved in my mind since the writing of Moving beyond Prozac, DSM, and the new psychiatry: The birth of postpsychiatry (2006). The book, which came out the same year as Pat Bracken and Philip Thomas’s Postpsychiatry: Mental health in a postmodern world, was the product of my layering an interdisciplinary PhD in arts, humanities, and cultural studies in with my previous training in medicine and psychiatry. At the time, I was director of a psychiatric day program at George Washington University. The book was designed to cross-think the many paradoxes I saw in the simultaneous emergence of biopsychiatry on the medical side of campus and contemporary theory on the arts and humanities side of campus.

The 'theory' at issue was widely called 'postmodern theory' and it produced lots of excitement in the academy (which helps explain why my book and Bracken and Thomas’s book came out at the same moment). That said, however, the term 'postmodern' was already becoming hard to think with since it signaled both a hopeful move beyond problematic aspects of modern thought and at the same time a pessimistic concern over the rise of a neo-liberal/neo-colonial global order. I was attracted to the more hopeful side and I tried to make it serviceable for re-thinking psychiatry — especially since psychiatry is such a quintessentially modernist discourse and practice.

Zigmunt Bauman coined my favorite version of the hopeful side, which to me is still worth quoting today:
Postmodernity is modernity coming of age: modernity looking at itself at a distance rather than from the inside, making a full inventory of its gains and its losses, psychoanalyzing itself, discovering the intentions it never before spelled out, finding them mutually canceling and incongruous. Postmodernity is modernity coming to terms with its own impossibility; a self-monitoring modernity, one that consciously discards what it was unconsciously doing. 
Bauman’s both/and understanding of modernity fits also with my understanding and use of Foucault’s oeuvre over the years. Unlike Scull, at least as Duncan describes his thinking (see previous post), I do not see Foucault as for or against the Enlightenment. Such broad brush, ‘metanarrative’, judgements do not do justice to the complexity and contradiction contained within particular discursive communities. When you combine Foucault’s early work on madness with his later work on discursive practice, power dynamics, and cares of the self, what you get, as I read it, is much more of a process critique than a content critique. The critical edge of concern is about who gets included in knowledge making, who is excluded, why and how are these inclusions/exclusions made, who benefits from making knowledge one way verses another way, who is hurt, who cries out in pain and protest, and how much openness is there to diversity and multiplicity of knowledge practices, world views, ways of life, and various aesthetics of existence?

Longtime mad pride activist, Judi Chamberlin, beautifully captured the relevance for psychiatry of this kind of thinking when she protested the deeply problematic ways that George W. Bush was trying to reform the U.S. mental health system using primarily insider/expert perspectives. Judi Chamberlin, announcing that she was a “psychiatric survivor” and “an advocate” on consumer/survivor issues for more than thirty years”, pointed out:
A basic premise of the disability rights movement is simply this: Nothing About Us Without Us. The makeup of the Commission violates this basic principle. Just as women would not accept the legitimacy of a commission of “expert” men to define women’s needs, or ethnic and racial minorities would not accept a panel of “expert” white people to define their needs, we similarly see the Commission as basically irrelevant to our struggle to define our own needs. 
Chamberlin argued that Bush’s reform process lacked the “expertise on the consumer/survivor experience” as well as the “expertise of disability rights activists, those knowledgeable about the legal and civil rights of people diagnosed with mental illness, and experts in community integration”. As I see it, this work of inclusion and diversity around mental health and mental difference continues to this day.

My own efforts since the postpsychiatry book involve work in two separate dimensions: the personal and the political. At personal level, I’ve tried to help articulate a narrative approach to clinical care which respects and facilitates people’s efforts to story their mental difference in a diversity of ways. Much of that work was developed in Narrative psychiatry: How stories can shape clinical practice. At the cultural/political level, I’ve worked to help augment mad pride activists voices and to help imagine alternatives to mental difference beyond the usual pathologizing clinical options. Pathologizing options focus on what is bad or broken that needs to be fixed. Celebratory options emphasize what is good about mental difference rather than what is bad or broken about the difference. These celebratory approaches see the increased sensitivity and yearning at the heart of much difference as a good thing rather than a bad thing — or at least as having something quite good mixed in with the bad and/or difficult. How can sensitivity and yearning be good? Because we want our political, spiritual and aesthetic leaders to be sensitive to the possibility that we could do better and, rather than simply take their medicine or see their shrink to dampen their sensitivity and yearning, we want to hear their perspectives and the possibilities these could be feedback to creating a better world. For samples of this kind of thinking, one might look at an article I wrote ‘A deep ethics for mental difference and disability: The ‘case’ of van Gogh’, and one I participated in ‘Mad resistance/mad alternatives: Democratizing mental health care’.

To me this ongoing work is still in the basic realm of postpsychiatry as it was initially outlined in both my book and in Bracken and Thomas’ version. The demand on thinking for people in psychiatry concerned with mental health and mental difference continues to be helping modern clinical care accomplish the on-going task that Bauman articulates for modernity writ large. Whether we call it “postpsychiatry” or not is less relevant.  

Bradley Lewis is associate professor at New York University's Gallantin School of Individualized Study. He is the author of Moving beyond Prozac, DSM, and the new psychiatry (2006), Narrative psychiatry: How stories can shape clinical encounters (2011) and Depression: Integrating science, humanities, and culture (2011). See his list of papers and books.

Wednesday, May 06, 2020

Enactive psychiatry makes the biopsychosocial model explicit

I said in a previous post that I was not convinced that Sanneke de Haan was correct that Engel’s biopsychosocial (BPS) model does not do justice to subjective experience. In her book, Enactive psychiatry, she does accept that “the way in which patients evaluatively relate to their disorder and their situation in general is implicit in the psychological aspect [of the BPS model]”.

She also notes that Engel “draws on general system theory (GST) as developed by von Bertalanffy“, although as I pointed out in in my article, what Engel actually said was that GST “provided a suitable conceptual basis” for his BPS model. As I wrote,
[A]n integrated biopsychosocial approach is not specifically dependent on systems theory, as evidenced by the psychobiology of Adolf Meyer. In Meyer’s understanding of science, there is a hierarchical relation of the disciplines with the lower or simpler categories being pertinent to, but not explanatory for, higher or more complex categories. This is comparable to systems theory, but Meyer made no attempt to create an overarching theory as in general systems theory. Von Bertalanffy ...  himself recognized that there had been many systems-theoretical developments in psychiatry that could be traced to Meyer and others, similar but separate from general systems theory itself.

Sanneke de Haan also says that the BPS model is "vague when it comes to explicating the precise nature of the interactions” between the separate aspects of biological, psychological and social. Again, I’m not sure if this is a specific fault of Engel’s model as such, although as I’ve said multiple times previously (eg. see previous post), the BPS model is now commonly wrongly interpreted in an eclectic way in modern psychiatry. I do accept, therefore, that a more explicit integrative model would be beneficial to help us to move on from the current eclecticism.

The enactive model may well be such an approach. There may even be overlap with what David Pilgrim has been doing applying critical realism to psychology and psychiatry (see previous post and recent book). An advantage of enactivism is its specific focus on the biological, viewing the brain as an organ of a living being in its environment. As Thomas Fuchs said (see last post), "An ecological neurobiology is ... obliged to draw on the integrated approaches of dynamic systems theory, psychology, cultural studies, and philosophy."

To quote from Sanneke de Haan, "we cannot understand cognition in isolation from the bodily being that is doing the cognising, nor from the environment that it is directed at". And again, "Instead of presupposing a gap between mind and world, enactivists argue that organism and world are dynamically coupled". Actually, I think both Meyer (see another previous post) and Engel had this "biological" emphasis, but restating it specifically, I think, does create a valuable new focus for critical psychiatry.

Tuesday, May 05, 2020

Ecology of the brain

It's a while since I've strung together tweets of quotes or amended quotes I've made from a book to summarise it (see eg. previous post). I do think Ecology of the brain (2017) by Thomas Fuchs is an important book, so here goes:-

A good place to start is:-
The brain can only be adequately understood as an organ of a living being in its environment. April 23, 2020
There are limits to trying to understand human action in terms of the brain:-
The brain cannot read or write, it cannot dance or play the piano, and so on. Thus, I am rather glad not to be my brain, but to only have it. April 23, 2020
That doesn't mean that neurobiology is not important; nor that the explanation of human action is merely in terms of the psychosocial.
Neurobiology and all other sciences emerge as a specialist form of human practice originating in the lifeworld, yet without ever gaining a position outside of it. The familiar world of everyday experience in which we coexist with others remains our primary and actual reality. April 17, 2020
A personalistic perception of the human being does not mean a rejection or devaluation of the naturalistic attitude as such. May 5, 2020
The reason that we need a personalistic perception is that:-
In a world without subjective experience there are no longer signs, nor symbols or information, representations or meta-representations, meaning or sense. April 23, 2020
Reflecting, feeling, wanting, and deciding—none of these can be found at the physiological level of description because these concepts do not exist there at all. April 23, 2020
What could be explained about people if one only described monotonous, electrochemical processes on their neuronal membranes? April 23, 2020  
Neuronal processes are vehicles of meaning making and merely part of over-arching life processes that include the organism as a whole and its environment. The definition of mental disorder depends on subjective and cultural factors that fall outside the domain of natural science. May 5, 2020
Seen in isolation, the brain is merely a fragment; however, in the context of the organism and its environment it can become a mediator for relational and intentional processes. May 5, 2020
The brain is embedded in relational phenomena, yet it can only mediate them and not produce their meaning. May 5, 2020
The brain is a socially and historically shaped organ, whose functions of transformation and pattern formation enable biographical experiences to be turned into permanent dispositions and capacities. May 5, 2020
We need to have both naturalistic and personalistic attitudes:-
It is erroneous to identify brain with human subject and to look inside for what makes up the person. Human persons have brains, but they are not brains. We have no other choice but to refer to ourselves as animate, embodied beings in 2 kinds of speech of lived and physical body. May 5, 2020
The dual aspect of the human person corresponds to two basically different attitudes: namely, those we can adopt towards ourselves, and those in relation to others. We described these as personalistic or naturalistic attitudes. May 5, 2020
As I've said before (eg. see previous post) referring to Kant, the mind-brain problem is an enigma that can never be solved.
A person’s "eccentric positionality" (from Plessner) ie. the ability to adopt a reflective position in relation to himself as well as his bodily existence, means a person can never get behind his perceiving body. His self-relationship remains irreducibly ambiguous. May 5, 2020
People not only live, but they lead their life, and in this way they also form themselves. The brain is involved in these circular structures as an organ of mediation and relationships and as an organ of the human person. May 5, 2020
There needs to be new approach to mental health research, as suggested by Wellcome (see previous post).
Attempt at “localization of the mind” through research into brain activities represents no future-oriented research program. An ecological neurobiology is rather obliged to draw on the integrated approaches of dynamic systems theory, psychology, cultural studies, and philosophy. May 5, 2020
The final sentence in the book is:-
We are not the figments of our brains, but human persons in the flesh. May 5, 2020

Monday, May 04, 2020

Psychosomatic symptoms as particularising of physical dysfunction

As Thomas Fuchs in his Ecology of the brain emphasises how the entire organism is a “resonance body” for experience. For example, feeling ashamed and afraid are “integral acts of life that equally involve intentional, emotional and bodily components”. Shame or fear emerge from an experience of the current situation provoking an autonomous organismic reaction.

If the physiological aspects of these reactions become withdrawn from their former integration in superordinate emotions, they can take on an independent existence as particularised physical dysfunctions. They may have originally had an expressive or activating function for coping with certain situations, but if removed from superordinate control and regulatory feedback, they can present as psychosomatic symptoms.

Thursday, April 30, 2020

Right to a second opinion for detained psychiatric patients

The Queen’s speech last December 2019 said work will continue to modernise and reform the Mental Health Act (MHA). This includes giving detained patients “better support to challenge detention” and a much greater say in their care.

I have been critical of the MHA independent review (eg. see previous post) for insufficiently promoting patients‘ rights under the Mental Health Act. We need to get back to the reforming spirit of the 1983 Act, which was lost with the 2007 amendments.

One reform introduced by the 1983 Act was the need for a Second Opinion Approved Doctor (SOAD) to review certain treatment decisions. In practice, SOADs now tend to “rubber stamp” the treatment plans of the Responsible Clinician, although I think when the Mental Health Act Commission (MHAC) first started this was not necessarily the case. The function of MHAC has now been taken over by the Care Quality Commission (CQC), which I think unfortunately means that a specific emphasis on the rights of detained patients has been lost, as CQC has the more general role of regulating health and social care.

Another problem is that SOADs are appointed by the CQC, so that the patient has no choice over which doctor provides the second opinion. Furthermore, it is uncommon for solicitors to obtain an independent medical report before a hearing to consider appeal against detention.

There is therefore much scope for increasing the independence of clinical opinion in the processes of detention appeal and enforced treatment. A patient ought to be able to have a second clinical opinion both about detention, and this can be given as evidence to the Mental Health Tribunal (MHT) and hospital managers, and about treatment, which should, as far as possible include any enforced treatment right from the start of detention. The Tribunal could be extended to make judgements about treatment as well as detention, but if not, or maybe if accepted by the patient, a decision can be made by the SOAD to approve any enforced treatment based not only on the evidence from the Responsible Clinician but also from the independent clinician. I think these improved safeguards at least need consideration by the government in its MHA reforms.

Monday, April 27, 2020

Reflections on postpsychiatry

I've mentioned Pat Bracken and Phil Thomas's work on postpsychiatry previously (see eg. previous post). I'm very pleased they've agreed to do this guest blog.

We would like to thank Duncan for the invitation to write a guest blog.

Our use of the term postpsychiatry began when we started to collaborate together in the 1990s. We were both working in Bradford and trying to change the way we encountered people with mental health conditions, how we understood their struggles and how we worked with them.

Employed as consultant psychiatrists, we were very conscious of working in a service that was very much ‘psychiatry-led’. We had come to realise how limited psychiatry was and how damaging its interventions could be; whether through the side-effects of drugs, demoralising diagnostic labels or theories that were sometimes little more than pseudoscience. We were sympathetic to the views of Thomas Szasz but were uncomfortable with, what we saw as, the binary nature of his thinking. We were also unconvinced by his characterisation of medicine as something that only had a legitimate role to play in relation to diseases that could be verified in the pathology lab, and were wary of his antipathy to any sort of collectivist politics.

After our training in medicine and our experience of work with different communities in different contexts, it was impossible for us not to see the ‘embodied’ and ‘encultured’ nature of all human suffering. It was clear to us that mind and flesh do not inhabit different worlds but exist as one. All experience of illness (whether we call it physical or mental) is complex. Thinking, feeling, relating to others are done by the same creature who sleeps, eats, has endocrine problems and gets old. And the same creature lives its life in the midst of language, culture and economy. We were interested in linguistics, anthropology and philosophy and had come to believe that states of madness, distress and dislocation were profoundly messy, and that no singular narrative, whether from psychiatry or anti-psychiatry, could account for it all.

This is what drew us to the work of Foucault, Bauman and others who might be characterised as ‘postmodern’. For us they offered a form of scholarship that did not see the messiness, contradictions and uncertainties of human reality as irritations that could be eliminated by more science, better science or more analysis and conceptual clarification. For us, postmodern thought was about facing and accepting the reality that there might not be solutions for all our problems, there might never be resolutions to all our ethical contradictions nor answers to all the questions we asked of the world. The word ‘postpsychiatry’ was used to signal our quest to imagine what a non-modernist medicine of the mind might look like. We wanted to think ‘beyond’ and ‘after’ psychiatry.

Crucially, we wanted a form of mental health medicine that worked towards the possibility of meaningful dialogue with the emerging ‘service-user’ movement. We saw that our job as critical psychiatrists was the creation of the conditions wherein genuine dialogue with this movement could take place. The main question for postpsychiatry was: how can we bring biological and medical insights to bear on mental suffering in a way that does not silence, distort and colonise the understandings that emerge from service users themselves both individually and collectively?

Of course there was no singular answer to this. In our work we looked for insights from post-colonial scholarship, feminist philosophy, queer theory, mad studies and critical pedagogy. Gayatri Spivak argues that educators and scholars who are genuinely trying to get beyond the legacy of colonial forms of knowledge must be engaged in ‘the unlearning of one’s own privilege. So that, not only does one become able to listen to that other constituency, but one learns to speak in such a way that one will be taken seriously by that other constituency’ (Spivak, 1990, p. 42). Postpsychiatry represented our attempt to unlearn, and to find a way of listening and speaking differently.

Pat Bracken & Phil Thomas are retired consultant psychiatrists. They were psychiatrists together in Bradford and professors of Philosophy, Diversity and Mental Health in the University of Central Lancashire. They co-authored Postpsychiatry: Mental health in a postmodern world (2005). They brought the group together that became the Critical Psychiatry Network.

Friday, April 24, 2020

Users and abusers of psychiatry

I said in a previous post that clinical psychologists may be more easily able to take an anti-reductionist position in mental health work than psychiatrists (see previous post). Critical clinical psychologists include Lucy Johnstone, Richard Bentall, Mary Boyle and Peter Kinderman amongst others. I see their work as part of the critical psychiatry movement. As I have said before (see another previous post), there are differences within the movement, and although mental health disciplinary training in itself does not necessarily create these differences, it can be a factor.

I just wanted to look at the work of Lucy Johnstone as an example. Her first book Users and abusers of psychiatry was first published in 1989. I wrote a review for the second edition and called it an "inspiring" book. The general lack of a whole person perspective can actually take responsibility away from people, so that they are encouraged to "rely on an external solution which is rarely forthcoming". The mental health system then can continue to blame them for their continuing difficulties and powerlessness. The personal meaning of people's distressing experiences and the psychological and social origins of their difficulties can be lost in psychiatric diagnosis, leaving them stuck in psychiatric treatment without alternatives.

Despite any differences I may have with Lucy about excesses and emphases, I totally agree with this critique of the psychiatric system. Clinical psychologists have tended to adopt the role of psychotherapists within mental health teams, but psychiatric practice is wider than this and includes detaining people if necessary under the Mental Health Act. As I keep saying throughout this blog, psychiatry needs to accept the limits of a mechanistic approach to mental illness and life in general.

I also did a review of Lucy's book, A straight talking introduction to psychiatric diagnosis. She makes an excellent case that psychiatric diagnosis is invalid, unscientific and not fit for purpose. Psychological formulation is necessary to understand people's problems (see previous post). Too often psychiatric diagnosis and the biomedical model effectively prevent practitioners from "seeing what is in front of their very eyes" (see eg. previous post).  I have argued that Lucy's argument about abandoning psychiatric diagnosis is at least potentially misleading (see eg. previous post). Nonetheless, psychiatry does need to move on from the facade it creates about biomedical diagnosis producing personal understanding.

More recently, Lucy has concentrated on the Power, Threat, Meaning framework, which she has created with Mary Boyle and others (see eg. previous post), and incorporated this in the 'drop the disorder' approach (see another previous post). I totally agree with Lucy that functional mental illness should not imply physical lesions in the brain (although this does not mean ignoring organic psychosis - see previous post). But I worry that the insistence on avoiding pathologising, again, can be misleading.

Nonetheless, I am keen to encourage further debate about whether psychiatry should become non-medical. Maybe my reservations about Lucy's expressions of the critical psychiatry position are because I am a psychiatrist rather than a clinical psychologist.

Thursday, April 23, 2020

Delusion as loss of intersubjective reality

Thomas Fuchs (who I have mentioned in a previous post) has an interesting PPP article on delusions. Delusions are failures of communication characterised by a disturbance of transcendental intersubjectivity. People do not "passively receive information from their environment which they then translate into internal representations. Rather, ... they constitute their experienced world or Umwelt through their ongoing sensorimotor interaction and embodied coping with the environment". Reality is constituted through active shifting of moving and multiple points of view reinforced by social perspective-taking.

Psychosis involves a radical subjectivisation of the processing of information so that understanding loses its intentional and decentering structure and the person adopts a solipsistic self-centrality. Basic trust in the shared world has been lost. A new sense-making is established fundamentally decoupled from the shared world (see previous post). "The possibility of intersubjective understanding is ... sacrificed for the new coherence of the delusion".

Monday, April 20, 2020

Overcoming the fairy circle of antiphlogisticism with traitement moral

Anti-phlogistic physicians saw disease as fundamentally a problem of inflammation and fever. The 'original' principle of phlogiston was posited by Georg Stahl (Taylor, 2006). Substances were flammable because they contained phlogiston, believed to be an elemental fatty earth. William Cullen was at the forefront of chemistry as well as medicine (see eg. previous post). For Cullen, phlogiston was not a metaphysical ‘principle’ of inflammability, but firmly in the world of ordinary matter.

As Searle (1835) said, in his Lancet article (Volume 23, Issue 594, 587-90), antiphlogistic treatment was "considered to be corrective of a phlogistic condition". As he goes on, antiphlogistic treatment by some was "not confined to inflammatory complaints, but ... [was] adopted in almost all other cases, with the view of preventing inflammation and fever" [emphasis in original]. Purgatives and emetics seemed to demonstrate the truth of Stoll's theory that most illnesses resulted from gastric impurities, especially bile. Bleeding, purging and making use of emetics, were all designed to counteract and to deplete the over-active, over-heated body.

From Phillippe Pinel's point of view in A treatise on insanity,
physicians have ... allowed themselves to be confined within the fairy circle of antiphlogisticsm, and by that means to be diverted from the more important management of the mind (p.4)
Pinel's approach which was called traitement moral (translated as moral treatment) gave preference to "ways of gentleness" and minimised the use of restraint. Essentially it involved the use of contrived situations, artifice and pious fraud. A variety of strategies were used to control difficult patients, including stern warnings, the manipulative use of food and privileges, and physical restraints, as well as various theatrical gestures designed to shock patients out of their morbid ways of thinking.

There are ethical questions about such techniques, but they at least focused on emotional factors, and such moral treatment can be seen as arising out of Pinel's conceptual understanding of mental disorders as "lesions of the function of understanding". As far as he was concerned, insanity has a "moral" cause rooted in ideas and the passions.  This did not mean the body was not implicated, as he took an integrated mind/body understanding, in that le moral and le physique were seen as interrelated. Standing out against many other anatomists, he was aware from his own dissections that insanity does not have a discernible brain lesion.

‘Anti-psychiatric’ voices that have haunted psychiatry

Sarah Kamens’ excellent article on post-colonialism and (anti)psychiatry shows how a discursive hierarchy in psychiatry subjugates certain communicative modalities while elevating others. As she says, we need to “gain a better understanding of those ‘antipsychiatric’ voices that have haunted psychiatry for all of these years”.

As I said in my previous post, anti-psychiatry is more to do with mainstream psychiatry wanting to dismiss criticism of the biomedical model (which ranges from radical reductionism to eclecticism). David Cooper, who coined the term, became an embarrassing figure who was very much out on his own in his later books (see extract from my book chapter). However, the rotten reputation of anti-psychiatry lingers on.

Anti-psychiatry at least overlaps with mainstream psychiatry in its emphasis on human rights, the therapeutic community and community care. Kees Trimbos (1975), one of the founders of Dutch social psychiatry, warned against imagining that anti-psychiatry was just a fad: "after all, anti-psychiatry is also psychiatry!"  There may be more benefit from looking for the continuities, rather than discontinuities, of anti-psychiatry with orthodox psychiatry.

Thursday, April 16, 2020

Now treatment-resistant schizophrenia is said to have a different neurobiology from treatment-responsive schizophrenia

Potkin et al (2020) argue that the underlying neurobiology of treatment-resistant schizophrenia (for which they give the acronym TRS) may differ from treatment-responsive schizophrenia. As the article indicates, clozapine's licensed indication is for schizophrenia in patients unresponsive to, or intolerant of, conventional antipsychotic drugs. The review is intended to facilitate the development of new pharmacological treatments.

Dopamine, glutamate and serotonin neurotransmitters are said to be potentially involved (as they have been implicated for schizophrenia in general). Dopamine supersensitivity has been suggested as the mechanism for tardive dyskinesia, and by extension it has been suggested that neuroleptics may cause a dopamine supersensitivity psychosis (DSP). I don't think the article makes as clear as it should do, that by suggesting that DSP may be the cause of TRS, it seems to be implying that antipsychotic medication causes treatment resistance.

Surely it's about time journals, including so-called Nature Partner Journals, stopped publishing such speculation as though it were science. It would also help if science itself gave up its wishful hope to explain mental illness in physico-chemical terms (see eg. previous post).

Was Foucault for or against the Enlightenment?

I'm very grateful to John Iliopoulos for providing this guest blog, following my criticism of Andrew Scull's recent History of Psychiatry article on Foucault (see previous post).

If we accept the standard interpretation that the History of Madness describes a continuous process of exclusion of madness which began in the Renaissance and lasted all the way to the late 19th century, then we are forced to deduce that the birth of the asylum which took place in what is called the Enlightenment, is a mere episode of this linear narrative, albeit one focused exclusively on insanity. In this case we are faced with a choice; if we side with the Enlightenment, we conclude that, after a long period of ignorance, prejudice and religious superstition, mental doctors finally reached a sufficient level of lucidity to insert insanity into the calm objectivity of science. No doubt an exclusion took place and harsh therapeutic methods were employed, but this was because psychiatry was still in its infancy. If, on the other hand, we consider the same narrative as anti-enlightenment and anti-psychiatric, we can conclude that the birth of psychiatry was the direct result of an oppressive rationalist and moral imperative to exclude and conquer Unreason. Lacking scientific rigor and being part of the larger project of suppressing madness, proto-psychiatry failed to treat insanity in accordance with the supposed humanitarian ideals of the Enlightenment.

This is the ‘blackmail of the Enlightenment’, that is, the question of whether one has to affirm or reject rationalism. Taking sides in this dilemma must necessarily rest on a value judgment and on ready-made concepts (for example, considering a priori exclusion as a social evil, or objectivity as the ultimate goal of science). Foucault, however, refuses to submit to this blackmail and decides to treat the Enlightenment in its own terms. For Foucault, the birth of the asylum is a unique, groundbreaking event in the history of western medicine, because the doctors of this period tackled madness first and foremost as a concrete anthropological problem. Part of a vast transdisciplinary domain in the late 18th century, alienism gave medical expression to the new anthropological mentality of the time, that is, the ‘strictly philosophical structure responsible for the fact that the problems of philosophy are now lodged within the domain that can be called that of human finitude’. Madness was the case of human finitude par excellence, the most alien experience, challenging ‘our very sense of what it means to be human’, as Scull rightly puts it, therefore it had to be assessed in its own, singular truth, free of all preconceived value judgments, naturalist or moral theories. If the alienists were ‘enlightened’, it was because they adopted a ‘limit attitude’ which permeated their theories and determined their practice. Let us follow Foucault’s historico-philosophical analysis of this phenomenon:

1) During what is called the Enlightenment, the criteria of rationalism, productivity and morality which had led to the Great Confinement, no longer applied, and the practice of massively and indiscriminately incarcerating individuals began to disintegrate. (Even if we accept that the great confinement never existed, there is ample evidence in the medical textbooks, the architectural planning, the legal context and the administrative framework of the time, that the French, English, or German early 19th century asylum was a novel and unique medico-anthropological institution). Also, the Enlightenment did not reinforce the scientific and experimental powers of man, which should normally lead to a continuation and deepening of the existing naturalistic and biological theories of the previous times. Instead, no new substantial naturalistic theories of madness were produced during this period, or at least they were minimal compared to the biological and psychological theories of the positivist (or scientistic) revolution 100 years later.

2) The exclusion of madness was primarily tied to a specific problematic of anthropological truth. To the political interests of the late 18th century (discipline, public hygiene), insanity presented a deep anthropological problem: why and how did madness pose limitations to the application of reason in society? (If certain individuals cannot be trained, educated or corrected, then there is an inhuman kernel in them resisting rationalization). The doctors of the time who were asked to respond to this question did not belong to an Enlightenment ‘movement’; they simply translated the general socio-political and philosophical anthropological problematic of their society, into medical language. They tried to examine, in clinical terms, the question: how can moral codes or psychological laws be applied to the mad individual who represents the impossibility of thought (Descartes)? Isn’t the study of the reasons why an insane individual fails to participate in the reasonable community of men, the condition of possibility for the empirical investigation of his ailment (Kant)? Thus, the alienists shifted the center of gravity from the age-old investigation of humoral aetiology to the anthropological examination of the mad subject and his truth and freedom. The result was a new nosographic and symptomatological field, a strict phenomenological description of signs and symptoms denoting experiences impervious to education, training or punishment - experiences at the margins of reason.

3) Importantly, this was the first time that medicine opened a dialogue with madness (reading Foucault’s two sets of lectures on psychiatry in the 70s, one has the sense that Foucault corrects himself or at least supplements his own earlier thesis on psychiatry’s ‘monologue on madness in the late 18th century’). The alienists were attentive to the truth that the mad discourse expressed. They isolated the mad individuals so as to listen, without distraction and outside interference, to their illusory, fantastic discourse, responsible for their alienation. (From the studies of Goldstein and Gauchet & Swain, up to recent research, it has been consistently shown how carefully the doctors of the time listened to the enigmatic speech of the patients, tried to decipher their discourse, manipulated their delirium (see for example, Huertas, 2014)). In fact, analyzing the methods of confinement and treatment in the proto-psychiatric period, methods which may appear unacceptable to the current psychiatric mind (Esquirol’s principle of isolation, Falret’s principle of the two wills), Foucault - especially in his Psychiatric Power lectures - shows no hostility or opposition; on the contrary, he seems to appreciate the rationale underlying those practices whose end goal was the revelation of the truth of delirium. The same goes for the ‘moral treatments’ of the time; attaching the mad individual to the procedures of discipline did not abolish the humanity and morality of Pinel, Willis or Tuke (unless we accept that disciplinary power is by definition enslaving); the aim was rather to identify and neutralize the insane beliefs using techniques whose application is possible only under conditions of protection and isolation.

Interestingly, Foucault’s criticism of psychiatry targets the post-anthropological, post-Enlightenment form that psychiatry has acquired since the late 19th century, a form which the rationalist optimists may view as the fullest expression of the Enlightenment: inclusion of madness instead of exclusion, increased scientific sophistication, humanitarianism, security. Foucault, however, sees in this process the intensification of rationalization and its inherent dangers, rather than the fulfillment of an Enlightenment ‘ideal’. Abandoning its anthropological focus on delirium as the heart insanity, psychiatry has sought to reduce illness to somatic localization, an effort which, instead of strengthening the epistemological status of psychiatry, has actually produced phenomena of lower scientificity and even abuse (perhaps even much greater than that which may be observed in the early 19th century asylums). Defining mental illness not as a disturbed relationship with truth, but in terms of its reality, that is, the voluntary and the involuntary, neurological disturbance and genetics, psychiatry has extended the scope of its application to all possible abnormal behaviors, becoming a science of abnormalities (today, one needs only to look at DSM-V where more and more aspects of human behavior receive a medical comment, and the notion of the spectrum has officially entered the scene); genetics has been coupled with totalitarian and ideological practices giving justification to racism; the doctor-patient relationship is downplayed in favor of impersonal bureaucratic practices and the quest for the truth of illness in the laboratory; forensic psychiatry is asked to provide expert opinion on the danger of insanity, overstepping the epistemological boundaries of medical science, since dangerousness is neither a medical nor a legal concept.

By way of conclusion let us note the following:

a) The early asylum does not constitute the embarrassing past or the infantile beginning of psychiatry; but neither does it represent a romantic origin to which we should nostalgically return. As Foucault notes, quoting Nietzsche, things are not ‘most precious and essential at their moment of birth’. (Nietsche, Genealogy, History). Its genealogical value lay in its epistemological lessons: psychiatry can never escape its inherent connection with the philosophical problem of madness, just like medicine in general is intrinsically tied to the metaphysical problem of death.

b) Foucault does not deny the reality of madness (‘I have never said that madness does not exist, or that it is only a consequence of these institutions. That people are suffering, that people make trouble in society or in families, that is a reality. What I have tried to analyse are the ways these conditions, and the context in which this kind of suffering—delirium, persecution, etc.—are problematized as an illness, a mental illness, something which has to be cured inside such institutions and by such institutions.’ or ‘when I say that I studying the ‘problematization’ of madness, crime and sexuality, it is not a way of denying the reality of these phenomena. On the contrary, I have tried to show that it was precisely some real existent in the world which was the target of social regulation at a given moment (Fearless Speech)). The lesson he draws from the early anthropologists-alienists is that studying the reality of mental illness presupposes the study of its truth. This is because: 1) Diagnosis precedes aetiology. We look for somatic or psychic causality - but what is this causality the causality of? 2) the patient is part of the human species with a nature which can be studied anatomically and statistically. But only the concrete individual, with his delirious relationship with truth, ‘continues to tease and to bewilder us, to frighten and to fascinate, to challenge us to probe its ambiguities and its depredations.’ (Scull) 3) the doctor-patient relationship cannot be neglected, not for reasons of morality, but because, madness does not have only universal, somatic (not only cerebral) causes, but also a unique individual expression, a singular mode of existence, which can only be revealed in a specific milieu and in the specific relationship with the particular examining phychiatrist.

c) Scull’s assertion that ‘madness has social and cultural salience and importance that dwarf any single set of meanings and practices’, could be rephrased. Madness provokes a gigantic battle around truth, where multiple practices, knowledges and interests engage in the mutual construction of a single meaning: ‘in what way does a society define its relation to madness?‘

d) In fact, for Foucault, in the Enlightenment this belligerent relationship ‘between power, truth and subjectivity’, reached ‘the surface of visible transformations’; which is why it is ‘a privileged period for historico-philosophical work,’ and we should try to see whether ‘we can apply this question of the Aufklarung to any moment in history, that is, the relationship between power, truth and the subject’. In this sense, it could be argued that Foucault is actually for the Enlightenment, provided that the Enlightenment is conceived as a critical and diagnostic way of thinking and not as a moral and rationalist movement laying claims to Universality.

John Iliopoulos is consultant psychiatrist and chairman of the Department of Philosophy and Psychiatry at the Hellenic Psychiatric Association. He is the author of The History of Reason in the Age of Madness (2017)

Monday, April 13, 2020

Opening up the world of diseases of the nervous system

As Foucault (2008) noted in History of Madness, William Cullen (see last post) wrote in The Practice of Physic that:-
I [ie. Cullen] propose to comprehend, under the title of Neuroses, all those preternatural affections of sense or motion which are without pyrexia, as part of the primary diseases; and all those which do not depend on a topical affection of the organs, but upon a more general affection of the nervous system, and of those powers of the system upon which sense and motion more especially depend (Foucault, p.203).
This new world of diseases of the nerves opened up “a whole new pathological space“ (p.203). Medicine was able to move on from ‘metaphysical claptrap’ to integrating the soul and body. “A whole world of symbols and images ... [came] into being, where for the first time doctors enter[ed] into a dialogue with their patients” (p.204).

Constituting medicine on the basis of the doctor-patient relationship led to a reorganisation of psychiatric classification. As Foucault said, quoting Voltaire,
"We call madness that disease of the organs of the brain ... " The problems of madness revolve around the materiality of the soul. (p.208)
The world of the soul opened up an immense reservoir of causes for madness. Foucault quotes from Dufour (1770):-
The obvious causes of melancholy are all those elements that immobilise, wear out or trouble these spirits; great, sudden frights, violent movements of the soul resulting from transports of joy or intense affection, lengthy, deep meditation on a particular object, intense love, lack of sleep, and all excessive exercise of the worried mind, particularly at night; solitude, fear, hysterical affection, anything that impedes growth, healing (p.221)

The reforms of asylums (see previous post) matched the "prevalence and heterogeneity about the genesis of madness" (p. 221). Alongside dementia, mania and melancholia, hysteria and hypochondria were being increasingly associated, and for Robert Whytt, “in the mid-eighteenth century, the assimilation has become complete (p. 277). ... [A]t the close of the eighteenth century, almost without dispute, hypochondria and hysteria are firmly classed as mental illnesses" (p.278). They had been integrated into the domain of diseases of the mind.

Sunday, April 12, 2020

Origin of psychosomatic perspective

As I mentioned in my last post, probably the first person to speak of functional disorders was William Cullen (1710-1790), a key figure in the Scottish Enlightenment. As Sean Dyde says in his article,
While for ... Cullen the body could not be explained as if it were a machine, nor could ... [he] agree with the animism of Georg Stahl (1659–1734), that all bodily functions depended upon some rational principle or soul (see eg. previous post). 
As far as hypochondriasis is concerned, Cullen saw it as   
a disorder that affected some of the most important powers in the body. In other words, it was not its distinct nervousness which made hypochondriasis unique, but its combined effects on the vital and intellectual functions. 
Dyde goes on:-
However, by 1820 a change had come upon British physicians and surgeons. Many believed that Cullen’s medicine was in need of revision, that the motivating powers had no place in classifying disease, that medicine could be given firmer foundations.
It was said that the underlying disease was being missed too often. Illness or disorder was an “unhealthy state of the feelings or functions of parts”, and more attention needed to be paid to the “visible alteration in the appearance or structure of the affected part“. As Dyde says, “What had changed was the meaning of the term ‘disease’”. Pathological anatomy was starting to reform medicine.

As Dyde says,
For an ailment such as hypochondriasis, already on the cusp of medical understanding, pathological anatomy only made its ambiguities more prominent. ... [T]here was an acknowledgement that the time had passed when great figures like Cullen could survey the entirety of medical practice and encapsulate it within a single work. Where for Cullen the precise nature of disease was relatively unimportant, for pathological anatomy the question was all-consuming.
Dyde concludes:-
British physicians in the 1830s were little different from their colleagues in the 1760s: unable to distinguish the myriad of nervous ailments which they faced in medical practice, and fully aware that the conceptual tools at their disposal were unfit for the task.
But pathological anatomy had darkened Cullen’s reputation. Nonetheless, Cullen was “an astute physiological and medical thinker, as well as a remarkably influential nerve doctor” and “remains significant today for the warning ... [he] provides against reductionisms”.

Saturday, April 11, 2020

The opposition between psychogenesis and organogenesis of mental disorders

I mentioned Yorgos Dimitriadis’ History of Psychiatry paper in a previous post. This is part I of his ‘History of the opposition between psychogenesis and organogenesis in classic psychiatry’.

As he says,
Probably the first person to speak of functional disorders was the Scottish physician William Cullen in 1776 (Minkowski, 1935). According to Cullen (see Minkowski, 1935), these were diseases that were not caused by organic alterations of cells or of nerve fibres, but by anomalies in their functioning in various parts of the nervous system without any precise anatomical corollary – anomalies of an erratic and fleeting character, and in theory reversible. ... The term ‘functionalism’ (a word that in 1866 Louis Fleury opposed to ‘organicism’; Starobinski, 1999: 393) was also sometimes used, though it did not persist for long. ... [T]he term ‘functional’ was already present in Pinel’s followers, in particular Georget, who considered it to be a principle of mental alienation.

As I mentioned in a previous post, psychiatry expanded in the last third of the nineteenth century to include a broader range of what we came to call neurotic conditions. Traditional categories such as hypochondriasis, hysteria and melancholy tended to be incorporated into psychiatry as having a bodily cause. This way of viewing these illnesses created hypothetical disease entities, such as George Beard’s ‘neurasthenia’. As Dimitriadis says,
Neurasthenia ... was described by Beard in 1880 (see Minkowski, 1935) as a mainly somatic disease, with alterations of the blood, internal organs and the sympathetic nervous system, although it also came with psychical disorders such as feebleness of will, character alteration, irritability, and so forth. 
Hysteria was also considered a reflex neurosis, “that is, a disorder originating from the viscera, and more specifically from the genital organs, according to Hippocrates’s theory which was able to maintain itself for so long”.

Describing the psychical element of functional diseases began with
the study of hysteria by Briquet (1859), who imputed an essential importance to psychical and moral factors that deeply affect the human personality, while admitting that there are specific regions of the brain that serve as the basis for various disorders. The work of the Nancy school (Liébault, Bernheim) on hypnosis and suggestion (see Minkowski, 1935) impacted on the evolution of these ideas, establishing the effects of psychical factors on the nervous system, both somatic and visceral. ... Charcot stressed  the importance of affective factors that may strike the imagination or the feelings, with regard to the preparation, triggering and causal determination of neurotic disorders. 
He goes on:-
Babinski, previously the head of Charcot’s clinic, went further and reduced hysteria to  pithiatism, that is, to phenomena that can be triggered and eliminated through suggestion.  This had the effect, as observed by Ehrenberg (2004), of sealing off neurology from the unobjectifiable. His contribution, according to Ehrenberg (2004: 137), is ‘having established a boundary separating the neurological from the pathological, thus questioning our ability to understand mental states from cerebral ones’. Babinski thereby opposed Charcot who wanted, through the anatomo-clinical method and based on objective grounds (p. 137), to establish a physical semiology of hysteria (stigmata, for instance).

A further stimulus to the study of functional disorders came from the effect of trauma, emphasising
the presence of heightened affective irritability and of an increased influence of emotional factors on motor, sensitive and – even more importantly – on vasomotor and secretory innervations, that is to say on the vegetative nervous system.
Freud changed hysteria’s status to a condition resulting from psychological causes. “Likewise, Janet (see Le Gauffey, 1992a, 1992b) distinguished from Beard’s neurasthenia those cases in which psychological factors play a predominant role, and gathered them under the term psychasthenia.“

Dimitriadis moves on to note that:-
Jacques Vié (1934), ... observed that the term functional was used for two very distinct categories of events, either related to morbid processes, or else in continuity with normal functions ... [and that] functional disorders extend beyond the boundaries of organic pathology ... produced in the relation between the organ and the object of its function
He goes on:-
Von Monakow (see Minkowski, 1935: 17) regarded neuroses as prolonged affective reactions, generally psychical ones, arising from the personality against intense assaults.  These assaults, often repetitive and cumulated, target the personality’s instinctive sphere, that is, its most vital interests, and can affect the subject’s sexual life as well as his physical, psychical or moral integrity by way of trauma, disease, depravation, outrage to one’s prestige and honour, and so forth. 

As I said in my previous post, I’m very grateful to Yorgos Dimitriadis for making available in English this summary of the historical literature in French. It very much enriches my simplistic discussion of the nature of functional mental illness in another previous post. I look forward to reading the second part of his article.