What is anti-psychiatry?

I’ve complained before that people continue to use the term ‘anti-psychiatry’ without being clear what they mean (see eg. previous post). There are people that want to abolish psychiatry and maybe that is the only way in which the term ‘antipsychiatry’ (without the hyphen) should be used (see another previous post). 

Psychiatry does need to change. The trouble with using the term anti-psychiatry is that it marginalises legitimate critique. 

Working towards abolishing community treatment orders (CTOs)

As Alex Ruck Keene said in his blog post, last week’s King’s Speech announced the introduction of a Mental Health bill to modernise the Mental Health Act (MHA) 1983. There is a sense in which it could be said to be misleading to imply that the 1983 Act has merely become out of date, which is how the government tends to present the case for reform (see previous post). Both the 1959 and 1983 Acts were progressive Acts in the sense of improving the rights of people with mental health problems. There were some progressive elements to the amendments introduced in 2007 by the previous Labour government, such as the introduction of independent advocacy, although this was never properly funded (see eg. previous post).  Essentially, however, the amended Act was a regressive step, particularly through introducing community treatment orders (CTOs). Hopefully the new Bill will actually further improve the rights of people with mental health problems (see eg. couple of tweets from Mind - first and second) and take into account WHO/OHCHR recent guidance on Mental health, human rights and legislation (see eg. previous post).

The Parliamentary Committee that scrutinised the draft Mental Health bill produced by the last government recommended that CTOs should be abolished for civil patients (see previous post). The Mental Health Alliance was formed in the context of the last Labour government’s attempt at MHA reform which led to the compromise of the 2007 amendments. There were major demonstrations against the Labour government’s proposals at the time (see eg. Early Day Motion). The Critical Psychiatry Network (CPN),  of which I am a founding member, was one of the original members of the Mental Health Alliance, although it resigned from the Alliance when it became clear that the Alliance was prepared to compromise on CTOs (see resignation letter and previous letter of concern to Alliance). Evidence since then has only essentially reinforced the view that CTOs do not work (see eg. previous post). CPN summarised its concerns about CTOs in a 2007 statement). 

The Alliance still exists and is a broader grouping than originally of mental health organisations. It does need to take on board, as does the government, the full implications of the United Nations Convention on the Rights of People with Disabilities (CRPD) (see eg. previous post). Both the World Health Organisation and the World Psychiatric Association urge countries to take action to promote non-coercive practices in mental health. This should include the UK government following the recommendation from the Parliamentary Scrutiny Committee to abolish CTOs for civil patients.

The government plans to introduce MHA reforms in phases as resources allow, and says it will not commence new powers unless there are sufficient staff in place to ensure it is safe to do so (see background briefing). Personally I’m not really convinced increasing the number of Tribunals and providing more access to SOADs and Tribunals, as proposed by the draft Bill, is really needed. It is also where more funding will be required, which could prevent implementation of any new Act. 

Reform of the Mental Health Tribunal to make it more human rights based could start now (see previous post), I think without any necessary legislative changes. Changes could also be made to improve independent advocacy by encouraging more integration between Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts (see another previous post), I think, again, without any necessary legislative changes. I suspect also that the CQC could ensure that the proposed S56 to introduce a clinical checklist to be followed by Responsible Clinicians and Second Opinion Approved Doctors (SOADs) could be implemented before such a change is reinforced and make legal in a reformed Act (see previous post). More could also be done to prevent the commissioning of secure placements by commissioners restricting, if not completely preventing, such funding for civil detentions. Work could also be undertaken on creating a new Mental Health Commissioner for England, as recommended by the Scrutiny Committee, probably incorporating and building on the current CQC MHA reviewer function (see another previous post). 

As part of taking forward its mental health strategy, the government needs to be clear that MHA reform starts now by improving patients’ rights. This programme of work can be taken forward alongside the development of a new Bill to be presented to parliament. 

The aspirations of psychiatry

King's College London press release announces that the "Wellcome Trust have awarded the funds [£5million] for a new 5-year ground-breaking research project ‘ASPIRE’, aiming to conclusively test if anti-inflammatories can be the right treatment for the right people with depression". Not sure how conclusive the results will be considering the description of the project on the Global Alliance of Mental Illness Advocacy Networks-Europe (GAMIAN-Europe) website. 

Also not quite sure what the Wellcome Trust meant a few years ago when it acknowledged that a radical new approach is needed for mental health research (see previous post), as it now seems to be allocating funding again on the same basis by wasting it on 'pie in the sky’ fantasies about what's possible with mental health treatments. I'm not wanting to polarise debate unnecessarily in psychiatry, and advocate, like Nik Rose (see previous post), for critical friendship between social sciences and neuroscience. However, I think this does need an acknowledgement from neuroscience that too much neuroscience funding is being wasted on the unattainable.

I've been ruthless in my criticism of the conceptual foundations of the psychiatry of Carmine Pariante, the primary investigator of ASPIRE (see eg. previous post). I also did a cutting, satirical review of the book by Ed Bullmore (see previous post), that made the case, like ASPIRE, for anti-inflammatory medications being used as treatment for depression by targeting the right people on the basis of levels of inflammation. To me, it's nonsensical to talk about depression as an inflammatory disorder, like rheumatoid arthritis (see eg. another previous post). More fundamentally, looking for abnormalities of inflammation in the brains of depressed people is a conceptual category error (see eg. last post). 

Summarising the argument of relational psychiatry

Depression of course is mediated via the brain but looking for abnormalities in the brain to explain why people are depressed is a category error. It is a fallacy to identify the brain with the person, in depressed people as much as in people who are not depressed.

I make this statement as a summary of the position of relational psychiatry (see eg. previous post), applying it to all functional mental illness, including schizophrenia and manic-depressive illness, not just depression. As I mentioned in a previous post, Bennett & Hacker call the category mistake of identifying the part with the whole the ‘mereological fallacy’. As I keep saying, psychiatry must stop identifying the brain with the person (see eg. another previous post). 

It is particularly people who have mental health problems who are reduced to their brains, and this is discrimination. However, such thinking permeates modern culture, reducing all people to their brains (see eg. previous post). Children are even being misled about the nature of mental illness (see eg. another previous post). What we need is a change from psychiatry being based on the notion that primary mental illness will be found to have a physical cause, to it moving on to a more relational practice (see eg. my article).