Opposing increased coercion in reform of the Mental Health Act

I have been looking at some minutes from when the Critical Psychiatry Network first started meeting in January 1999. A paper was written before the meeting by Phil Thomas and Pat Bracken because of concerns about the potential for coercion increasing in the context of the reform at the time of the 1983 Mental Health Act (MHA) (see my website at the time, now essentially defunct because of dead links, but maybe these need to be resurrected). Initially the group was called the 'Bradford group' after the city in which the first meeting took place. At the 6th meeting of the group in October that year the name 'Critical Psychiatry Network' was adopted to reflect the fact that the group had taken on wider critical psychiatry concerns.

As mentioned in a previous post, my edited book Critical psychiatry: The limits of madness came out of three conferences that I organised for the Critical Psychiatry Network (CPN) in 2001-2003, to which I added four chapters. What I suggested in my first chapter was that "although critical psychiatry has its roots in anti-psychiatry, it does represent an advance over the polarisation in the debate about psychiatry engendered by anti-psychiatry" (p.3) (see my chapter in the book on 'Historical perspectives on anti-psychiatry'). In my last chapter, I summarised where CPN had got to by 2006 (see extract), just before the MHA was amended.

More recently Pat and Phil have reflected on where critical psychiatry is now (see previous post). This is relevant, considering that the MHA is again currently under review (see another previous post). There are concerns that people’s dignity, autonomy and human rights are overlooked (see report from Mental Health Alliance, from which CPN resigned when it looked as though the Alliance was going to compromise on the introduction of CTOs, which essentially proved to be the case). I have had no response to an email to the Chair of the Mental Health Alliance about this situation, nor  does the Alliance, I guess like a lot of organisations, seem to have responded to the formal request for evidence from the Independent Review. Still, I have managed to find responses from Agenda, the Law Society, Faith Action, the Royal College of Psychiatrists and a response coordinated by the Centre for Mental Health, Prison Reform Trust, and Together for Mental Wellbeing. Although the Review's website says that it is still open to submissions of evidence, I have not had a response to my email asking for confirmation that it is not too late to submit evidence. There does seem to be a question about how open this review, chaired by Sir Simon Wessely, has been before a report with recommendations is produced in the autumn.

What’s happened to Harvard psychiatry?

Theo Manschrek and Arthur Kleinman in their introduction to a 1977 book, Renewal in psychiatry, that I have mentioned before (see previous post), decried the “current deficiency of critical rationality in psychiatry” (p.1). They wrote these words soon after they started training in psychiatry, but I think they still apply today.

They also edited their book to honour Leon Eisenberg (who I have mentioned in another previous post). Their contribution was written from “strong backgrounds in clinical medicine” (p.2). They recognised “how ubiquitous within psychiatry the practices of uncritical thinking and inattention to methodological issues are” (p.2). People after my own heart!

They divided the state of psychiatry at the time into what they labelled the semicritical and hubris positions. The first is what I have called the atheoretical, eclectic position, for example adopted by Anthony Clare after the anti-psychiatry debate (see previous post). It’s a consensus position taken by mainstream psychiatrists, such as Simon Wessely (see another previous post). It’s sometimes called the biopsychosocial model by its advocates, but this is not fully understanding what George Engel meant when he said there was a need for a new medical model (see another previous post). Manshreck & Kleinman say that the semi-critical position “fails to see the limitations of the medical model in clinical medicine ... and, thus, does not push its critique far enough” (p.7).

The hubris position is what I tend to call the biomedical model. This is a more dogmatic position, which Engel reacted against to produce his biopsychosocial model (see copy of my talk). More recently it has been called a ‘remedicalised psychiatry’ (see another previous post). Manschrek and Kleinman “see this position as very dangerous” (p.7). It’s interesting their book was published in 1977, the same year as Engel’s paper in Science. There is, therefore, no cross referencing. Both propose a new way forward and this is set in the context of what they see as the more radical critique of authors such as Thomas Szasz.

Quoting Callway (1975), Manschrek & Kleinman say that “psychiatry needs to tidy up the mess left by its snake oil salesmen” (p.8) and conclude that “special psychiatric techniques ... have sold themselves too well” (p.8). To discover the ”roots and consequences of this crisis” (p.9), they do an excellent examination of the clinical, biological and sociocultural traditions within psychiatry at the time.

Interestingly they saw psychiatry then as in the same state as the origins of psychology with William James (see my book review). They found that ”much is amiss in psychiatry” (p.22). From their point of view, psychiatry needed a firmer foundation. They recognised the “barriers to the realisation of this consensus“ (p.22) and their solution was that “psychiatrists employ a critical stance toward knowledge” (p.33). I couldn’t agree more.

Manschrek & Kleinman promoted critical rationality as a “tool that ... can go far to discipline the fields of psychiatry” (p.29). Of course, a truly scientific perspective should start from the null hypothesis, even though most so-called scientific research speculates beyond the evidence (for example, see my comments about cannabis and psychosis (see previous post) and/or tobacco and psychosis (see eg. another previous post)). Manschrek & Kleinman encouraged explicit goals for training (eg. see previous post) with an emphasis on method. As they said, “rationality alone is not a sufficient answer” (p. 23). I have also looked at the definition of ’critical’ (eg. see powerpoint slide).

What is of interest is what happened to Manschrek & Kleinman's perspective. As is known, Arthur Kleinman went on to become central to integrating anthropology with medicine and psychiatry (see previous posts linking to two of Kleinman's classic books: Rethinking psychiatry and The illness narratives). But what about Theo Manschrek? He was, after all, the first author of this chapter. I suspect he got taken up with neo-Krapelinianism (see eg. my book chapter). I may be wrong but it would be interesting to find out, because the need for a critical rationality in psychiatry is even more pressing now than it was then (eg. see another previous post).

Further reflection on antidepressant efficacy

Having first reflected (if that’s the right word) in the media, Cipriani et al now reflect on their network meta-analysis (see previous post) in Lancet Psychiatry (see article), which is a more sober affair. Again they admit that differences between antidepressants are small, but qualify this by saying that “exceptions exist”, but then do not spell out what those exceptions are. They come up with a slightly lower figure for placebo response in clinical trials than a BMJ editorial (see previous post), but who’s going to argue about a few percentage points in a matter like this? They don’t really say that the range of antidepressant responses for different drugs in the trials included in the analysis could be due to the trials themselves rather than the drugs.

As I said previously, none of this is new. To me, all the fuss about this study, which has led Cipriani et al to reflect on it, seems to have been created because this is 6 years work which only reaches weak conclusions. Going slightly off message, they go on to argue for open access to data from clinical trials at the anonymised individual patient level. Having always been open in this blog, I couldn’t agree more, although I suspect that all this will do is show up even more biases in the data.

Anyway, Cipriani et al seem to be agreeing the debate about antidepressant efficacy has not been ended by their study. As I have said several times previously, I would also encourage them to research the placebo amplification hypothesis, however difficult this may be.

Carmine Pariante is having a great time

I’ve expressed concern before about the scientific credibility of American academic psychiatry (see previous post). Following the recent article from Carmine Pariante, who I have mentioned before (eg. see my previous post with which Pariante said he agreed - with qualification - in a tweet), about ‘A parallel universe ... ‘, I think we should also be concerned about British academic psychiatry. 

Pariante promotes psychoneuroimmunology, otherwise known as immunopsychiatry. He regards this “new discipline as an example of successful translational neuroscience overcoming the brain-mind-body trichotomy” [his emphasis] (quoted from his article). I agree with Pariante that “psychiatrists, psychologists and social scientists can work together to link the mental and the neural” (quoted from his article with Nik Rose - see my previous post). But I don’t think Pariante has understood Nik’s notion of ‘critical friendship’ between social sciences and neuroscience.

The trouble for Pariante is that there is a difference between psychiatry and medicine. There should actually be agreement that psychiatry is different from medicine. Where there is disagreement is about how much to make of that difference (see another previous post). As I keep saying, I don’t want to be misunderstood. As Pariante himself says in the latest article,  “We have a body (which includes a brain)”. Like him, I’m not wanting to create barricades between biomedical and psychosocial approaches in psychiatry. But he does need to understand that minds are enabled but not reducible to brains (eg. see another previous post). 

I think Pariante needs to come down to earth, otherwise it’s going to get him in trouble with the General Medical Council (GMC), as he acts as a Royal College of Psychiatrists spokesman. There’s already been one complaint to the GMC. Perhaps we need Nik to come back out of retirement to sort this mess out.

Clarifying Szasz's critique of psychiatry

Nassir Ghaemi has published his invited commentary which was rejected for a new book on Thomas Szsaz (see article). It's the advantage of the internet that these pieces can still be published, as I know from my own critical psychiatry blog!

Of course, Szasz was known as an anti-psychiatrist (see previous post). I'm glad he had the academic freedom to promote his views (see another previous post). Szasz started at the Chicago Institute for Psychoanalysis from 1951–56. He was particularly influenced by Franz Alexander (see book).

But I worry that Ghaemi has become too much of an 'anti-psychoanalyst' by believing that psychoanalysis in the 1950s, when Szasz was in Chicago, "stunted any free thought". He argues that "[t]he psychiatry that Szasz railed against in his most famous book was full of myths and was mostly false", because it was primarily psychoanalysis. I agree that the prominence of psychoanalysis did help to make psychiatry more pluralistic then. But I don't think Ghaemi fully understands about the myth of mental illness (see another previous post). And, as I've also said before, "Despite his protests, he [Szasz] will always be associated with the history of anti-psychiatry" (quote from previous post).

I'm certainly not resting my criticisms of psychiatry on the same viewpoints as Szasz. Have a look at my actually quite generous, I think, review of one of his books (see book review).  But, in fact, Szasz was quite scathing (as he could be about lots of things) about the Critical Psychiatry Network (eg. see previous post), of which I am a founding member. I don't even take the same view as him on the insanity defence (see previous post).

I did wonder what was going on when Ghaemi seemed to become more questioning about psychiatric diagnosis (see previous post). But it's clear from the latest article that he hasn't given up his beliefs in biological markers and the genetics of mental disorder. This is why he thinks Szasz was wrong. But he's actually not arguing for the right reasons, which is what he accuses Szasz of doing (see another post). Let me work towards a conclusion with a quote from another previous post:-

The primary problem with modern psychiatry is its reduction of mental illness to bodily dysfunction. Objectification of those identified as mentally ill, by insisting on the somatic nature of their illness, may apparently simplify matters and help protect those trying to provide care from the pain experienced by those needing support. But psychiatric assessment too often fails to appreciate personal and social precursors of mental illness by avoiding or not taking account of such psychosocial considerations. Mainstream psychiatry acts on the somatic hypothesis of mental illness to the detriment of understanding people's problems.

Szasz was correct that he first made this argument in The myth of mental illness. 

From my point of view Szasz undermined this argument by insisting on such matters as abolishing all psychiatric coercion. I've said before (see book review) that it can seem quite muddling arguing with Ghaemi but I've tried here to clarify the positions of Szasz and myself, not make them more confusing.


(with thanks to Neil MacFarlane whose tweet linked me to the Ghaemi article)