The Gorizian experiment

There will be a book launch and discussion of John Foot's new book on Franco Basaglia: La "repubblica dei matti". Franco Basaglia e la psichiatria radicale in Italia, 1961-1978 (Feltrinelli, 2014) at 5.30 pm on Wednesday 4th February 2015 at Bloomsbury Room G35, Institute of Historical Research (IHR), Senate House (Malet St, London, WC1E 7HU). Discussants: Howard Caygill and Barbara Taylor. Chair: Ilaria Favretto. For updated information see event details at IHR. 

An English edition The man who closed the asylums will be available in August 2015. To quote from the blurb:-

Asylums incarcerate the "mad" and exclude them from society. Gorizia, a grim mental asylum, right on the edge of Italy, miles from anywhere, was no exception. Yet, when a new director was appointed in 1961, everything changed. Drawing on the writings of Erving Goffman and Michel Foucault, interested in experimental "therapeutic communities" in the UK, the work of Frantz Fanon, and the ideas linked to radical psychiatrists like Felix Guattari, Franco Basaglia was convinced that the entire asylum system was morally bankrupt. So he decided to abolish it. This is the first comprehensive account of Basaglia's revolutionary approach to psychiatry and mental health. The book is a gripping account of one of the most influential psychiatrists of the twentieth century.

Basaglia's influence has not always been assessed positively in the literature in english, particularly as he is seen as the architect of law 180, passed by the Italian parliament in May 1978. This law prevented new admissions to existing mental hospitals and decreed a shift of perspective from the asylum to treatment and rehabilitation in the community with diagnosis and treatment beds in general hospitals. The asylums actually started reducing in size in the UK and USA before Italy. Even though there has been controversy about Basaglia, the traditional asylums have come to be closed anyway as they became increasingly irrelevant to modern mental health practice. The historical perspective in the book on the origins of Basaglia's anti-institutional practice in Gorizia provides a corrective to some of the misunderstandings in the english literature.

PsychoPolitics in the Twenty First Century: Peter Sedgwick and radical movements in mental health

Call for papers for conference on Peter Sedgwick's Psychopolitics (see flyer). Proposals to sedgwickconf2015@hope.ac.uk by 27th February 2015. In the meantime, read Mark Cresswell & Helen Spandler (2009) on Sedgwick's legacy for the politics of mental health.

What does it mean to say psychotic experiences are symptoms of an illness?

I have been reading the report by the Division of Clinical Psychology Understanding psychosis and schizophrenia. The report states that calling experiences, such as hearing voices and feeling paranoid, symptoms of mental illness is "only one way of thinking about them, with advantages and disadvantages" (p. 6). It says that "not everyone agrees that there is an underlying illness" (p. 7). It goes on, "The idea that they [experiences such as hearing voices] are symptoms of illness, perhaps caused by some sort of chemical imbalance or other problem, is just one of the theories. There is no objective biological test such as a blood test or scan for diagnosing mental illness" (p. 17).

In the section on the advantages of seeing such experiences as mental illness, Laura Lee, one of the contributors to the report, is quoted as saying, "If the concept of illness was extended from biology to include our emotional/spiritual/thinking and meaning-making faculties we would have a holistic approach which would offer more" (p. 25). I agree with Laura (although may not make as much of the spiritual reference). I think the rest of the report could have been clearer on this point. There's nothing intrinsically wrong with using the term 'mental illness'. Although the terms illness and disease are used interchangeably, there are specific meanings. To quote from Eric Cassell in The Healer's Art, "Disease is something an organ has; illness is something a ... [person] has". The error is to think mental illness is a brain disease.

Psychiatric orthodoxy

I've just taken the Amen Clinic ADD type questionnaire. I didn't know that Daniel Amen had suggested there are 7 types of ADD: classic, inattentive, overfocused, temporal lobe, limbic, ring of fire and anxious; and that this matters for treatment. For today's special price of $77, I could have started healing my ADD, but I decided not to go ahead, despite the marketed attractive benefits of "improving attention and focus, boosting positive behaviour, and reclaiming my mental edge".

A Washington Post article called Daniel Amen the most popular psychiatrist in America. I doubt whether Amen likes critical psychiatry, which doesn't have that much of a following. I'm obviously not making enough outlandish claims (eg. see previous post). Amen recommends a SPECT brain scan as part of psychiatric assessment, when it isn't indicated. As the Washington Post article says, Amen's "claims are no more than myth and poppycock, buffaloing an unsuspecting public". In a Telegraph interview, he defends himself by saying, "If I'm defrauding them [patients] how would I stay in business for decades ... ?". The answer is that regulation of his practice is poor. As the Washington Post article, again, says "the man has grown fabulously wealthy — he lives in a $4.8 million mansion overlooking the Pacific Ocean — by selling patients a high-priced service that has little scientific validity, yet no regulatory body has made a move to stop him".

Gina Pera, who recently called Peter Kinderman a 'nincompoop' (see his Mad in America blog post), was influenced by Amen. I've said before (see previous post) that Peter can express the essence of critical psychiatry better than me, although I don't totally agree with his views. To take a quote from his Scientific American blog:-

It’s all too easy to assume that mental health problems — especially the more severe ones that attract diagnoses like bipolar disorder or schizophrenia — must be mystery biological illnesses, random and essentially unconnected to a person’s life. But when we start asking questions about this traditional disease-model way of thinking, those assumptions start to crumble.

Amen and Pera may have taken the biomedical assumption to extreme, but it's still the same biomedical assumption. Trouble is that Peter and I are more likely to be seen as unorthodox than them.

Global human rights violations in mental health

Following up my previous post about global mental health, I understand the motivation of #FundaMentalSDG to include mental health as one of the UN sustainable development goals post-2015 (see their blog post). I don't think we should look away from mentally ill people being neglected and abused, including being "tied to beds, kept in isolation in psychiatric institutions, being chained and caged in small cells, and being physically abused by ‘traditional’ healing practices" (see Guardian documentary).

However, I worry about saying that mental illness affects 1 in 4 in the world, as though it is almost normal. And, by saying that mental illness is treatable, implying that the simple answer is psychotropic medication. Management of mental illness may not just be a problem in low and middle income countries. The madwoman in the attic in Jane Eyre may not be that much different from the practice of pasung in Indonesia (see ABC News item on documentary "Breaking the chains"). The commitment of the Indonesian government to eradicate the practice is to be welcomed. Further measures need to be taken to protect the human rights of the mentally ill worldwide.

Important developments in psychiatry

From a survey of mental health experts, Mark Micale has produced a list of the 12 most important changes in American psychiatry since World War II (see article).

1. The ‘psychopharmacology revolution’ of the 1950s.
   
2. Deinstitutionalization, or the movement of massive numbers of psychiatric patients out of state asylums into community health care facilities.
3. The ‘decline and fall’ of psychoanalysis.
4. Shifts in the practice of psychotherapy from psychiatrists to non-medical professionals, especially clinical psychologists and clinical social workers.
5. The rise of a vast scientific research programme, including massive institutional and financial resources, for studying the neurochemistry and neurobiology of mental illness.
6. The introduction and widespread adoption since the 1980s of a new generation of antianxiety and anti-depressant compounds, especially the so-called SSRIs such as Prozac (fluoxetine).
7. A steady increase in the influence of the pharmacology industry throughout the psychiatric profession (e.g. ‘big pharma’).
8. The growth in influence of the Diagnostic and Statistical Manual of Mental Disorders.
9. The multiplication of ‘new’ diagnoses.
10. The de-pathologizing of homosexuality
11. The emergence or expansion of particular subfields of psychiatry, most notably geriatric psychiatry and child psychiatry
12. The changing role of the mental health insurance industry and the coming of a managed care model of health services
    

Heh, critical psychiatry, or even anti-psychiatry, isn't important! And, young people mention mental health blogging, which doesn't feature in the main list. So, perhaps I should go on with this blog.

Outlandish claim about chemical deficiency in depression

Juliette Jowit makes a case in a Guardian comment that parity of esteem in mental health services is a scientific necessity rather than a gracious concession. She rightly indicates that Freud may well have thought that psychoanalysis would be replaced by psychopharmacology. However, she's been badly misled by Tim Cantopher in his book Depressive illness. The curse of the strong. She correctly quotes from Cantopher:-

If I were to perform a lumbar puncture on my patients (which, new patients of mine will be pleased to hear, I don't) I would be able to demonstrate in the chemical analysis of the cerebrospinal-spinal fluid (the fluid around the brain and spine) a deficiency of two chemicals.

Piffle! Cantopher doesn't just not do a lumbar puncture on his patients because it's an unpleasant investigation. It wouldn't show what he suggests. He might be 'struck off' by the GMC for doing an inappropriate investigation. Jowit rightly surmises that Cantopher means serotonin and noradrenaline as the 'two chemicals'. I presume Cantopher believes what he wrote but there are no references in the book, so it's difficult to know where he got the idea from. How does he get away with misleading journalists, let alone patients?

Just to be clear, I'm not advocating mental health problems being dealt with separately in the NHS. Jowit does note that "some psychiatrists have been driven to an obsession with biology". Perhaps she needs to investigate further why the public is being misled about mental illness being a physical illness. As I keep reiterating, do not misunderstand me. Of course mental illness is due to the brain - that's mere tautology. But, to make the claim that Cantopher makes in the quote above is outlandish.

DSM needs to return to its origins

Following my previous post, I just wanted to be clearer about why I am not advocating totally abandoning psychiatric diagnosis. My position may seem surprising as essentially I agree with the critics of psychiatric diagnosis. Biomedical diagnosis has failed in the sense that mental disorder is not due to brain abnormalities. Symptoms and signs in psychiatric assessment are about mental, not bodily functioning. Psychiatric diagnosis and biomedical assessment act as a means of avoiding the uncertainty and pain of people's life stories.

Yet, I'm not the only psychiatrist that has given a priority to personal assessment rather than psychiatric diagnosis. Nor am I the only one that does not see mental illness as a brain disease. There has always been this conflict in modern psychiatry, since the origins of the asylums and the introduction of the anatomoclinical understanding of disease in medicine in general. Particularly in American psychiatry, the biomedical assumption was undermined by the views of Adolf Meyer (eg. see previous post). As Erwin Stengel (see my mention of him in another previous post) wrote in his review of psychiatric classification in 1959:-

Recently, the attitude of many psychiatrists towards the conventional type of classification has become one of ambivalence, if not of cynicism. This attitude derives partly from a low estimation of diagnosis, which in large areas of psychiatry has remained imprecise and has proved a poor guide to prognosis and therapy. Also, the concept of mental disorder, which in Kraepelin's view closely approximated that of physical disease, has changed in such a way that a conventional medical diagnosis no longer seems applicable. In many schools, especially in America, mental disorders are viewed as reactions of the personality to known or unknown pathogenic factors (Stengel, 1959).

In other words, there was a time when psychiatrists were much more aware of the limitations and problems of psychiatric diagnosis. DSM-I used the term 'reaction' throughout the manual, influenced by the ideas of Meyer. For example, functional disorders were called "disorders of psychogenic origin or without clearly defined physical cause or structural change in the brain" and this included manic depressive and schizophrenic reactions. There was no pretence that mental disorder is due to brain abnormalities.

Now that it is apparent that DSM-5 has failed (eg. see previous post), we need to undo each of the steps taken along the way. DSM-IV dropped the functional-organic distinction, which needs to be reinstated (see previous post). DSM-III encouraged a biological view of mental illness and introduced operational criteria, but did not improve diagnostic validity. DSM-II was not too different from DSM-I, but dropped the term 'reaction'. Conceptually the DSM process has been totally misguided, and we need to rethink and return to basic principles if there is ever going to be a DSM-6.

Is community mental health care really worse in USA?

Allen Frances asks "How do we create a compassionate, cost effective mental health system?" and Psychiatric Times collects some answers in a blog post. There seems to be general agreement that the US mental health system needs fixing. Francis explains that, "Sixty years ago, community psychiatry was the big new idea". He thinks, "The dream worked well in many countries, but turned into a bitter nightmare in the US".

I'm not so sure that community care is the problem. Nor that the situation is much worse in the USA. Providing personalised mental health care worldwide is not easy and is not necessarily any better in the community than it was in the asylums.

Cigarette use associated with psychotic episodes

Cannabis use and cigarette use at age 16 were both associated, to a similar degree, with psychotic episodes at age 18 in a cohort study published in Psychological Medicine. I report this because it is commonly assumed cannabis can cause psychosis, but as the authors of the article say, there is no evidence that tobacco has a causal effect in psychosis. Of course, cannabis intoxication can cause transient psychotic-like experiences, but what is less clear is whether cannabis can cause psychosis not related to intoxification effects.

As I said in my BMJ letter, "Cannabis use is likely to be a proxy measure for poor premorbid adjustment associated with psychosis." I went on, "I am not saying that cannabis does not cause emotional problems; nor that people do not use it to deal with their emotional problems." The degree of correlation between the use of cannabis and cigarette smoking means it is difficult to disentangle independent effects. However, the likelihood is that cannabis use and cigarette smoking are both markers for socioeconomic and environmental factors associated with psychosis. It's illogical to interpret the association between cannabis and psychosis as causal, as it is to do the same for cigarette smoking.

Keeping Tom Szasz's ideas alive

John Breeding is concerned about the legacy of Thomas Szasz in his article in SAGE open. He rightly emphasises Szasz's focus on "greater autonomy and higher levels of personal responsibility". As John Breeding points out, Szasz never really wanted to be a doctor. Instead he trained to be a psychoanalyst. Szasz practiced autonomous psychotherapy, although he didn't like the term 'therapy'. I understand how John Breeding as a counsellor sees that he can 'practice Szasz'.

That's fine for patients who have mental capacity. People decide to undertake psychotherapy and counselling. However, people who are psychotic may not make the most rational of decisions because of their mental illness. Society might have a role to intervene and psychiatrists manage madness on behalf of society. Psychotherapists and counsellors don't need to undertake these murky responsibilities.

Hence, using quotes from the article, Tom Szasz thought that, "A person should be deprived of liberty only if proved guilty of breaking the law". To reiterate, he said, "if the 'patient' is not a criminal, then he or she has a right to liberty; and if the patient is a criminal, then he or she ought to be restrained and punished by the criminal law, like anyone else". Essentially, Szasz didn't think society should have mental health legislation.

I suppose it could be said I'm only defending my role as a psychiatrist, but I don't agree with Szasz on this point (see previous post). He was also pretty scathing about the Critical Psychiatry Network of which I'm a founding member (see another previous post). I'm sure I could learn to be clearer in expressing my views, like him, although I do accept uncertainty and perspectives may not always be as black and white as he often argued. However, his critique of the biological basis of mental illness will survive.

(With thanks to Around the Web item on Mad in America)

Psychiatric diagnostic uncertainty

Mary Boyle and Lucy Johnstone (@clinpsychlucy) argue for alternatives to psychiatric diagnosis in a Lancet Psychiatry comment. As I have said in an article, Mary has contributed significantly to the critique of psychiatric diagnosis. Lucy has as well, particularly in her recent A straight talking guide to psychiatric diagnosis. As I also said in my article, "The problem with biomedical diagnosis is that it potentially produces the facade that [personal] understanding has been created".

However, my article also suggested that the proposal to abandon psychiatric diagnosis is potentially misleading. Joseph Hayes and Vaughan Bell (@vaughanbell) in their comment in response to Mary and Lucy point out that formulation and diagnosis are complementary. I worry though about their inability to see the difference between functional and organic mental disorders (eg. see previous post). I do think that DSM has been so overtaken by biomedical assumptions that it should be abandoned (eg. see another previous post). But, as I said in response to Peter Kinderman's new book (see post), psychiatric diagnosis needs to be recognised for what it is. Peter essentially agrees with Mary and Lucy. The process of psychiatric assessment is primarily psychosocial not biomedical.

One million pageviews

According to Blogger statistics, this blog has now had more than one million pageviews. Is this correct? And why is this post on the recovery model the most popular, with getting on for a quarter of a million pageviews?

"Something is wrong with my mood"

Yesterday was Bipolar UK's third annual national bipolar awareness day. What Bipolar UK is concerned about is that people may have to wait an average of 13 years for diagnosis (see press release for the first bipolar awareness day in 2012).

On the same day, Anne Cooke tweeted to remind us of the BPS document Understanding bipolar disorder. I also received an email from the National Institute for Health and Care Excellence (NICE) with the publication details of the update for the Bipolar disorder clinical guideline (see full guideline).

Bipolar UK changed its name from the Manic Depression Fellowship in 2011. I wish it hadn't. Since the term manic-depression was changed to bipolar in DSM-III in 1980, the concept has become so broad that its validity must be in question (eg. see previous post). Some may want to question the validity of any psychiatric diagnosis (eg. see another previous post). However, I think there is some meaning in the original concept of manic-depression, which goes back to Emil Kraepelin. This condition was recognised previously, for example, by Falret in 1851 as la folie circulaire. Mania was a psychotic diagnosis and its lesser form, hypomania, was seen as an indication that a person could be on the verge of developing a full-blown mania. The change to bipolar has allowed the inclusion of non-psychotic presentations. In particular, bipolar II only requires episodes of hypomania. Asking people with depression whether they have had episodes of being 'high' may uncover non-clinical such episodes and may not be a very rigorous way of deciding whether someone has had true hypomania. Such people may well not have been psychotic.

Furthermore, recognising the continuity with normal mood variation has encouraged a 'softer' version of bipolar spectrum. Almost anyone with a history of mood swings or instability can be seen as being on the spectrum. It may be important to note that NICE emphasises that, "The clinical utility of these proposed ['softer'] diagnoses has yet to be established and there is currently no indication whether treatment is necessary or effective". We shouldn't be using mood stabilisers for bipolar spectrum.

After all, the development of mood stabilising medication must have been a factor in promoting the bipolar concept (see previous post). We may well look for simple solutions to our emotional problems. To quote from Goodwin & Malhi (2007), "Put simply, the term mood stabilizer sounds comforting and may reflect our fond and perhaps somewhat naive hopes." Mental tranquility may sound attractive when feeling volatile.

Strong feelings derive from one's circumstances. Abnormal emotional states are likely to arise from the difficult situations we find ourselves in. 'Peace of mind' may not always be that easy to find.

From reductionism to hermeneutics

Pat Bracken in an article in World Psychiatry says psychiatry is in trouble and needs to move from reductionism to hermeneutics. He builds on the 'Bracken manfesto' paper (see previous post), as named by Peter Kinderman (eg. see another previous post), that the problem is the technological paradigm which dominates psychiatry. As Pat says, "Hermeneutics is based on the idea that the meaning of any particular experience can only be grasped through an understanding of the context (including the temporal context) in which a person lives and through which that particular experience has significance." Most medicine and surgery is concerned with the natural order, whilst psychiatry is mostly concerned with the human order.

Mario Maj in an editorial argues that the Bracken manifesto has gone too far in rejecting the technical aspects of care. He can't be as sceptical about the value of psychiatric medication or even that non-psychiatric medication could be just as ineffective (see previous post). He raises the spectres of the Italian reforms following the introduction of law 180 and the concept of the 'schizophrenogenic mother' to boost his argument of the dangers of a non-technical approach. However, evaluation of the influence of Franco Basaglia has been controversial. It is also obviously wrong and naive to blame families for causing schizophrenia. However, the problem with the reaction against the 'schizophrenogenic mother' idea is that it has undermined further legitimate family studies of schizophrenia. Maj also sees early intervention to reduce duration of untreated psychosis as a benefit of the technical approach without mentioning the critique of the early intervention approach (eg. see Jo Moncrieff's book The bitterest pills). Nor is it clear, as Maj suggests, that a non-technical understanding of psychiatric diagnosis necessarily leads to the abandonment of any attempt at classification (see previous post).

Still, it's good that there has been some mainstream response to the Bracken manifesto, rather than just ignoring it.

Controversy in psychiatry

A Lancet Psychiatry editorial argues for compromise in debates about mental health issues. I do agree that "the opportunities for global discussion on blogs and social media [shouldn't be] ... squandered". However, it is important, if there is going to be any change in mental health services, that the critical psychiatry position is stated explicitly.

The danger of accommodating all perspectives is that what is being said becomes "intellectually empty" and "ethically blind". This was the verdict, for example, of Andrew Scull on Meyerian psychobiology in his book Madhouse about Henry Cotton, whose programme of radical surgery led to significant mutilation and death by removing parts of the bodies of patients to eliminate what Cotton thought were focal infections believed to be the cause of mental illness. Meyer seemed unable to acknowledge the damage Cotton caused, instead writing a favourable obituary, suggesting he had "an extraordinary record of achievement". When Cotton was alive, Meyer suppressed a report of the poor outcome of Cotton's work in the forlorn hope he could persuade Cotton to accept the reality of his results.

I have indicated several times in this blog that Meyer's theoretical position was not dissimilar from critical psychiatry. However, his compromising position meant that he did not follow through on his challenge to biomedical psychiatry. I quote in my article from a heartfelt note written in the early hours of the morning a few years before he died, where he questions whether he "pussyfoot[ed] too much". He wished he had made himself "clear and in outspoken opposition, instead of a mild semblance of harmony" [his emphasis]. I would actually like mainstream psychiatry to engage more with critical psychiatry, rather than marginalising it.

Reducing numbers of psychiatrists in community mental health teams

Following up previous posts (What place for diagnosis in mental health care? and Responsible clinicians under the Mental Health Act) on Peter Kinderman's new book A prescription for psychiatry, I want to comment on a central theme of the book about replacing psychiatrists with GPs. I'm not necessarily against this suggestion. Too many psychiatrists are too biomedically orientated and may as well be replaced by GPs with a more psychosocial orientation. What GPs want from a mental health service is good assessment and management of their patients with mental health problems. Peter is clear that mental health care should reject the notion that it is (or should be) 'treating illnesses'. He would go along with the view of some mainstream psychiatrists, responding to what they see as the threat to their professional role (eg. see previous post), that psychiatry should focus its efforts on what it sees as the medical aspects of healthcare, specifically biological aspects of mental healthcare. Less psychiatrists may well be needed to do this.

I know what Peter means when he suggests mental health problems are not illnesses. This blog has often enough emphasised the lack of biomarkers for mental illness. Nineteenth century medicine developed because of its anatomoclinical understanding of disease. Just how misguided to expect the same advances in psychiatry is demonstrated by the awarding of the Nobel Prize in Physiology or Medicine to Wagner-Jauregg for malarial treatment of dementia paralytica and Moniz for leucotomy, and the nomination for the same prize of Sakel for insulin coma therapy, von Meduna for shock therapy with metrazol and Cerletti for ECT treatment of schizophrenia and manic-depressive illness. Have these really been the main advances in psychiatry?

I am happy to use the terms 'mental health problems' and 'mental disorder'. And, I am less worried about using the term 'mental illness' than Peter. In fact, I go along with Bill Fulford in Moral theory and medical practice that medicine is primarily an ethical activity. In that sense, psychiatry is the pre-eminent medical speciality. Many people go to their doctor with physical complaints whose origins are psychosocial. Peter doesn't mention this issue in his book. In Germany, for example, psychosomatic medicine has developed as a separate speciality. There may not be that much advantage in me having a medical training for much of my work as a psychiatrist, but at least I do understand psychiatric problems in their medical context. I'm certainly not advocating neuropsychiatry as the solution to the commonly identified crisis in the role of a psychiatrist (eg. see book review). What's needed is a more patient-centred approach to medicine in general. Peter's prescription for psychiatry may provoke this response. But encouraging psychiatrists to be neuropsychiatrists is not the right way to do it. This is a central theme of what Peter calls the 'Bracken manifesto' (see previous post). And clinical psychologists and other mental health professionals do need psychosomatic understanding to be complete practitioners.

Responsible clinicians under the Mental Health Act

As I said in my previous post, I have been reading Peter Kinderman's new book, A prescription for psychiatry. He suggests that, "In time, I believe it should be routine for the 'responsible clinician' [under the Mental Health Act] to be a psychologist or social worker". He makes an interesting reference to discussions on New Ways of Working in which he was involved on behalf of the British Psychological Society. He objected to a phrase, which did not appear in the final report, about the "clinical primacy of the consultant [psychiatrist] in dealing with treatment resistant, acute, severe or dangerous clinical situations". Peter does not agree with the concept of 'clinical primacy'. However, if it does have any meaning, it may arise because generally consultant psychiatrists, not psychologists or social workers, undertake the responsible clinician role.

I've commented before on this issue (see previous post) in relation to an eletter by Sam Thomson and Peter in response to what Peter calls in his book the 'Bracken Manifesto'. Clinical psychologists have been split about whether they should take on the role of responsible clinician. Peter quotes from David Smail, who unfortunately recently died (see tweet), who thought that it was good that "the only power we have [as clinical psychologists] is power of persuasion". Peter thinks what's more important is the "markedly different framework of knowledge and skills" of clinical psychologists, rather than their "historical absence of formal power" under the Mental Health Act.

I would have liked to have seen more discussion of this issue in Peter's book. Would Peter go as far as suggesting that recommendations for detention under the Mental Health Act should not be restricted to doctors? I think the logic of his position suggests he would.

What place for diagnosis in mental health care?

I have been reading Peter Kinderman's (see previous post) new book A prescription for psychiatry. Peter is very clear that "there is no place for medical diagnosis in mental health care". He suggests this is "a challenging assumption" and "may sound revolutionary". He even recognises it "may go against decades of accepted wisdom in psychiatric circles".

I'm not sure how many decades Peter wants to go back! The publication of DSM-III in 1980 marked a return to medical diagnosis in Peter's sense. However, he might have been happier with Karl Menninger's The vital balance published in 1963, which represented a pragmatic consensus, at least in American psychiatry. And going back even further, Adolf Meyer, regarded as the dean of American psychiatry in the first half the 20th century, developed psychobiology which has parallels with Peter's psychobiosocial approach. As Menninger put it, "As a result of his efforts ..., American psychiatrists began to ask, not "What is the name of this affiction?" but rather, "How is this man reacting and to what?"". DSM-III replaced the Meyerian approach to diagnosis, which it saw as too woolly.

Meyer said of the American Medico-Psychological Association's (1918) Statistical manual for the use of institutions for the insane, "I have no use for the essentially 'one person, one disease' view". He went further and suggested that "... statistics published ... are a dead loss ... and an annual ceremony misdirecting the interests of staff". Susan Lamb has described Meyer's psychiatric development from neuropathologist to psychobiologist (see previous post).

For my position on diagnosis, you might want to look at the slides from my presentation 'Some aspects of the moral basis of diagnosis: The challenge of Meyer's psychobiology'. My views are:-
(1) Psychiatry should not abandon diagnosis but recognise it for what it is
(2) Psychiatry should not be panicked by the unreliability of psychiatric diagnosis
(3) Psychiatry should avoid the reification of diagnostic concepts
I think this is a similar but more subtle, maybe, manifesto than Peter's.

Blogging on psychiatry as symbolic representation of the Universe

Tom Stockmann has started his Mandelas blog which looks as though it will be interesting.

Soteria Network (UK): AGM and Open Forum

Saturday, 20 September 2014 11 am – 4 pm, Manchester

Promoting the development of drug-free and minimum medication therapeutic support for people experiencing 'psychosis' or extreme states

Part of an international movement of service users, survivors, activists, carers and professionals fighting for more humane, non-coercive mental health services

Please come and join us at our Annual General Meeting and open Forum event for a day filled with the sharing and exchanging of ideas, knowledge and discoveries, the exploration of opportunities, and inspiration for new initiatives.

We will begin the day reporting on the activities of Soteria Network over the past year, our aspirations as we move forward; our financial position and the election of trustees.

The afternoon will be dedicated to Soteria groups, speakers, and poetry. There will be time for you to ask questions, participate in discussions and share your experiences throughout the day.

We are pleased to announce that we will be launching our new website at the event and, premiering a short film we have made, interviewing Peter Stastny (INTAR founder) on his time and recollections of Loren Mosher. Loren opened the first ever Soteria House*; the man who is the inspiration and reason all Soteria-related organisations exist.

This event is free of charge and open to all.

Complimentary lunch and refreshments will be provided

Further information, including how to book a place at the event is coming soon!

*Soteria House began life in 1971 as an experimental research project in America which was designed to see whether people experiencing a ‘first episode’ acute psychosis, who might otherwise be diagnosed with schizophrenia and treated with medication in hospital, might fare just as well in a house with minimum medication, but with maximum support

Soteria Network (UK) Registered Charity number:1146183

Psychiatric coercion

I've been re-reading one of Thomas Szasz's last papers (see previous post) in which he is quite scathing about the Critical Psychiatry Network (CPN). He says "The CPN's position is not psychiatric criticism, it is a plea for prettifying the psychiatric plantations." The choice of the word 'plantation' is deliberate, as what he wants to do is unshackle "the psychiatric slave from his psychiatric master". He suggests Dorothea Dix soothed American families and communities "with the fiction that her proposed psychiatric plantations would make the slaves healthy and happy".

Such rhetoric may increase the force of his argument that the "psychiatric critic's primary duty is, and always has been, to reject the legal-political legitimacy of the use of psychiatric force and fraud". However, I'm not trying to abolish psychiatry, which Szasz makes clear was his aim. I'm not justifying torture as treatment and can distinguish coercion from torture. Torture does involve coercion but not all coercion involves the infliction of pain. Torture is a type of coercion and ethical practice in psychiatry avoids it.

Explaining neuroscientific basis of mental disorder

I've just tweeted the link to Peter Kinderman's recent post on Mad in America. Peter may overuse the term "distress" from my point of view, as I think people can be mentally disordered without necessarily experiencing it as distress. However, I look forward to the publication of his book. He explains far better than me what I have been going on about all these years with critical psychiatry. To quote from him:-

Some neuroscientists have asserted that all emotional distress can ultimately be explained in terms of the functioning of our neural synapses and their neurotransmitter signallers. But this logic applies to all human behaviour and every human emotion – falling in love, declaring war, solving Fermat’s last theorem. It clearly doesn’t differentiate between distress – explained as a product of chemical ‘imbalances’ – and ‘normal’ emotions.

Why should the way we explain mental illness be any different from our normal emotions? Why should there even be a different neural substrate? Peter seems to think this idea might be catching on. I do hope so.

A historical perspective on academic psychiatry in Sheffield

Following his death (see previous post), I have been re-reading Alec Jenner's personal memoir (1) of Erwin Stengel, his predecessor as Professor of Psychiatry in Sheffield. Alec also wrote Stengel's Lancet obituary. Stengel founded the University Department of Psychiatry in Sheffield in 1957. Alec stepped into his shoes in 1967. 

Stengel was from Vienna, as was Freud, and I remember Alec showing me an imitation Graeco-Egyptian pot that Freud gave Stengel for treating his maid. As Alec put it, "despite considerable neurological sophistication, there is a struggle to find humanistic explanations" in Stengel's writings. 

Alec himself had an interest in philosophy even when Director of the MRC Unit for Metabolic Studies. Early in his career, he did nonetheless think he would explain manic-depressive illness biochemically, and probably never gave up the idea that a biological solution to mental illness may be found. Still, after his retirement there were those who sought to undermine his open-minded interest in democratic psychiatry, which they called "anti-psychiatry", and replace his emphasis with neuroscience. The current research interest of Sheffield academic clinical psychiatry is "biological investigation of psychiatric disorders, and includes the use of neuroimaging techniques to investigate psychotic and other psychiatric disorders".

Such a narrow modern focus on neuroscience is in contrast to the broader interests of Stengel and Alec Jenner and we at least need to return to a more pluralistic, if not critical, understanding of psychiatry.


(1) Jenner FA. (1991) Erwin Stengel. A personal memoir". In: Berrios GE & Freeman H: 150 Years of British Psychiatry 1841–1991. London: Gaskell. pp. 436–44.

Death of founding editor of Asylum Magazine announced

Professor Alec Jenner, founding editor of Asylum Magazine, died on July 3rd. The funeral service will be held in St Nicholas Church, High Bradfield, Sheffield on Wednesday 16th July at 12:00. Following the funeral service the family would like to invite attendees to join them at the Old Horns, Towngate, Jane St., High Bradfield, Sheffield where refreshments will be served and where good memories of Alec can be shared.

I'm particularly sorry to hear of his death. In 1989, he appointed me Lecturer in Psychiatry in Sheffield University, when nowhere else wanted me for senior registrar training. He was professor there for 25 years. He organised regular fortnightly outside speakers in term time on Tuesday evenings, which Tim Kendall and I carried on after he retired, until I left Sheffield in 1996. 

Alec's contribution to critical psychiatry was immense. He may have preferred to call it democratic psychiatry following Franco Basaglia. More to follow to honour his life and work, but for the moment look at his own view as a psychiatrist from the alternative textbook of psychiatry, which Lin Bigwood and he helped Phil Virden to write.

The americanisation of critical psychiatry

Sandra Steingard has posted a video of a talk "Why I became a critical psychiatrist" on her Anatomy of a Psychiatric Practice blog on Mad in America. She also posted last November the introduction to the forum on the Critical Psychiatry Network (CPN) - North America webpage of the International Critical Psychiatry Network (ICPN) website.

Freud was always fairly pessimistic that the move of psychoanalysis to America would preserve his key ideas. It may be said that he was proved right in this expectation. On the other hand, I have always seen critical psychiatry as a broad church (eg. see previous post). So, the American take up of critical psychiatry shouldn't be plagued by similar arguments about doctrinal purity. And I think it would be good if Americans did embrace critical psychiatry as they did psychoanalysis. Thanks to Sandra for her lead.

The sense in saying antidepressants don't work

According to a Times article, Sir Simon Wessely, President-elect of the Royal College of Psychiatrists, thinks it is "nonsense to say that antidepressants do not work". I presume he's saying that antidepressants are more than placebos. He may know more than I do, but he doesn't seem to think that the small effect size in clinical trials could be due to placebo amplification due to unblinding (eg. see previous post).

I guess he has to believe this as head of the Royal College of Psychiatrists. My scepticism means I'm never going to fulfill this role! It's alright for Simon to say that he doesn't really buy parents promoting the idea that their children who get into Oxford are mildly autistic. And, that modern services couldn't be less well designed to join up physical and mental health care. But it's beyond the pale to suggest that psychotropic medication is not effective.

The benefit-to-harm ratio of antidepressants

A Lancet Psychiatry article attacks Peter Gøtzsche (who I have mentioned in a previous post) for saying that antidepressants do more harm than good. Although his Guardian article has this headline, in fact what he wrote was "the way we currently use psychiatric drugs is causing more harm than good" [my emphasis]. He doesn't seem to be advocating not using antidepressants at all, but "much less, for shorter periods of time, and always with a plan for tapering off, to prevent people from being medicated for the rest of their lives".

As I commented in my previous post about Gøtzsche, the problem is that attacking him in this way deflects from the validity of what he is saying. I wish mainstream psychiatry would engage more with me. I do know it is important to avoid overstatement (see previous post). The Lancet Psychiatry article emphasises the effect size found in antidepressant trials. What it doesn't discuss is whether this finding could be explained by placebo amplification due to unblinding in clinical trials (eg. see previous post). Nor does it discuss the bias in the literature introduced through selective publication. These days this is because data submitted by the drug companies to the regulatory authorities is not always examined completely. Previously, with older trials, this was because of what was called the 'file drawer problem' (see further information) in that negative trials did not always get published. This may well have affected the amitriptyline data that the Lancet Psychiatry article cites.

As I said in a comment on a previous post, it's important not to get too hung up by the size of effect in clinical trials. Maybe I'm too sceptical, but the finding that non-psychiatric drugs have similar effect sizes in clinical trials does not imply that psychiatric drugs are effective, but that medical as well as psychiatric clinical trials are subject to the same biases of unblinding (see previous post).

The authors of the article speculate about the reasons for doctors questioning the effectiveness of antidepressants, suggesting it is the anti-psychological bias of doctors that makes them want to believe that there can't be a physical treatment that could possibly be effective for mental illness. So, they try to turn the tables on critics by suggesting it's the critics not them that are stigmatising mental illness. They feel insulted by the critique but it is important to be open to argument and not prejudiced.

Finnish psychologist sacked after expressing critical views about antidepressants on TV

Aku Kopakkala, who worked for Mehiläinen, a private health care organisation in Finland, has been sacked after appearing on a TV programme about antidepressants with Peter Gøtzsche (who I have mentioned in a previous post). Can someone create a better transcript of the programme for me than Google translate? Critical views about psychiatry are discriminated against (see previous post) and this may well be an unfair dismissal.

I see that the Vice President, Working Life Services at Mehiläinen was managing director at Pfizer Oy. And, Erkki Isometsä, Professor of psychiatry at the University of Helsinki, does not seem to have liked being asked on the programme how much he was paid for public speaking by the drug companies. However, this is relevant as he is chair of the Task Force for the National Current Care Guideline for the Treatment of Depression. Confrontation about these conflicts of interest can have destructive consequences.


(With thanks to Jeremy Wallace)

Psychiatry for a new generation

Maybe because I am approaching pension age, I have been thinking about the impact of critical psychiatry on practice. There seems to be little shift in mainstream biomedical bias, which tends to ignore any challenge to its approach. I seem to have been wasting my time trying to get critical psychiatry's message across.

In a previous post, I mentioned Aubrey Lewis, who influenced the generation of professors that I saw retire. I think there's now less passion for thinking about the basis of psychiatry, which he encouraged. That passion has been diverted into promoting neuroscience as the solution to mental illness (eg. see previous post). Trainees are supposed to get excited about discovering the scientific cause of mental illness rather than be interested in the conceptual foundations of psychiatry. I think this is a recipe for disillusionment as fulfillment of this wish is unobtainable.

Of course, psychiatry has always held out the hope that the biological basis of mental illness will be uncovered. However, at times, it seems to have been more open to recognising the uncertainty of human action. For example, Adolf Meyer (see previous post) and George Engel (see conference presentation) encouraged a patient-centred approach to psychiatry. These days, however, a full personal assessment of a patient is almost seen as out of date in psychiatry (see another previous post). Do trainees even know who Adolf Meyer and George Engel were?

So, how can younger mental health professionals be interested in critical psychiatry? They need to be reassured about its legitimacy and not have their careers blighted because they express an interest. Critical psychiatry is not anti-psychiatry, in the sense that it denies the reality of mental illness. It may be almost unbelievable that mental illness is not associated with neuropathology, considering the research effort put into trying to find just that association. But, in fact, the neurobiology of mental illness may be no different from that of our "normal" behaviour (see my article).

I haven't seen any debate about these issues on the Early career psychiatry webpage at Psychiatric Times.

Human rights and mental health worldwide

The Movement for Global Mental Health emerged from a 2007 Lancet series, which concluded with a call for action. According to Vikram Patel (2011), the demand for effective implementation of human rights is as important a goal as the increase in availability of and access to a range of mental health services in the global south. People with mental illness can be abused worldwide. As Arthur Kleinman (2009) says:-

I have personally witnessed individuals with mental disorders in east and southeast Asian towns and villages chained to their beds; caged in small cells built behind houses; hospitalised in for-profit asylums where they are kept in isolation in concrete rooms with a hole in the floor for urine and faeces; abused by traditional healers such that they become malnourished and infected with tuberculosis; scarred by burns resulting from inadequate protection from cooking fires; forced to dress in prison-like clothes in asylums with shaven heads and made to perform child-like dances and songs for gawping visitors; knocked to the ground and forcefully held down for electroconvulsive therapy when psychotic in an emergency room; laughed at by the police; hidden by families; stoned by neighbourhood children; and treated without dignity, respect, or protection by medical personnel.

For example, the Human Rights Watch report, "Like a death sentence", describes abuses against people with mental disabilities in Ghana. The three public psychiatric institutions in Ghana and 8 prayer camps in the southern parts of the country were visited. All the camp leaders interviewed considered mental disability to be caused by evil spirits or demons. Most people brought to the camps for healing for mental disabilities were chained to logs, trees or other fixed spots. Hospitals were found to have poor sanitation. Individuals are routinely institutionalised by their family or police and denied the right to refuse or appeal their confinement, which may include forced treatment, physical abuse and seclusion. The report of the UN Special Rapporteur on torture expressed concern about the use of electroshock with the use of restraints, without adequate anaesthesia.

The call for "scaling up" of mental health services in low and middle-income countries (LMICs) has caused controversy. For example, books by Suman Fernando, Mental health worldwide: Culture, globalization and development, and China Mills, Decolonizing global mental health: The psychiatrization of the majority world have criticised the Movement for Global Mental Health. This is because LMICs may do better to develop their own solutions rather than emulate high-income countries (HICs). Do LMICs really want to develop the same pharmaceutical emphasis as so-called developed countries? Being disempowered and living in conditions of persistent poverty may not be improved by perceiving the emotional consequences of such social disadvantages as a brain problem. Wellbeing may be more than a medical problem.

As Suman says, "care is needed in how the concept of 'human rights' is interpreted" and may not mean having the right to the same psychiatric treatment practiced in the West. As he also says, "Perhaps asylums should never have been introduced in LMICs". Human rights are violated in these institutions, which requires urgent attention. Some religious healing activities may need to be controlled. Suman agrees that injustices must be remedied, but I'm not sure if I agree that legislative changes (which clearly must take account of local services rather than merely being copied wholesale from legislation in HICs) should have less priority than community service development. I do agree, though, with his view that a paradigm shift envisaged by Bracken et al (2012) (see previous post) is required to create a psychiatric practice "sufficiently flexible to play a constructive role in mental health systems worldwide". Such an approach must be driven by the human rights of people with mental health problems.