Friday, March 30, 2018

The psychiatrist as a cultural interpreter

I responded to a BMJ review of Sami Timimi’s book Pathological child psychiatry and the medicalisation of childhoodwhen the book first came out in 2002 (see response). This was before the publication of Post-psychiatry (discussed in a previous post). So, if Post-psychiatry is seen as one of the first texts of the Critical Psychiatry Network, Sami’s book has priority. Sami has published several other books since (see list on Wikipedia page). He also wrote a chapter for my Critical psychiatry book.

Sami came to England from Iraq when he was aged 14. This means he is very aware of discrimination, although during his training he found himself “becoming more and more critical of ... Arabic culture” (p. 126). Western powers’ involvement in war and destruction in Iraq led to him having a more balanced perspective (see my 2010 Openmind psychiatric update column). As Sami says, "[r]esistance is in my bones" (p.163).

Sami found his psychiatric training “a very confusing experience” (p.1). He found it difficult to understand why he was being indoctrinated in the way he was. He came to appreciate that “the whole mental-health business is about belief systems rather than hard science” (p. 59). He also came to appreciate that "[c]hallenging the mainstream can be a lonely, isolating experience" (p. 71). As I’ve said before (eg. see previous blog), psychiatry is more like a faith than a science. I have tried to take this understanding forward by using Clifford Geertz’s definition of culture as "a system of inherited conceptions expressed in symbolic forms by means of which men communicate, perpetuate, and develop their knowledge about and attitudes toward life" (see eg. another previous post). Sami likened the kind of experience he went through to that described by Frantz Fanon when "black families in Europe often had to choose between alienation or adopting a European outlook and pretending that the racism around them did not exist" (p. 71). When seen as a non-believer at a pro-Ritalin and pro-ADHD conference, Sami "left the conference feeling he had attended an extremist cult convention" (p.85).

Still, Sami is a child and adolescent psychiatrist and this field used to be a haven for those that wanted to escape the abuses within adult psychiatry. Sami rightly worries that the increasing biologising of childhood has brought child and adolescent psychiatry within these parameters. When he and I trained, we were taught that there were emotional and conduct problems in childhood. Now medical students tend not to be taught this, instead being told to focus on ADHD and autistic spectrum disorders. Childhood depression, then, when we trained, was not recognised in the same way as adult depression, like it is now (see my BMJ letter).

In his first book, Sami said, "In essence what all of us who are working in the field of therapy for social suffering are doing is acting as cultural interpreters" (p. 83). Here he is using the notion of symbolic healing. Psychiatric practice is “using culturally meaningful mediated symbols” (p. 80). Sami recognises the way in which the 'new transcultural psychiatry' criticises orthodox psychiatry for "not giving proper consideration to context" (p. 156). He utilises "post-modern therapies" (p.130), defined widely, to include narrative and solution-focused approaches. His honesty even leads to him at times sharing "information from my own life" (p.135).

As Sami himself says, he has used "quiet persistence" (p.163) to get his message across. He has contributed significantly to modern critical psychiatry.


Anonymous said...

Sami Timini is such a well respected humane person who has saved many children from the horrors of often life long harmful drugs being prescribed for them - and the consequential loss of a childhood celebrating their own personhood. . Many parents have cause to be grateful to him. Are you not practicing in the same Trust Duncan? Is there something about that Trust which enables clinicians to practice without imposing harmful diagnoses and treatments on vulnerable children? What by the way has happened to Suman Fernando? What will be the fate of all youngsters and indeed adults when such people hang up their boots? susanne stevens

Duncan Double said...

Thanks Duncan
I’m very flattered. One thing I think might come across the wrong way is the bit about being critical of Arab culture. The reason I mentioned that at the time was post-hoc reflection on how my training (both psychotherapy and psychiatry) led me to this view (primitive not psychologically minded etc), so it was an example of the inherent racism and Western bias in the field that led me to criticise my own background unfairly. I don’t know if it’s also relevant that whilst my earlier writing had a politics of mental health focus and hence more influenced by postmodernism later I also became interested in how politics affects mental health and this is more influenced by Marxist ideas. Thanks again Duncan,

Duncan Double said...

Thanks, anonymous. Sami’s in Lincoln; I’m in Lowestoft. We’re both part of the Critical Psychiatry Network. Suman’s commented on a previous post with links at the bottom to what he’s doing (see He’s also part of Critical Psychiatry Network.

Neil MacFarlane said...

The first chapter of Sami's 2002 book evokes the early 1990s very well: I started 18 months before him, early 1988, at the so-called 'Transcultural Psychiatry Unit' in Bradford. His descriptions ring so true:

'The psychotherapy consultant at this first hospital that I worked at in London appeared to me a very serious man who was always deep in thought. I can’t remember him ever smiling or laughing at anything and soon I found myself carrying this sense of deep seriousness into psychotherapy sessions with patients. One common feature of both the psychiatric and the psychoanalytic approach seemed to be an emphasis on pathology and what was wrong and the seriousness of what was wrong.'

When I first read Sami's work in the mid 2000's I was underwhelmed by it's naive rejection of 'modernism' and setting up of 'postmodernism' as the answer. Bracken and Thomas' 'Postpsychiatry' was similar. For me, and for many who read the broadsheet press, the Sokal Hoax had deflated PoMo, Deconstructionism and Foucault in 1996-8. With hindsight, this was best anticipated by Terry Eagleton's Illusions of Postmodernism (1992).

But looking at the 2002 book again, the use of academic jargon seems non-essential and the evidence and reasoning are often well-deployed. There are plenty of good old-fashioned practitioner anecdotes. I also found a couple of very interesting pages (74-6) on Soviet psychiatry which end proposing that: 'in both systems, psychiatry pretending to be an objective science-based practice, has, in effect, been used by the state to successfully marginalize dissenting voices and support ‘official’ versions of what ‘normal’ thinking and behaviour should be.'

Sami has a place in the history of the British media by featuring in the only BBC Panorama programme ever to be retracted (2010) after broadcast (2007): see my Blog pieces at The BBC tries to keep it off Youtube but right now someone (probably anti-ADD / ADHD) has put a couple of excerpts up. Sami appears about 6 minutes in:

Anonymous said...

Regarding your quote Neil Macfarlane about Soviet psychiatry - you possibly have read a book illustrating what you say is 'A Question of Madness. by Zores and Ray Medvedey - How a Russian scientist was put in a Soviet mental hospital , and how he got out'.The 'diagnosis' used to try to incarcerate him was 'reformist delusion'. After the publication of his book in 1971 he was bared from returning to Russia from UK. susanne

Neil MacFarlane said...

Hello Susanne...I have never read the book but I have heard of so-called 'reformist delusions'. For me, the interesting point would be the extent to which the Soviet psychiatrists actually believed in them. I suspect that some did, some didn't but went along.

The two pages in Sami's book are supported by a classic piece of cross-national research from the early 1970s, the 'US-UK Diagnostic Project', which showed that diagnosis of schizophrenia was ten times higher in the US: When I first encountered psychiatry as a medical student in 1984-5 that was very recent, and of course the Soviet Union looked set for decades, at least.

The recent problems between the UK and Russia I find very sad, because a visit there is on my (very short) bucket list.