Monday, August 14, 2017

Differences within critical psychiatry

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

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

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


(with thanks to Kermit Cole for making the video)

17 comments:

cobweb said...

Thank you very much Duncan for putting up the video. To be honest I am not sure how much the significant differences between you all are going to help service users. One of the big problems is actually that people have no choice about who they get referred to - and as you point out one will have one perspective another a different one which will effect how a service is provided and the lives of real individals . The truth is that there is a rise of over 30percent of people going to emergency departments by ambulance as there are no appropriate services to get help - psychological, medical or social. It is likely to lead to more over medication and more involuntary hospitalisation. Whereas at one time therapy seemed to provide hope even that is being undermined by the obvious lack of provision , the m0st person centred practice of all - psychoanalysis, is being corrupted by the mechanisation of assessment and diagnoses as described in the Psychodynmic Diagnostic Manual -pub july 2017 which apes the dehumanising psychiatric diagnostic manual in an attempt to make it more 'scientific'. The training of new mental health workers is being made to seem more modern and 'exciting' by the neuroscience project.
So you ask for suggestions - abolish the college of psychiatrists which has too many vested interests which do not serve the public, close down the remaining institutions where people do not get properly cared for, close down the private clinics which are profiting from misery and open small user led centres, give the massive amounts of funds which are wasted on institutions to projects users want including 'meetups' and other peer led projects. let service users themselves employ those who will best serve and genuinely care about them. Psychiatric colleges have had their day. Small is beautiful. The power differential needs to be radically adjusted =there are a whole two services users and carers on the college of psychs cttee - what a joke - so that service users and others who could radically change the services are enabled rather than constantly disempowered from making provision humane and trustworthy.

Claire Muir said...

Obviously the fact that one can be forced treated even if you have capacity should be changed in the scottish mental health act and the human rights act should be amended to reflect any disagreement on this.As it stands, we have two conflicting laws. This can't be right no matter who agrees or disagrees.

cobweb said...

A complete ban of people being pinned face down, their clothes pulled down and injections given in the buttocks. Apart from being an assault, some clinics have never used it, that this has obvious sexual implications is obvious.
Bring in sanctions against heath workers who make derogatory remarks in persons' files - not only insulting and unethical but has knock on effects on how subsequent workers may behave.
Strengthen rights to have proof of consent to medications and other treatments recorded on files ie clients' signatures to state informed consent has been given.
Give people rights to know what type of treatment the health worker they are referred to favours and practices and in reality rather than on paper the right of choice of an alternative.
When adverse effects of medication is experienced there must be reliable way of clients being able to report them and have their report acknowledged and recorded on a data base if they agree. so that a record of adverse effects can be built up too often -they are belittled and undermined which is causing harm. The Yellow Card Scheme is not working. People can still be blocked from reading their files - there needs to be something done about this.
More funding to be given to 'user' controlled projects

Professor Peter Kinderman said...

Hi Duncan,
To address, very swiftly, your questions:
1. Yes. My view is that we need genuinely multi-disciplinary care, and so my medical colleagues play a valuable role. So psychiatry should be a medical discipline, and medical psychiatrists should be part of those teams, and should - explicitly - add that medical perspective. But... 'psychiatry' should be synonymous with 'that branch of medicine contributing to mental health care', not synonymous with 'mental health care'. The latter issue is multidisciplinary and psychiatry should play it's part. That also, by extension, means an end to 'clinical primacy' and 'sapiential authority'. In my view, it's great to have medical experts as part of teams, but that's not the totality of the system.
2. Yes... or at least predicted on capacity. In my view, there are some differences between long-term and emergency care for people who are unable to make valid decisions for themselves, and so I'd welcome a radical reform of the Mental Health Act - setting out the circumstances and procedures under which we might make best interests decisions for people whose distress or confusion means they cannot make decisions for themselves. I have (sorry, I know!) written about this in my book.
3. No. Like broken legs or pregnancy, there are many issues that benefit from the input of our medical colleagues, but that absolutely doesn't mean the underlying issues are best though of as disorders or illnesses. Indeed (as, again, we've written about at length), that thinking has major negative consequences.
So... Yes, yes, no. And psychiatry is valuable and admirable... but I do want significant changes.
Peter

Duncan Double said...

Thanks for your comment and clarification, Peter. In this spirit, as you say you have written about the Mental Health Act in your book, but I was left with the question as to whether you would support professional recommendations for detention being made by other than doctors e.g. clinical psychologists - see previous post. Any thoughts?

And, I suppose something has 'gone wrong' if one breaks a leg or there are complications in pregnancy. Similarly, something can 'go wrong' with mental functioning.

And I totally agree about medical authority, which does not have a right to any dominant position in mental health care. I would want to encourage psychiatrists to be patient-centred and not just focus on biological aspects, although as you say their medical training can be helpful in understanding physical disease. Still, it can also be a hindrance to giving up the disease model of mental disorder (see another previous post). I agree with you about need for significant change.

Professor Peter Kinderman said...

Hi Duncan,

Yes (page 126 and subsequently)
In essence, yes.
So my view is yes, professional in addition to doctors - psychologists AND others should be involved.
Just as in the reformed (2007 reform) I can see much merit in a range of mental health professionals offering evidence.
But I should just contextualise "offering evidence"
In the circumstances we're discussing, I think we - mental health professionals - should offer evidence on a number of key issues; a) a plan for care, b) why it's necessary (to avoid serious and imminent harm), c) why all other possibilities have been exhausted, d) why what is proposed is not only the 'least restrictive alternative' but also, e) in the person's best interests, and indeed, also f) is the best way to protect their rights (all of which is pretty close to what we've got, to be fair)
Then, I think what's also crucial is that we should provide evidence that the person is not able to exercise their autonomy. This is the 'capacity' issue. I am very close to the idea that we don't need mental health legislation at all, but in fact need reforms to the Mental Capacity Act, but there's a lot of discussion to be had there.
Then, I think that, instead of us (whether that's medical psychiatrists or other professionals) being empowered to detain and treat 'under the Act', I believe that we should present that evidence to a Magistrate or Judge. And then... the question is really which professionals should have the responsibility of providing that evidence? And I think, yes, several professionals have the qualifications to provide that evidence - obviously similar to the 'responsible clinician' skill-set.
So... for me, a capacity-based issue, protecting people's autonomy unless they are unable to make decisions themselves, then, if we have good professional grounds for arguing that a person's rights need to be protected on their behalf because they can't exercise that judgment themselves, I think that we (a number of relevant professionals) should present that evidence to a Judge, and obtain a Court Order for our proposed care plan.
And... to answer your specific point, who should give evidence and who should be empowered to implement such Court Orders? Yes, a range of professionals, as envisaged (partially) under the idea of 'responsible clinicians' from a number of professional backgrounds.

Duncan Double said...

Thanks for clarification and I think I essentially agree. Let's hope these issues get addressed by government review (see previous post. But I'm not convinced Mental Health Alliance is way forward and wonder what representative body there could be.

Professor Peter Kinderman said...

Agreement !
Shock !
We'll go together into Bruegel's vision of hell.

Duncan Double said...

Shouldn't be such a shock!

cobweb said...

Most of those in the Network are in touch service users --ask them directly ,m,ost have no idea this blog exists but if personal disagreements are flagged up they need to be clarifies or it gets to seem like cosy groups on non users are communicating mainly with themselves

Anonymous said...

HI there,

In terms of forced treatment: I think there should be a distinction between allowing for 'forced safety' (which may involve temporary, humane forced confinement) and 'forced treatment'. I do not think that forced treatment decisions should ever be made by professionals alone. In the case where there is reduced mental capacity, a parent or significant other should also be involved to act of behalf of their loved one and only if they also give 'informed consent' should forced treatment ever be considered. Although this is not the perfect scenario, (a more perfect scenario would be if the service user had appointed someone as their spokesperson but this usually wouldn't be the case for first episode psychosis) but at least the professional and significant other could act as 'brakes' for one another. This is so very important due to the conflicting state of the research (e.g. people should not be forced on treatment which is at best experimental)
Also before all this is even considered, a whole process of deeming whether someone is mentally competent should take place that would mean that only the very, very severe and non-responsive people would be considered to have reduced mental capacity (not just because they hear voices or have some delusions or do some bizarre unpredictable acts - this is what 'forced safety' is for.) All of this would take time to sort out, and would involve a more open dialogue type model, which I think are the most important factors: treatment needs to slow way, way down so that medication etc. is only used as a last resort, and people need to have a chance to recover first in a supportive environment

Anonymous said...

Just to add to my comment above: a judge of course should be involved in the deemed compentent part, but I would like to add to Peter Kinderman's points that it should not only be responsible clinicians, but also responsible caring significant others. These decisions should never be made by professionals alone.

Duncan Double said...

Again, I'm inclined to agree with you, Anonymous.

Nradabhatse die Katze said...

I would like to caution that state-sponsored judges and legal aids do nothing to change the situation in e.g. Germany: Police rough you up for giving lip, find no legal means to punish you for long and let you be transported to a hospital for "being aggressive". A Psychiatrist rubber stamps you mental ill after the exchange of a few sentences or it is night-time and you can try to sleep fixated to a bed at all four extremities with the obligatory injection of neuroleptics. In the morning you are persented to a judge and little jury and 15 minutes later you have lost all rights to self-determination for at least 6 weeks. I would recommend a civil, tax payed and independently and qualitity selected legal council antagonist to psychiatrist and judge. Good luck. :)

Duncan Double said...

Agree there is potential problem of legal system just rubber-stamping professional opinion. There needs to be the potential for challenge to professional opinion.

Steve McCrea said...

"...coercion needs to be minimised." The problem is, "minimized" is way too vague a concept. We should say, "Coercion should be eliminated except to the extent that is needed to avoid immediate harm to self or others. Conceiving of coercion of any form as "treatment" should be completely eliminated from consideration. There is no such thing as "forced treatment." Force is social control. Treatment may only be considered treatment when it is voluntary.

cobweb said...

EXASOL which analyses massive data has published results of analysing prescription of anti depressant in England - a shocking 64 million p.a. Twice as many in NE England as S.E and London.
There is a conference to be held in Paris May 2019 International Conference on Anti Depressant Prescribing. There must be some service users/survivors who are able to tackle the science and technical input to this - there is no specific intention to include but no specific intention to exclude. It is a long way off but may hold out some hope that the findings will provide better services in future. Until then something should be done about the shameful inequality across the UK both in quality of life and over prescribing of anti depressants in different areas. Some useful info on the Yellow Card Website