Fearless speaking about psychiatry

John Heaton has been mentioned in this blog before (eg. in a guest post by Miles Clapham). John wrote a chapter in my edited Critical psychiatry book. He used the Greek notion of parrhesia from Foucault to help explain that critical psychiatry is a practice that states frankly what one thinks about the nature of persons and psychiatry. 

In the Fall Term of 1983, Foucault gave 6 lectures in English at the University of California in Berkeley as part of a seminar entitled ‘Discourse and Truth’ devoted to the study of parrhesia. These were taped recorded and edited by Joseph Pearson and published as Fearless Speech (2001). The general objective of the seminar was to construct a genealogy of the critical attitude in Western philosophy. 

The parrhesiates is someone who uses parrhesia and opens their heart and mind completely to other people through their discourse. The parrhestiastes makes clear they are expressing their own opinion by using the most direct words and expression they can find to express what they actually believe. In a positive sense, they are telling the truth because they know it is true. They are saying something dangerous because it is different from what the majority believe. They expose themselves to harm as the truth may cause hurt or anger but they prefer to be a truth-teller rather than being false to themselves. Parrhesia is therefore a form of criticism from a less powerful position than the one with whom the parrhestiastes speak. 

Parrhesia may become a problem of truth if it is seen as mere frankness in speaking when everyone is equally entitled to give their own opinion. It actually has a relation to knowledge and education. Bad, immoral or ignorant speakers may endanger democratic organisations. Saying what people want to hear avoids the necessity of being critical and the need to attempt to change people’s understanding and will. Parrhesia, in the positive sense, is, therefore, a virtuous personal attitude and quality to speak the truth boldly. 

I’ve commonly said that psychiatry is more like a faith than a science (eg. see previous post). That implies it is not true that primary mental illness is brain disease. Challenging the claim that primary mental illness is brain disease, as does critical/relational psychiatry, is not denying the reality of mental illness. It is a necessary challenge to the power of psychiatry speaking from the position of the parrhesiastes (see recent post ‘Truth-telling in psychiatry’ on my personal blog).

The definition of critical psychiatry

I mentioned before my interview with Awais Aftab (see previous post), which has now been published as a chapter in his edited book Conversations in critical psychiatry. Awais has added an introductory chapter to the interviews he has collected in the book. In that chapter he quotes my comment that “critical psychiatry may be difficult to define precisely” and suggests that the most specific use of the term is merely to make reference to psychiatrists, such as myself, associated with the Critical Psychiatry Network (CPN) (see eg. previous post). This suggestion fails to take account of my further comment that CPN takes an ideological position that primary mental illness cannot be reduced to brain disease. There is a range of views within CPN, true, but it coalesces round a systematic collection of ideas (see eg. previous post) and seeks to move on from the reductionism and positivism of much of modern psychiatry. 

Awais tries to be open to critical perspectives in psychiatry (eg. see previous post), but he is not as explicitly ideological in his position as CPN. The trouble is that he is inclined to see what he calls the integrative tradition as continuous with the critical. He wants to see integrative and critical pluralism as a variant of critical psychiatry. I’m very much in favour of an integrative and pluralistic perspective in psychiatry but this is based on CPN’s ideological position about the nature of psychiatry and the uncertainty in the field, rather than wanting to hold on to the possibility of biomedical perspectives, as does Awais.

As Robin Murray says in his foreword to the book, Awais suggests critical and integrative pluralism as a corrective to what he calls the lack of self-criticism of critical psychiatry. I’m not so convinced that critical psychiatry is lacking in self-criticism. It's more Awais saying he can't accept at least part of its critique. True, there are those within the critical psychiatry movement that want to abolish psychiatry but actually, as Awais acknowledges, members of CPN are psychiatrists themselves. As he says, “They fundamentally see critical psychiatry as a form of psychiatry”. They are open to different perspectives and take a reflexive position in their critique.

Awais is correct that “The folk judgements of 'something has gone wrong’ [in mental illness] might or might not be indicative of failure of a psychological or neurobiological mechanism to perform its ‘natural’ function”. But Awais suggests critical psychiatry creates “various binaries that sort psychiatric conditions into diseases versus problems of living, biologically caused vs representing self-directed behaviours, and illnesses vs understandable reactions to circumstances”. I agree with him that there is a form of critical psychiatry that does that. But it need not, nor do I, as a member of the Critical Psychiatry Network, so therefore representing 'critical psychiatry', at least part of it, in his sense. Those that do, as Awais notes, can be called neo-Szaszian critical psychiatrists.  Critical psychiatry does not need to be neo-Szaszian. I have always emphasised how it needs to be integrated with the mainstream (see eg. previous post). Awais should take on board, as I say in my interview, that "most presentations to psychiatrists do not have an underlying physical cause, even if that is presumed still to be discovered". Psychiatry came out of its previous phase of brain mythology in the 19th century by recognising the structural/functional distinction of mental illness at the beginning of the 20th century (see eg. previous post). Over recent years this distinction has been fudged, if not obliterated (see eg. another previous post). The point is though that psychiatry must stop reducing people to their brains (see eg. yet another previous post).

Awais is clear that he thinks it is plausible that psychiatric medications “act on mechanisms that produce, sustain, and modify symptoms”. I agree with his emphasis on outcome-based prescribing (see eg. previous post). But he is not sufficiently critical of the notion of whether medication “works” (see eg. previous post). He speculates that it “is likely that psychiatric medications act on symptom mechanisms while also producing global psychoactive effects”. He doesn’t want to consider that any effect of psychiatric medication may be primarily due to the placebo effect (see eg. previous post). 

In the same way that Anthony Clare did for a previous generation by emphasising psychiatry's eclecticism against anti-psychiatry (see eg. previous post), mainstream psychiatry seems to be defending itself against the message of critical/relational psychiatry by promoting integrative and critical pluralism. The publication of Awais' book is welcome. The trouble is that although it engages with the critique of psychiatry, it does not properly take its message on board because psychiatry does not want to change. However difficult it may be to hear the critique of critical/relational psychiatry, it does need to be stated boldly in the interests of patients (see eg. another previous post). Otherwise, psychiatry will merely continue to defend and maintain its biologism.

Do antidepressants cause manic switch?

As I said in a previous post, some critics of psychotropic medication do not always seem to apply the same rigorous scepticism to side effects as they do to treatment effects of medication. For example, in my review of Peter Breggin's (2001) The Anti-Depressant Fact Book: What Your Doctor Won't Tell You About Prozac, Zoloft, Paxil, Celexa, and Luvox, I expressed concern that people were being misled about the side effects of antidepressants. One of these controversial areas was whether antidepressants can cause people to shift to manic symptoms, potentially leading to a diagnostic transition from unipolar depression to bipolar disorder. 

Ironically, mainstream psychiatry also tends to believe in a causal relationship between antidepressants and manic switch (see eg. previous post). Current guidelines do not recommend using antidepressants in first-line treatment for acute bipolar depression, at last partly because of the risk of manic switch (see recent American Journal of Psychiatry editorial). Even so, generally the evidence for antidepressant induced mania has been seen as uncertain.

Rhode et al (2024) used data from a Danish health register to compare the occurrence of mania and bipolar depression in the year after discharge from a psychiatric ward of bipolar depressed patients who either received antidepressants or did not. There was no statistically significant association between treatment with an antidepressant and the risk of mania in the full sample, nor in the subsample concomitantly treated with a mood-stabilizing agent, nor in the subsample not treated with a mood-stabilizing agent. Neither was there any statistically significant association between treatment with an antidepressant and bipolar depression recurrence. This study may add to those questioning whether the risk of manic switch is overblown.

Another recent study (Tondo et al, 2024) found that about 6.7% of patients initially diagnosed as unipolar depression followed over a period of a mean of 12.7 years had their diagnosis changed to bipolar disorder, mostly type II (76.7%) rather than type I. This conversion rate may not be as high as expected, considering the fears of manic switch. 

Moreover the way in which the concept of bipolar disorder has expanded over recent years (see eg. previous post), in association with the introduction of mood-stabilising medication (see eg. another previous post), highlights how malleable psychiatric diagnosis is. There is a legitimate issue about what bipolarity means when it has become such an all embracing term, essentially amounting to mood instability, which of course is very common and not always necessarily best described as a mental disorder (see eg. yet another previous post). The mechanism of manic switch is unclear, and psychogenic, rather than physiological factors, may be significant. A sceptical approach to interpreting the inconsistent evidence is required. Manic switch is a risk in the use of antidepressants but how significant this is and whether it is physically caused remains uncertain.

Do people want to hear the message of critical/relational psychiatry?

I said in a previous post that mainstream psychiatry ignores critical psychiatry and I seem to have been wasting my time trying to get my message across in this blog. I have subsequently changed the name of this blog from critical psychiatry to relational psychiatry (see another previous post), partly in case the term 'critical', which tends to have negative connotations, is what puts people off. But it does seem to be the content of the message that people do not want to hear, rather than necessarily the way it's expressed. I'm not convinced psychiatry is really interested in relational psychiatry either. Why is that?

People not wanting to hear the message of critical/relational psychiatry may seem surprising to some, because isn't psychiatry primarily about relationships with people, as the term ‘relational psychiatry’ implies? Surely it's about trying to support them with their difficulties in their personal situation and relationships with others through an independent professional relationship. Is psychiatry then not really about helping people?

Well, yes and no seems to be the answer! Psychiatry does think it is helping people but not apparently necessarily through relationships with them. The focus tends to be on treating their brain problem. Psychiatry believes people's psychosocial difficulties may well be correctable by some physical intervention, such as prescribing medication, or by a simple, brief psychological course of therapy. The person will then be alright, or at least better with that treatment. Is there any more to it?

That’s the positive component to psychiatry's answer, is it? But what about the negative? What's wrong with just accepting this mainstream psychiatric view? However much of a caricature of psychiatry I'm presenting, it does seem to describe the essence of what people think psychiatry is expecting them to believe. No need to wrap it up in an academic critique of psychiatry called critical/relational psychiatry. Just express it in plain terms. That's not to deny that mainstream psychiatry certainly seems to suit some people. If that's all that's needed, all well and good. Keep things simple. That's fine for them at least, maybe!

But is that generally what people want from mental health services? Most people know their problems are more complex. They might hope they can be made simple and corrected easily. But generally, when they think about it, they may well be prepared to admit to themselves that might be wishful thinking. It might well take time and effort to recover from personal difficulties. And anyway, by reducing people's complex emotional difficulties and personal situation to a brain problem, hasn't the essence been lost of trying to understand why they are thinking, feeling and behaving in the unhealthy way they are? Ok, there might be a brain problem behind it. But for the vast majority of presentations to mental health health services, that is not the case.

So, what’s the point of encouraging people to believe that there is a brain problem? There are several reasons for this. As I’ve already said, it’s simpler to reduce the complexity of mental illness to brain disease. Understanding the relationship between mind and brain is difficult. For example, do we think and feel and do things because of our brains? We certainly need a brain to be alive. When we’re dead, it’s definitely not working! But then neither are our other bodily organs. We need a body to be alive. The brain is certainly an important part of that body to create the people we are. To some extent our human functioning is localised in specific parts of the brain, but actually not as well localised as people often think. The brain functions very much as a whole, despite all the attempts in research over the years to localise mental illness within it. Certainly mental illness shows through the brain but not necessarily in particular places within it. Nonetheless it’s attractive to think that mental illness may be localisable within the brain. We then don’t need to bother about what it means to be alive and can avoid having to deal with difficult abstract concepts like the nature of mental illness. Troublesome ethical debates about what psychiatry needs to do to manage such problems can then be short-circuited.

Another advantage of reducing mental illness to brain disease is that it makes mental illness more like physical illness. We can then follow the same kind of physical approach as the rest of medicine, which seems to have been remarkably successful in finding treatments for our various illnesses. Although, in practice, we may often overestimate how successful medical treatments are, it’s seductive to think that psychological medicine may be able to utilise the same scientific principles as the rest of medicine. Any differences between mental illness and other illnesses can, therefore, be minimised, if not obliterated. All well and good! As well as simplifying the conceptual issues, we now have a technological solution to mental illness following the same methods in psychiatry as the rest of medicine.  However much people may be fearful of mental illness, and want to exclude disturbed people from society, psychiatry has provided a way to give itself professional respectability in its dealings with them by making it more like the rest of medicine.

By adopting the same principles as the rest of medicine, psychiatry then creates another apparent advantage. It now needs a massive research industry, with considerable funding behind it, to find the so-called 'answer' to mental illness. It doesn’t matter that people are being reduced to their brains by seeing their mental health problems as being in the brain. It’s anyway more commonsensical, surely after all, to think that people are driven by their brains. There must be a need for neurobiological research to understand what’s gone wrong when people become mentally ill. Psychiatry's now avoided complex conceptual issues, found that it can follow medical methods and technologies, and just needs to invest more in research to make progress.  Psychiatry has created a firm edifice and foundation to provide care for mentally ill people, or has it? The problem is that it may suit us to think solutions are just round the corner but meanwhile there are still a significant number of people with mental health problems that need help, and we’re being distracted from dealing with what matters by seeking unattainable solutions in the future.

Biomedical psychiatry has, therefore, created a remarkably successful economic model. No wonder people don’t want to give it up and feel threatened when it is challenged. The problem is that taking this approach to psychiatry means that it has become more like a faith than a science. It has certain tenets which need to be believed. As we have outlined, these are: firstly, that mental illness will be shown to be due to brain disease and that there’s subsequently no need to get bogged down in complicated conceptual issues about the relationship between mind and brain; secondly, as mental illness has a material basis as do physical illnesses in general, it follows that psychiatry is not that different from the rest of medicine, so psychiatry can follow the same methods and technologies as the rest of medicine; and thirdly, that the scientific ambition of psychiatry and its associated research programme is to uncover the neuroscientific causes of mental illness and great progress has already been made in this aim. These fundamental tenets must not be questioned, otherwise the edifice of modern psychiatry may come tumbling down.

That's fine, maybe, but psychiatry has considerable legal powers, such as being able to detain mentally disordered people in hospital, subject to certain criteria within the Mental Health Act. It may well think it needs a firm foundation to be able to exercise that authority. It can’t really have people undermining its conceptual foundations, when it has such important social responsibilities. However, it is perhaps particularly because of the power that psychiatry has over people with mental health problems, that it's important to be honest about the state of its practice. Psychiatry may not want to listen to any candid criticisms, but it should. We're now back to where we started this post. If psychiatry is primarily about relationships with people, then it does need to accept this reality. However successful psychiatry may be in marginalising any critique, people do feel obliged to speak openly and fearlessly about how psychiatry needs to change. Otherwise, it may just continue to be designed more for its own interests than the people it purports to serve.