Understanding psychosis

At least the new guide Understanding psychosis: Voices, visions and distressing beliefs is clear that psychotic experiences do not result from a brain disease. The document has been edited by Anne Cooke from the original British Psychological Society (BPS) publication Understanding psychosis and schizophrenia. Anne was also one of the co-editors of the BPS report on Understanding depression, which I defended as a helpful, balanced report in my last post.

If only to show that I'm not merely a BPS acolyte, just to reiterate, I have been more critical of the psychosis report than the depression one (eg. see previous post). A strength of both reports is that they provide personalistic explanations of mental health problems, taking a holistic perspective rather than narrowly focusing on the brain. But I don't think, for example, that the psychosis report makes clear that psychotic symptoms can occur in delirium and dementia (see eg. previous post). Nor that psychosis may well not be associated with people asking for help because they have no insight into their problems. For example, it does not distinguish dissociation from psychosis (see eg. another previous post). 

Another strength of both documents is the attempt to explain mental health problems in everyday language. Psychiatry is not an exact science and therefore controversial, and unfortunately debates can become polarised. I would like to see more focus on the BPS position expressed in both documents that mental illness is not a brain disease (see eg. my Lancet Psychiatry letter and previous post). 

Understanding depression

The new British Psychological Society (BPS) document on 'Understanding depression' has created controversy, at least on twitter. For example, @ProfRobHoward sent a tweet saying that it is "stigmatising and politically motivated", and @wendyburn in her tweet linked to what she called a "powerful and disturbing" blog post by Lucy Dimbylow (@lucywriter), who in turn had sent a tweet saying the report "trivialises depression, gaslights sufferers and suggests it's [depression's] not even an illness".

Actually the report says there can be advantages in thinking of depression as an illness and some people find medication helpful. Depression of course can be a normal experience and there can be benefits for some people of 'normalising' depression. The report also makes clear that depression can be debilitating and associated with psychosis at the other end of the spectrum. A strength of the report is that it provides personalistic explanations of depression, taking a holistic perspective rather than narrowly focusing on the brain.  I don't think the report is misleading or undermines depression as an illness. It is a helpful, balanced report written in everyday language.

The argument on twitter about whether depression is an illness deflects from taking on board a key message of the report that depression is not a brain abnormality. I wish these debates would become less polarised and focus on the fact that depression is not the result of a brain disease. The symptoms and signs of depressive illness, although enabled by the brain, are not merely epiphenomena of a causal brain process. Depression needs to be understood in interpersonal context. Maybe that's why some people feel so threatened by the BPS report, because they know that depression is not a brain abnormality but wish it was. 

Fear of stopping antidepressants

In a trial of withdrawing antidepressants in patients who no longer needed the medication, Eveleigh et al (2017) found that half of the patients in the intervention group did not comply with advice to stop antidepressants. Only a few of the patients who were willing to follow the advice actually managed to stop, which was about the same number as in the control group who stopped their medication in the year of the study without the specific intervention. The patients in the intervention group also reported a higher rate of relapse than the control group.

To investigate further why so many people were unwilling to even try stopping their antidepressant medication despite it not being indicated, Eveleigh at al (2019) interviewed some of the participants in the trial. They found that fear (of recurrence, relapse, or to disturb the equilibrium) was the most prominent barrier, and prior attempts fuelled these anticipations (see eg. previous post). Another important barrier was the notion that antidepressants are necessary to correct deficient serotonin levels (see previous post). As Verbeek-Heida & Mathot (2006) found, the fear and uncertainty about stopping were stronger than the fear and uncertainty about continuing. Users of antidepressants tend to think they are better off 'safe than sorry' by continuing medication (see another previous post). Patients are uncertain and fearful about what they will be like without medication (Leydon et al, 2007).

The evidence for what it is worth is that continuing antidepressant treatment reduces the risk of relapse. Relapse rates in discontinuation trials can be substantial. Although fear of relapse may be biasing the results of such studies through unblinding, doctors have to be realistic that discontinuing antidepressants may not be easy. Patients tend to think doctors should take responsibility for initiating contact about discontinuation (Bosman et al, 2016), but in practice this tends not to happen. A good proportion of the increase in antidepressant prescribing over recent years is because of long-term repeat prescribing (see previous post). 

Taking antidepressants can be identity altering (see previous post). Patient's preferences and concerns affect their decisions about medication (Malpass et al, 2009). These sort of factors should have been obvious to doctors (see my book chapter). As I keep emphasising, psychological factors cannot be denied in causing antidepressant discontinuation problems (see eg. previous post). The question is whether they are a sufficient explanation or whether underlying clinically significant brain changes also contribute (see last post).

(With thanks to a MIA blog post by Peter Simons)

Outcome-based prescribing

In her recent MIA blog post, Joanna Moncrieff concentrates on what psychiatric drugs actually do. She's right that it's commonly wrongly assumed they are correcting some sort of brain imbalance, which she calls the disease-centred model of drug action (see eg. previous post). 

She also mentions the harms caused by psychiatric drugs. For example, antipsychotic medication can cause brain shrinkage, although I think the clinical significance of this finding is unclear (see eg. previous post). Antidepressant discontinuation problems may have become better recognised since a formal complaint made to the Royal College of Psychiatrists two years ago (see eg. previous post). I actually think that believing the disease-centred model of antidepressant action is likely to increase the risk of discontinuation problems (see another previous post). 

Joanna defends what she calls a drug-centred rather than disease-centred model of drug action (see eg. another  blog post from her). As she also notes, psychiatrists may have an outcome-based understanding of drug action, without necessarily any apparent particular commitment to an explanation of the drug's action. I certainly don't believe in the disease-based model, but still prescribed psychotropic medication when I was working because the evidence, for what it is worth, is generally said to be that such medication is effective within NICE guidelines. It was difficult for me to refuse a request for medication within these parameters. This is despite my scepticism about the evidence (see eg. previous post) and recognition that any effect may be due to placebo (see eg. another previous post). I don't want to undermine people's belief in their medication, but not everyone is helped in the clinical trials and the difference between placebo and active medication in these trials is generally much smaller than most people realise. Because of psychological factors, I was very aware of the risk of discontinuation problems and often it seemed easier for patients maintained on medication to continue with it rather than stop (see eg. another previous post).

An advantage of the drug-centred model is that it makes us realise, as Jo says, "how little we really know about these drugs". Modern psychopharmacology started with the introduction of chlorpromazine in the 1950s. When testing drugs for treatment of protozoal infections and parasitic worms, chlorpromazine was noted to have strong anti-histamine properties. It was therefore investigated with allergic patients and reported to cause drowsiness. This 'drowsiness' effect was explored by Henri Laborit, a French surgeon, using chlorpromazine to potentiate anaesthesia with other agents by preventing surgical shock. He reported it induced 'detachment' in his patients, suggesting it produced an 'artificial hibernation' because of its hypothermic and hypnotic qualities. Jean Delay and Pierre Deniker, therefore, investigated the potential for the drug on its own at higher doses in calming manic patients. Their papers talked about chlorpromazine causing a 'chemical lobotomy' different from other sedatives. They coined the term 'neuroleptic syndrome' referring to a slowing down of motor activity, affective indifference and emotional neutrality. Trials of chlorpromazine undertaken by Heinz Lehmann in Montreal facilitated the new drug's introduction to North America. Extrapyramidal effects, such as parkinsonism, were difficult to differentiate from any anti-psychotic properties.

Imipramine, the first antidepressant, has a similar chemical structure to the phenothiazines, like chlorpromazine, but different psychoactive effects. Initial trials in schizophrenia failed but it was said to be spectacularly effective in vital depression (see previous post). As Jo says, the SSRI antidepressants seemed to be "relatively innocuous" compared to the tricyclic antidepressants, like imipramine. She speculates about how they might be "changing the brain in significant ways that we do not understand".

The trouble is that these are only speculations and psychological dependence could be a sufficient explanation of antidepressant discontinuation problems (see eg. previous post). I agree with Jo that we should concentrate on psychiatric harm (see eg. another previous post) and the way to do that is to be much clearer about the pharmacological effects of psychotropic medication. 

Psychiatry and its critics

I've mentioned before (see previous post), that it's about time we moved on from the debate about 'anti-psychiatry'. It is generally seen as a passing phase from the 1960s/70s in the history of psychiatry. The trouble is that the term continues to be used (eg. see Psychology Today blog post). Part of the reason for wanting to move on is because of the confused way in which the term is used, which the Psychology Today piece to me seems to exemplify.

As I've also mentioned before, there actually was some value in the work of anti-psychiatry (see previous post). It shouldn't be seen merely as a negative contribution to psychiatry. As I wrote in my editorial, "it is difficult to accept that there was no value in the approach and what may be more beneficial is to look for the continuities, rather than discontinuities, with orthodox psychiatry" (see also my essay review). Personally I've always tended to emphasise the links of critical psychiatry (which I differentiate from anti-psychiatry) with mainstream psychiatry (see another previous post).

The term 'anti-psychiatry' was coined by David Cooper (see eg. previous post). It came to incorporate earlier writings by R.D. Laing, Michel Foucault, Erving Goffman and Thomas Szasz. It was most associated with the views of Laing and Szasz, who actually had very different perspectives (see eg. another previous post). Szasz, for example, equally rejected both mainstream psychiatry and Laing’s views. The emphasis on therapeutic communities in the Laingian version of anti-psychiatry led to positive developments such as the Philadelphia Association (see previous post) and the Arbours Association. The anti-institutional concerns of anti-psychiatry contributed to the rundown of the traditional asylum, with political impact such as that of Franco Basaglia in Italy (see previous post). The application of social labelling theory to mental illness, for example by Thomas Scheff (see my book review), had particular implications in the study 'On being sane in insane places' by David Rosenhan, which caused a crisis of confidence for psychiatric diagnosis at least for American psychiatry (see previous post). This was countered by the development of DSM-III. There were also international perspectives to anti-psychiatry, such as: French anti-psychiatry, particularly identified with Gilles Deleuze and Felix Guattari; Frantz Fanon in Algeria; and Jan Foudraine in the Netherlands (see my book chapter).

Maybe the term 'antipsychiatry' (without the hyphen) should now be reserved for the argument for the abolition of psychiatry (see previous post). But, I'm afraid it's still being used in the same way (eg. in the Psychology Today blog post mentioned above) as it was originally by mainstream psychiatry to denigrate any criticism, including valid criticism, of the biomedical model in psychiatry. I think this usage goes back to articles such as that by Martin Roth (1973).

In the article, Roth frames the debate about anti-psychiatry as an attack on the deterministic scientific nature of psychiatry. He recognises that this issue raises difficult philosophical questions and creates a need to reconcile deterministic concepts of causation with the inner experience of free will. He sees psychiatry as making progress towards this end by, for example, being able to describe the medical and social profile of those who commit suicide. He believes the Enlightenment represented the replacement of moralistic and transcendental attitudes with rational and deterministic explanations. 

Roth is correct that the conflict between determinism and free will is ultimately unresolvable. However, critical psychiatry does not take the same positivistic view of biological and biomedical sciences. In fact, the postpsychiatry version of critical psychiatry explicitly sees such a modernist agenda as untenable (see eg. previous post). 

A mechanistic worldview, which Roth calls science, confers an apparent advantage by providing a predictive and systematic way of understanding and manipulating nature. However, this leaves the phenomenon of life in an equivocal position because it cannot be totally stripped of its intrinsic purposiveness (see previous post). Rene Descartes (1596-1650) regarded both animate and inanimate matter by the same mechanistic principles. Animals are therefore machines; and human physiology is also mechanistic. Descartes stopped short, though, of including the human mind in this mechanistic framework. The soul was denied any influence in physiology. Descartes, thereby, avoided the materialistic implication that man himself is a machine. 

Although Georg Ernst Stahl (1659-1734) claimed erroneously that living things possess a vital entity, his dualistic notion was different from Descartes, in that he differentiated organic life from the inorganic, not the soul from the body. Unlike Descartes, the soul and body were not separate but integrated in the organism. Stahl originated an organismic perspective in the life and human sciences. This perspective formed the basis for Stahl having an emphasis on psychosomatic medicine, and a focus on clinical medicine rather than the physical sciences. 

Despite what Roth implies about the modernism of enlightenment thinking in the second half of the eighteenth century, the critical philosophy of Immanuel Kant (1724-1804) was clear that it is absurd and futile to expect to be able to understand and explain life in terms of merely mechanical principles of nature (see previous post). A mechanistic conception of nature fails to provide a complete characterisation of living systems. Organisms, unlike machines, are self-organising and self-reproducing systems. Different modes of explanation are therefore required for teleological and mechanical points of views. 

What's needed is a pragmatic approach which focuses on nature and experience and the centrality of the organism-environment interaction. Life’s dynamic, systemic and purposive character needs to be promoted as a way of moving on from physico-chemical reductionism, which tends to eliminate the meaning of human action. Life is continuously and dynamically preserving its internal environment and is therefore, a perpetual stream of matter and energy, better understood as a process than a static unchanging entity (see previous post). 

Roth rightly recognises that it is the mechanistic approach to mental illness that is being criticised and notes the difficulties in identifying the social cause of mental illness. But his reason for rejecting a social perspective is not valid. This is because he expects social explanations to be determinist, which they are not. Moreover, he resorts to genetic factors to avoid environmental explanations. I agree with Roth’s conclusion that constructive endeavour is required to resolve the manifold problems of contemporary psychiatry. However, his labelling of any criticism of the biomedical model of psychiatry as ‘anti-psychiatry’ has hidden the extent to which the critique of reductionism and positivism in psychiatry is valid. Modern apologists for psychiatry by labelling their critics as ‘anti-psychiatry’ are doing the same. Instead they should examine how much psychiatry reduces people to objects and uses an inappropriate mechanistic psychology and biology.

Information about antidepressant withdrawal

I expressed concern about the position statement on antidepressants and depression produced by the Royal College of Psychiatrists (RCPsych) last year (see previous post). The College has now produced an online resource on stopping antidepressants. Even though the document has a disclaimer, I’m not convinced the information for patients is as good as it should be.

For a start, the licensed indications for the various antidepressants on the market do not only include depressive illness, anxiety disorder or obsessive-compulsive disorder. Licences have been granted for other indications that RCPsych does not mention eg. bulimia nervosa.

I think it would have been helpful if the document made clearer that continuation treatment of antidepressants is only really recommended if the medication helps. Some people with depression are not helped within six weeks and there is unlikely to be much point in persisting with the same treatment beyond this period. A change of antidepressant is often tried, and even though no antidepressant has been found to be any better than any other, this change may seem to help. But not everyone benefits from antidepressants, even in the clinical trials.

I can’t find any mention in the document of what I think is probably the most important advice about withdrawal symptoms (which is included in the NICE depression guideline). This is that people should be warned of the risk of discontinuation/withdrawal problems when they first start medication. I commonly used to make a comment like “try not to get too dependent on your medication”. I’ve no evidence that this sort of advice necessarily helps, but I think it stands to reason that it might. People can get psychologically dependent on all sorts of things. Starting antidepressants when one might be feeling desperate and unwell, hoping that the medication may help with such negative feelings, is almost inevitably likely to create a psychological dependence, perhaps particularly if the medication seems to help. When I was working, I always found that patients generally understood what I was saying about the risk of psychological dependence (see previous post).

I’m not quite sure what the evidence is for the position taken in the document that the severity of risk of withdrawal symptoms varies with different antidepressants. For example, as I mention on my ‘Antidepressant discontinuation reactions‘ webpage, fluoxetine was reported to be less likely to cause discontinuation problems, maybe because of its longer half-life, but there was conflict of interest in this work, as it could have had marketing implications for fluoxetine. Perhaps more significantly, no mention is made of the similarity of antidepressant withdrawal with the symptoms of benzodiazepine withdrawal.

Although the document says that the cause of antidepressant discontinuation problems is poorly understand, it does seem to very much favour the idea of re-regulation of receptors. But I’m not sure what the evidence is for this speculation (see eg. previous post). It also uses this speculation to support the argument for tapering. but if this is the explanation for the cause of withdrawal symptoms, then why, for example, is it generally easier to withdraw from antidepressants if they have been prescribed for a shorter period of time? I’m not saying that tapering is not important, which it usually is, but some people do seem to be able to stop suddenly, and the need for tapering also fits with my hypothesis of psychological dependence.

I’m also unclear what the evidence is when the document states that only one third to one half of people experience withdrawal symptoms. For example, in a failed trial of CBT to prevent relapse when withdrawing antidepressants, only 36% of patients succeeded in discontinuing antidepressants over 16 months (see previous post).

Although the document says, “Withdrawal symptoms normally start soon after your medication is reduced or stopped”, I’m not sure if the authors believe in delayed withdrawal problems. Late onset can occur (see previous post).

It is a common misunderstanding that antidepressants take weeks to work (see previous post). Where this comes from is that it generally takes 4-6 weeks for a statistically significant difference between active and placebo treatment to be detected in clinical trials. But this is an artefact of the way in which statistical significance is measured. Larger size clinical trials will detect a statistical difference earlier than trials with smaller numbers of subjects. Actually, the largest improvement per unit time produced by antidepressants occurs within the first 2 weeks of treatment.

There’s no mention in the document about making sure that people close to you are supporting you if you are withdrawing from medication. I think it’s much more difficult to withdraw from antidepressants if your relatives, for example, do not agree that you should be stopping.

I wonder whether it should have been made clearer in the document that gradual tapering does not completely eliminate the risk of withdrawal symptoms. Moreover, taking antidepressants also seems to increase the vulnerability to relapse, as well as cause withdrawal symptoms. That’s why continuation treatment was proposed in the first place.

Personal reflection on critical psychiatry

My invited submission to BJPsych Advances on ‘Clinical reflections on critical psychiatry’ has been rejected. As I’ve mentioned before (see previous post), an advantage of the internet is that these rejected manuscripts don’t have to just be put in a file drawer, never to be seen again. 

The invitation to submit followed a tweet in a conversation with @TheBJPsych suggesting I submit a proposal to BJPsych Advances for a special issue on critical psychiatry. I contacted the journal saying I didn’t know how seriously to consider the suggestion, and the journal answered that it would be pleased to consider a proposal if I would like to submit one, which I duly did. When the editorial board discussed the proposal, it felt that as it already had three special issues in the pipeline for the coming year, it would be better to commission and publish select pieces individually. This led to three of the original contributions to my proposal not being commissioned at all, and at least my contribution to the proposal being rejected.

I have discussed before (see previous post) the difficulties in getting critical psychiatry into mainstream journals. Twitter conversations with @TheBJPsych have tended to be more openminded. It’s even possible that Kam Bhui, as BJPsych editor, had an influence over the acceptance of my recent editorials in BJPsych and BJPsych Bulletin.

Towards a more relational psychiatry

I have mentioned 'relational psychiatry' before (see previous post). Even though I come from a critical psychiatry position, which has never hidden that it grew out of what mainstream psychiatry called 'anti-psychiatry', there are more recent developments from anti-cognitivist phenomenological and enactive accounts of psychopathology that come to the same conclusion about the biomedical model of mental illness. For example, I have mentioned books like Sanneke de Haan's Enactive psychiatry (see eg. previous post) and Thomas Fuch's Ecology of the brain (see another previous post). 

Laurence Kirmayer summarises his perspective on what he calls ‘ecosocial psychiatry’ in an article in World Social Psychiatry. As he says, "Cognitive science supports the view that mental processes are intrinsically social, embodied, and enacted through metaphor, narrative, and discursive practices". As I've argued throughout this blog (eg. see previous post), there needs to be a shift in perspective from a narrow biomedical perspective towards a more truly biopsychosocial approach. As Laurence puts it, what's required is "a shift in perspective from a psychiatry centered on brain circuitry and disorders toward one that recognizes social predicaments as the central focus of clinical concern and social systems or networks as a crucial site for explanation and intervention". In this quote and the article in general, Laurence also helpfully illustrates the importance of social psychiatry, as focusing on the person inevitably means including the interpersonal dimension. This leads, as Laurence says, to an emphasis on "the powerful effects of structural violence and social inequality as key determinants of health".

Reductionism leads to the loss of meaning of human action and a mechanistic psychology cannot be realised in practice (see eg. previous post). This critique of reductionism and positivism in psychiatry, including mechanistic psychological approaches, creates a framework that focuses on the person and has ethical, therapeutic and political implications for clinical practice. It also has consequences for psychiatric research, which has become far too focused on speculative neurobiological notions. 

Descriptive psychopathology is not studied organically at the level of neurobiology. History and mental state examination instead produce a formulation of people’s problems in terms of differential diagnosis and aetiology. Examining the brain in a scanner, for example, does not tell us anything about the cause of thoughts, emotions and behaviour. An integrated understanding of mental dysfunction in the context of the whole person, including emotional needs and life issues, forms the basis for patient-centred and relational psychiatry. The physical disease model of mental illness is outdated and needs to be replaced by a relational psychiatry.

Misdirected aspirations for psychiatric classification

Peter Zachar et al (2019) have published an oral history of the development of DSM-5. For some reason, this does not seem to have included interviewing David Kupfer, the chair of the Task Force, so I do wonder if the article has been affected by the retrospective glosses of Darrel Regier, one of the co-authors of the paper and vice-chair of the Task Force, and Kenneth Kendler, another co-author and chair of the Scientific Review Committee appointed by the President of the American Psychiatric Association (APA). I hadn't realised how much the APA Board of Trustees (BOT) had a role in the DSM-5 process, including appointing Task Force members. 

As Zachar et al note, what was originally envisioned was a shift to a "more scientific basis of psychiatric classification" to take account of the aetiology of mental disorders (see eg. previous post). The paper suggests that any hope for a shift from descriptive to aetiologically-based diagnostic criteria had been largely abandoned by the time the workgroups were finally formed in 2008, not least because the human genome project had not produced candidate genes for mental disorders and there was more questioning about what neuroimaging could achieve.

Darrel Regier reports that DSM-5 leaders were not willing to delay publication, even though the National Institute of Mental Health (NIMH) were about to launch its experimental approach that became the Research Domain Criteria (RDoC) (see previous post). This was because of "what amounted to a resurrection of those very aspirations [that had initially motivated DSM-5]". If this was really the case, then DSM-5 had some foresight, as speculation about neural circuits has gone overboard (see previous post) and Thomas Insel, the previous NIMH director, in my view led NIMH completely 'off beam' with RDoC and so-called precision medicine (see another previous post). 

The paper suggests any decisions about changes were left to the workgroups. To give more direction to the process, BOT created an oversight committee in summer 2009. New guidelines accepted that “DSM-5 will not ‘in itself’ represent a paradigm shift, nor abandon the categorical system of classification, but will start a process that will lead to more useful ways of classifying and diagnosing disorders”. I’m not convinced it really did so, ending up merely with a tinkering with diagnostic criteria far short of the original misguided intentions. It would have been better if the time had been spent rethinking the basis of psychiatric classification (see eg. previous post).

Treatment of depression with antidepressants is primarily a placebo treatment

I’ve mentioned before that NICE may be laying itself open to judicial review about its depression guideline (see previous post). I’ve also emphasised the lack of clear evidence from clinical trials that antidepressants are effective, because placebo amplification may be an explanation of any statistically significant results (see eg. another previous post). This means we should have more of a psychological rather than pharmaceutical model of antidepressant action (Ankarberg & Falkenström, 2008).

Although it should not be surprising, empirical findings confirm that one of the most influential factors in the treatment of depression is the quality of the early therapeutic relationship, not necessarily medication (Blatt & Zuroff, 2005). Pretreatment characteristics of patients may also be factors in outcome. Training in the treatment of depression, therefore, needs to focus on teaching competence in establishing effective therapeutic relationships. Randomised controlled trials, which NICE tends to concentrate on, may be considered the gold standard of experimental design, but naturalistic studies may well have more external validity. The long-term outcome of treatment for depression may not necessarily be that good (see previous post). I’m not encouraging exploitation of the placebo effect, but merely acknowledgement of the importance of the doctor-patient dynamic, even when medication is used (see my BMJ letter). Perhaps NICE should start from a position of therapeutic nihilism before it makes any recommendations about treatment (see last post), but at least it should be clear that the therapeutic relationship is significant and almost certainly affects outcome.

The argument for medical nihilism

Jacob Stegenga published his book on Medical nihilism in 2018. He aligns himself with therapeutic nihilism meaning that "it is impossible to cure people or societies of their ills through treatment' (see Wikipedia entry). This view is contrary to the widespread faith that people tend to have in medical practice. Financial incentives, even corruption, influence medical science. Its research methods are malleable enough to lead to exaggerated claims for effectiveness. We should not be confident about such claims and should be sceptical that medical interventions are effective.

Jacob comes to a position of medical nihilism without apparently fully taking on board the scientîfic challenges in the application of randomised controlled trials (see eg. Kramer & Shapiro, 1984), perhaps particularly the problem of unblinding (see eg. my letter and follow-up). He emphasises the common small effect size of clinical trials, and the fact that some interventions are removed from clinical practice because they are later found to do more harm than good. Few drugs are ‘magic bullets’ in the sense of specifically targeting the cause of a disease. In practice not all clinical trials generally show a benefit for a drug. Bias, even fraud, in clinical research tends to be minimised.

Jacob makes clear he is not saying that no medical intervention is effective. But assessing the effectiveness of medical treatment generally is not merely an empirical matter because of the methodological problems of such research. Research methodology does need to be improved, which will reduce effectiveness estimates, but even so there are still problems about interpreting the data. There is a sense in which it is impossible to be objectively certain about the effectiveness of the vast bulk of treatment. 

Medicine has not really advanced as much as we might like. Broader socioeconomic conditions of health may well be more important than medical treatment itself. In general, there is too much medicine (see eg. post on my personal blog). Jacob encourages medicine to be gentler in its approach, and not so radically aggressive. There needs to be enhanced regulation of medical interventions. The profit motive in medical research is distorting social priorities. The art and science of medicine needs to be rethought (see another post on my personal blog).

“[P]ast 20 years have not been good for the quality of care [in mental health services]”.

BJPsych Bulletin has an interview with Tom Burns, who I have mentioned previously (eg. see previous post). He talks about the OCTET study on community treatment orders (CTOs), which I have also discussed before (see post). Personally I think CTOs should never have been introduced (see eg. another previous post) and Tom now thinks he made a mistake in promoting them. It always strikes me as ironic that there used to be so much concern that a few detained patients were being kept on S17 leave too long, whereas essentially CTOs provide just such a 'long-leash' arrangement. As far as I can see, the introduction of CTOs has led to insufficient use of S17 trial leave. This almost certainly has reduced the opportunity for arranging informal community care without CTO.

Tom is also critical of DSM-5 (see eg. previous post). He's right to focus on descriptive psychopathology as a strength of psychiatry. He calls it 'diagnosis', which can be misleading because history and mental state examination actually lead to a formulation which includes differential (not necessarily a single and certain) diagnosis and aetiology. Diagnosis should not be overemphasised in psychiatric assessment (see eg. previous post). 

Tom's also right about the fragmentation of services over the last 20 years. Hopefully the community mental health framework for adults and older adults will provide a basis for development but it does need leadership to implement it. Despite what Tom says, I haven't abandoned the use of the term 'patient', although also use the term 'service user', even 'survivor', certainly recognising the importance of mental health advocacy (does he?). Tom rightly expresses concern about clustering, which was supposed to support so-called payment by results, which seems to have been quietly dropped (see post on my personal blog). As he also indicates the overpreoccupation with risk has been damaging (see eg. my unpublished article and talk).

A younger version of Tom Burns sounded more optimistic in an e-interview. He even noted the "sense of excitement and 'importance' of psychiatry" created by RD Laing and how anti-psychiatry made the profession "glamorous, albeit controversial". He's still writing about the history of anti-psychiatry (see previous post and my letter).

(With thanks to Suman Fernando who alerted me to the recent interview)

What is a case of depression in the coronavirus period? A case for what?

The Office for National Statistics (ONS) reported yesterday that the Patient Health Questionaire (PHQ-8) scores for most people had increased in June 2020 compared to a score recorded sometime between July 2019 and March 2020 (although had actually decreased for 3.5% of the population). Considering the anxiety caused by coronavirus, social distancing and lockdown, I guess this finding should not be surprising.

These figures were used by the Royal College of Psychiatrists to warn again about a "looming mental health crisis and the tsunami of referrals we are expecting over the coming months" to reinforce their argument for significant investment in mental health services (see Guardian article). Headlines were that depression had doubled during the coronavirus period. But as Elaine Fox said to BBC news online, "It is important to remember that this [PHQ-8] does not give a diagnosis but rather an indication of everyday depressive feelings and behaviours". Certainly it’s misleading to imply that the number of depression cases has doubled because of coronavirus.

I don't want to underestimate the impact of the pandemic on mental health. But I'm not necessarily convinced there will be an inevitable vast increase in cases coming forward for, or even needing, antidepressants, psychological therapy or other mental health treatment. We've all had to adjust to it, and such adjustment does not necessarily create mental health problems.

I'm reminded of the book of the symposium What is a case? (1981) edited by Wing et al. As David Goldberg noted (see article), a contribution at the symposium by:-

Copeland (1981) reminds us that the concept of a case is a chimera ... . Rather than regard the concept as a sort of Platonic ideal he suggests that investigators should ask - 'a case for what?'

Despite whatever symptoms are measured on the PHQ-8, people's coping mechanisms may not have necessarily broken down because of the pandemic; nor would they necessarily seek, or need, medical or psychological help even if they have difficulties. Feelings as recorded on the PHQ-8 may well be understandable in the circumstances. It is important to ask if the Royal College of Psychiatrists, for example, may be manipulating the ONS data to its own advantage to obtain more resources. I wouldn't want to discourage people who need help from coming forward, but they actually may have considerable personal resources and resilience to be able to overcome and adapt to any difficulties caused by the pandemic. Mental health treatment can be helpful, but it isn't always.

Developing a non-medical mental health service

I've said before (eg. see previous post) that I'm keen to see how non-medical mental health services could be developed within the NHS. Doing so would make explicit that treatment on offer in such a service does not include medication (despite there now being a limited amount of non-medical prescribing by healthcare professionals other than doctors and dentists). Psychological therapy of course is non-medical in this sense, and non-medical treatment is in fact much wider, including all psychosocial interventions.

Improving Access to Psychological Therapies (IAPT) was originally designed as a non-medical service. In the NHS plan, IAPT has now become the service for common mental health problems, for example being renamed within NHS Trusts as Wellbeing Services. Severe mental illness is managed within the traditional community mental health team (CMHT). Unfortunately, this means that some people who are explicitly seeking a non-medical service are told they are "too complex" for IAPT and become quite confused when they are referred on to the CMHT.

I've mentioned before (see eg. previous post) that some clinical psychologists, such as Peter Kinderman, want mental health services to become non-medical. There's even support from within psychiatry for such a position (see eg. another previous post). Although the motivation for such a change may largely be coming from a 'drop the disorder' argument, in the sense that it's thought to be wrong to regard mental health problems as 'illnesses', it is possible that a non-medical mental health service could actually encompass a range of different views about the nature of mental illness/ health problems. Its fundamental feature would rather be about managing mental health problems without medication. Such a service would provide real options for patients, alongside more medically based services to deal with medication and psychosomatic issues.

There are plans to increase the number of people working in the psychological professions in NHS commissioned health care (see vision). Increasing the number of clinical psychologists makes sense, considering the difficulties in recruitment to other mental health professions at present. Clinical psychology has no difficulty with recruitment, and in fact could be made even more attractive, by its training being geared towards creating the new leaders in a non-medical mental health service. 

I'm not undermining the importance of medication in treatment or the role of the doctor in mental health work, having been a doctor myself in my working life. I just think that a division between medical and non-medical mental health services may well make more sense than the current division between services for common versus severe mental health problems. 

Minds are not disembodied

Thomas Fuchs, who I have mentioned before (eg. see previous post), has a useful summary (see article) of the concept of circularity from an embodied and enactive point of view. Living beings have the two aspects of lived or subject body (Leib) and living or object body (Körper). These correspond to two different attitudes respectively: the personalistic, which takes a holistic view of the person experiencing the body from the first person perspective and the others’ body from a second person perspective; and the more narrow naturalistic, which observes and investigates the body from a third person perspective. 

Neuroscience, by turning only to the physical, sidelines the circular interaction of the brain, body, and environment. Examining the brain in a scanner does not tell us anything about the cause of thoughts, emotions and behaviour. These need to be understood by considering the circular causality of embodied subjectivity, it’s situation and history. As Thomas Fuchs says:-

The brain is not the locus of subjectivity but only a mediating component of the cycles of self-regulation, sensorimotor, and social interaction, in which the life of a human person consists.

Brain effects of antipsychotic medication

An article in JAMA Psychiatry reports a secondary analysis of a randomised controlled trial of antipsychotic medication to show that antipsychotic medication is associated with changes in brain structure. Exposure to olanzapine compared with placebo was associated with significant decreases in cortical thickness in the left hemisphere in those who sustained remission. This kind of finding is is not new (see previous post). Postmortem studies in animals have been linked to imaging findings (Vernon et al, 2013, Konopaske et al, 2007). 

The clinical significance of these findings is unclear. How adverse these apparent brains changes are requires further elucidation.

(With thanks to Mad in America research news item by Peter Simons)

Reifying the mind

Mohammed Abouelleil Rashed (whose book I have recently reviewed) has an article on ‘The identity of psychiatry and the challenge of mad activism: Rethinking the clinical encounter’. He suggests that medicine is committed to the hypostatic abstraction (from Charles Pierce) which implies that doctors treat "things" that people "have". Mohammed does recognise that physicians frame their work to take account of the whole person and psychiatry is different from the rest of medicine because it focuses on mental disorders rather than physical disorders. 

I have argued throughout this blog (eg. see previous post) that psychiatry should not reify psychiatric disorder. Mohammed does acknowledge that some psychiatrists do not think the hypostatic abstraction is central to their work. He accepts that the clinical encounter can provide understanding and have therapeutic aims without such an assumption, but falls short of wanting to "rethink the entirety of mental health practice".

As I've said before (eg. see previous post), our modern concept of illness only really goes back to the mid-nineteenth century. Understanding illness in terms of underlying physical pathology does make disease a thing that people have (in Mohammed's terms). The trouble is that psychiatry never really fitted with this development of the anatomoclinical method, which related clinical symptoms and signs to underlying pathology. Most mental illness (apart from organic illness) is functional, in the sense that there is no underlying pathology in the brain (see eg. another previous post).

This situation was why Engel proposed the biopsychosocial model (see eg. previous post). Medicine needs to be person-centred (see eg. another previous post) and this is more obviously the case in psychiatry where there is no physical illness. I'm not suggesting taking the challenge of mad activism as far as abolishing the notion of mental disorder (see eg. yet another previous post) but I would encourage Mohammed to take further his analysis of the critical challenge to the biomedical model of psychiatry. Despite what he seems to think, psychiatry does not need to accept the hypostatic abstraction to be a medical speciality (see eg. previous post). 

Demarcating 'abnormality' from 'normality'

I've said before (eg. see previous post) that insisting on avoiding pathologising in mental health services can be misleading. I understand why people may want to do this because, for example, they think that pathologising mental problems implies brain disorder, when this is not the case.

Sanneke de Haan in her book Enactive psychiatry (see previous post) discusses what she calls 'sense-making' (see another previous post). Organisms need to make sense of their environment to survive. We need to understand the organism-environment as a system not an isolated individual, let alone its brain. 

How do we distinguish pathological from normal sense-making? Of course there are differences between people. It is normal to struggle with life at times. The appropriateness of sense-making depends on context and sense-making needs to be attuned to the real world. Norms can vary over time and shared sense-making or the common sense of people in cultural context is what matters. People can still be eccentric but the stance one takes on oneself and one's situation can mean that one fails to recognise the inappropriateness and inflexibility of one's ways of interacting. One's stance can become unbalanced. Problematic sense-making can cause suffering, although not necessarily so. Patterns of sense-making may be identified which are abnormal.

As I've also pointed out, the concept of illness goes back further than our modern understanding since the middle of the nineteenth century of illness as physical lesion (see eg. previous post). We use the same criteria to decide whether an illness is mental or physical and, even though the concept of illness as physical lesion is relatively recent, we tend to think that we are extending the principles of physical illness to the concept of mental illness. 

In fact, the concept of psychological illness had been opened up before the application of the anatomoclinical method in medicine (see previous post). The recognition of psychosomatic illness focused on the doctor-patient relationship creating a new space for mental pathology (see previous post). We may now have more modern understandings of psychosomatic medicine (eg. see previous post), but, as I've pointed out before (eg. see previous post), those that want to move away from the concept of mental pathology, do not seem to deal with the issue of psychosomatic pathology very well. 

Of course madness has always been recognised. Still, medical psychology created a descriptive psychopathology (see eg. previous post) and how we make sense of delusional thinking is still an important issue (see previous post). Normalising mental pathology can fail to do justice to the sense in which something may have gone wrong in mental functioning.

Psychiatry in need of a paradigm

In his letter to the editor of Acta Psychiatrica Scandinavica, Gordon Parker argues for "multiple niched paradigms" in psychiatry. Parker's letter was written in response to a letter from Tilman Steinert arguing that psychiatry needs a new paradigm. Parker contends that psychiatry doesn't need a single over-arching paradigm, but instead should "determine which paradigm (of many current and candidate ones) best explains why this individual is suffering this condition at this particular risk period".

I agree with Parker than psychiatric assessment should be individualised, but I'm not sure this is to do with paradigms as such. Like Steinert, I too was trained in a hierarchical approach to psychiatric assessment and diagnosis, with organic factors trumping psychotic, then neurotic then personality factors. Karl Jaspers understood the history of modern psychiatry as a conflict between two factions of somatic and psychic approaches rather than a simple chronological development. Georges Lanteri-Laura divided modern psychiatry into three sequential paradigms (see previous post), although I tend to prefer the implication of what Jaspers was saying, that there's always been a conflict in the origins of medical psychology in its attempt to move on from Cartesianism (see my editorial).

I also agree with Steinhart that psychiatry has got quite muddled in how it understands mental disorder. As he says, there's a need for "an effort of rethinking, sorting, and grouping of available findings". That's partly been the motivation of this blog! For example, Pat Bracken has argued for the need to move from reductionism to hermeneutics in psychiatry (see previous post). A BJPsych 2012 special article talked about the need to move beyond the current paradigm in psychiatry (see another previous post). More recently, as another example, I've pointed out the value of enactive psychiatry (see eg. previous post).

George Engel proposed his biopsychosocial model as a middle way between biomedical reductionism and Thomas Szasz's 'myth of mental illness' position, which Engel called exclusionist. Since Engel's time, psychiatry has become quite muddled about what 'biopsychosocial' means (see eg. previous post). We do need to be clearer about the aetiology of mental disorder (eg. see previous post). I also think the mistaken abolition of the distinction between organic and functional mental disorders by DSM-IV has clouded perspectives (see eg. another previous post).

It seems to me that Gordon Parker has not really taken these issues seriously. I suspect this is because he wants to perpetuate the current eclecticism of psychiatry to avoid dealing with fundamental ideological issues. Psychiatry found it difficult coping with the onslaught from so-called "anti-psychiatry" and, to my mind, has still not really recovered a balanced perspective (eg. see my editorial).

Relational psychiatry

I wrote in my book chapter:-

Critical psychiatry is the name for an approach that encourages a self-critical attitude to psychiatric practice. An adverse consequence of the term 'critical' is that it tends to have a negative connotation. In this sense, 'critical' means 'inclined to find fault, or to judge with severity'. However, 'critical' also has other meanings, such as 'being characterised by careful, exact evaluation and judgement'. Also, it may have something to do with a crucial turning point, in this sense meaning 'of the greatest importance to the way things might happen'. These latter senses are included in the way I am using the word 'critical' in relation to psychiatry.

There is a problem about how oppositional to be about the current state of modern psychiatry (see eg. previous post). Critical psychiatry has never hidden the fact that it grew out of what mainstream psychiatry has called “anti-psychiatry” (see eg. another previous post).

I have also always emphasised the extent to which critical psychiatry actually is mainstream psychiatry (see eg. previous post). Even though critical psychiatry is a minority position within psychiatry, the dominance of biomedical psychiatry perverts what psychiatry should be. Although psychiatry says it adopts the biopsychosocial model of mental illness, unfortunately it still has a tendency to positivism and reductionism (see eg. my editorial).

I have always wondered if there should be a more positive name for critical psychiatry. I’d be interested in how people react to the notion of ‘relational psychiatry’, instead of critical psychiatry. Understanding how people relate to themselves, to others and to their situations is crucial for making sense of and managing mental health problems (see previous post). An advantage of the term ‘relational psychiatry’ may be that it is more easily understandable than enactive psychiatry, which has had recent uptake (see another previous post). It also links with traditional interests in psychiatry in therapeutic communities (see eg. previous post).

Another advantage of relational psychiatry is that it may make explicit the social dimension of person-centred care in psychiatry (see previous post). Despite all the hype about neuroscientific progress in psychiatry, patients still feel stigmatised and there is ongoing conflict about psychiatric practice. People may be able to converge round relational psychiatry to provide both a conceptual and practical way forward.

Psychiatric harm

I've mentioned before, when discussing the Royal College of Psychiatrists' views about antidepressant discontinuation problems (see previous post), that the College has not paid enough attention to adverse reactions to antidepressants and psychotropic medication in general. Fava & Ravanelli (2019) discuss psychological and behavioural iatrogenic effects of psychiatric medication.

These effects include: ''paradoxical' mood changes eg. increased anxiety with anxiolytics and worsening depression with antidepressants; 'pendular' mood changes eg. euphoria with antidepressants; tolerance and loss of treatment efficacy, dependence and withdrawal effects, which may be persistent; cognitive impairment and apathy. Frequency of such reactions varies enormously.

Fava & Ravanelli may not differentiate as clearly as I would like between the physiological and psychological/behavioural effects of taking medication. I've said before (see eg. previous post) that I find the oppositional tolerance model too speculative. I'm not saying adaptive changes do not take place at receptor levels but any behavioural effects of these changes are unclear. The brain's homeostatic mechanisms may in fact mask any behavioural effects of the adaptation of receptors to medication.

Dismissing iatrogenic side effects of psychotropic medication as trifling may well be unhelpful. In practice, the specific pharmacological action of a psychotropic drug in terms of its intended therapeutic action (eg. antidepressants intended to improve depressed mood; anxiolytics intended to treat anxiety) may in fact be very difficult to differentiate from side effects or even the general physiological effects of the drug. For traditional neuroleptic medication, for example, such as chlorpromazine, even though it is called antipsychotic medication, any apparent antipsychotic effect may be far less obvious than parkinsonism, which is called a side effect. Similarly, as another example, the gut effects of an SSRI antidepressant, even though generally short-lived and seen as side-effects, may be more obvious that any so-called antidepressant action. Furthermore, it is not always easy to decide whether an adverse reaction is caused physiologically, rather than psychologically, by the drug.

Besides prescribed harm, more generally, psychiatry, despite whatever good it may do on occasions, has always caused harm, including the abuse and neglect of people. For example, one of the main reasons traditional asylums were closed was because the conditions under which people were kept could be appalling and disgusting. Psychiatric practice may not always be very ethical (eg. see my book chapter). As I've kept saying in this blog, psychiatry has a tendency to reduce people to objects, and not treat them as people but things. I'm not saying psychiatry can't do good (see eg. previous post), but working alongside abuse and neglect in psychiatry, not just in its history, may not be easy (see eg. my article).

I, therefore, can understand the anger of the prescribed harm community in psychiatry. Some of them gain more support from each other online than from psychiatry. Psychiatry needs to engage properly with this issue and it's more than just an issue about antidepressant withdrawal (see previous post).

The Philadelphia Association: Meeting oneself in the other

I’ve previously (eg. see post) mentioned the Philadelphia Association (PA). Its first therapeutic community was the infamous Kingsley Hall (see another previous post). The PA still runs two community houses and provides a full psychotherapy course and other training. I did a review of Bruce Scott's book which presents the testimonies of 14 people who have lived in PA households. I’m very grateful to Miles Clapham for agreeing to do this guest post on the PA. 

“understanding meaning impinges on myself in the other...” Karl Jaspers¹

At a Philadelphia Association open evening this May, a participant asked about the different theories favoured by different psychotherapy trainings: Kleinian, Freudian, Lacanian, and so on, wanting to know where the Philadelphia Association stood in relation to these ideas. A colleague replied with elegant simplicity that most psychoanalytic trainings ask you to see the client or patient through the lens of their favoured theory as the way to truly understand the position that person is caught in; in contrast at the Philadelphia Association we want to try and meet the person (of course seeing the person in front of you involves many complexities, and with or without theories we bring all sorts of expectations, prejudices, hopes and desires which may distort or influence the way any meeting may go). My response, not so elegant, was perception is part of the world, language is part of perception, and theories inform or regulate the language used and therefore our way of seeing or perceiving. What we want to do is to find, if there is such a thing, “wild perception”², untutored perception, astonishment at the world and each other, to break out of captivation by our preformed ways of seeing. And somehow do psychotherapy with or within this way of being.

The Philadelphia Association was founded by R.D. Laing with others. Laing, who was an extraordinary person, wrote some extraordinary books, influenced many doctors to come into psychiatry, including myself, and influenced many to criticise psychiatry, including a number of psychiatrists. Arguably Laing was part of the large scale social critique that resulted in the eventual change in the law from the 1957 Mental Health Act to the 1983 Act, which gave many more rights to psychiatric patients than previously. The 2007 amendments to the Act took some of those rights away again, making it easier to justify detention for a ‘mental disorder’, a change that many psychiatrists opposed but was forced through regardless.

The Philadelphia Association started with the once famous/notorious ‘therapeutic community’ at Kingsley Hall in 1965, which has been much written about. A year or two later, led by Dr John Heaton, originally an ophthalmologist who became interested in perception and philosophy especially phenomenology, and trained as a psychoanalyst, the PA developed a psychotherapy training. The training was and is based in philosophy and psychoanalysis, particularly developing a phenomenological and existential critique of psychoanalytic approaches. The PA is now a locus for a critique of psychiatry and the many and various psychotherapies based in psychoanalysis and academic psychology, such as CBT. The ‘style’ of therapy offered is outside any simplistic divide between objectivity and subjectivity, inner world and outer world, mind and body, strongly opposing a scientistic world view in therapy that sees only the measurable as real.

The Philadelphia Association currently runs two houses in London for people struggling with life, and who may have been (this is not essential) through psychiatric services and therefore in some sense a survivor. These houses require people to self-refer, and then once invited by the residents, to attend at least one and sometimes more meetings with the house residents, along with the house therapists. One has to ‘find one’s way’ to the house, you cannot be referred by your community mental health or social care team, although that said social workers or community mental health teams may be involved in some way to encourage a person to look into the houses. The houses have therapists who conduct group meetings for the residents three times a week, and residents also need to have individual psychotherapy, often at a ‘low cost’ rate. This is mostly paid for through benefits, sometimes disability allowance. Residents may have paid employment, not organised through the house, and pay rent themselves. The houses are therefore not a drain on NHS or social care resources, and are amazingly cheap compared with more formal residential care ‘placements’ or inpatient care.

The house therapists do not participate in the Care Programme Approach (CPA), although some residents remain involved with their community mental health team. Some residents are on medication. When the PA was founded in 1965, there was an idea that residents would not have any psychiatric medication. There is still a debate about this, and certainly it is an option if someone is on medication that they can come off it while living in the house. If the person wanted medical oversight for this reduction or cessation of medication, this would need to be by a doctor outside the PA. Alternatively, the individual can take responsibility her or himself for this.

The houses are not set up to manage serious crises, although back in the day some people came in quite acute psychotic states and lots of those involved in the PA and the psychotherapy training would spend time, sometimes many hours, in the house with the person in crisis, to try and see them through without psychiatric intervention. It is fair to say this did not always work, although for others this was enough to allow them to manage their own journey. One example, the person concerned has written about this, was a young man who spent two years in his room, almost never coming out, at one point almost starving himself to death. There was huge concern in those around him about leaving him. Most psychiatric doctors, nurses and others would think this terrible neglect. Nevertheless, and while the PA would eschew measuring success as a return to social conformity, this young man did subsequently go to University and complete a higher degree.

The houses are therapeutic communities, in perhaps a minimalistic sense. There is no daily programme of activities, no occupational therapy, no particular routine other than the house meetings. The houses provide a safe living space, a community of others who have their own often difficult life journey, and there is no pressure to stay a quick few weeks or even few months and then leave and move on. The houses are a limited resource, as people may sometimes stay for 2-3 years, and movement from the house would be considered slow by other services. That said the houses tend to have vacancies. It is not always easy to find people who want to live in these interesting and quite difficult places. Because of the unstructured ‘referral’ process, and the PA houses being unorthodox and relatively unknown, there is not always a steady stream of applicants to live in them.

Some research has been done on outcomes, but the PA has not been good at organising research, nor has it wanted to particularly. The PA’s philosophical position is to eschew ascientific, objectifying approach, although there are good examples elsewhere of phenomenological research into other approaches to ‘mental illness’, in Europe and in Australia. The PA does not claim to be treating people’s ‘mental illnesses’, nor does it claim anything special, rather emphasising ordinary living. People may choose to come to the houses, live there for a while, and perhaps find a different direction for themselves in their life. Nothing is promised, nor could it be.

The same is true of the psychotherapy the PA tries to show a way towards. Therapy in our privileged society (for many but certainly not for all, and maybe for a lot less now) is often seen as a treatment for ‘mental illness’. With mental illness destigmatised especially for young people, many embrace a diagnosis - bipolar disorder is popular - as some sort of indication of self-awareness. We now expect solutions to life problems, happiness is a commodity we must have, CBT or mindfulness supposedly reshape our minds or thoughts so we are no longer anxious, depressed or in despair. There is perhaps a sense in our society, although this is not unique, that it is your social duty to get ‘sorted’ so you are not a burden – read cost – to others, and you can take your place in a commodity and consumer driven neo-liberal capitalist society, without worrying too much about the climate emergency or even Covid-19. Medication is a huge part of this as we know, many people expect targeted drugs, perhaps tailored to genetic or immunological differences, to rapidly rebalance their neurotransmitters and endorphins.

The PA takes a sceptical view towards theory and practice in psychotherapy. One of the main thinkers behind this scepticism was John Heaton. Heaton was for a long time, from an early member in 1965, until his death in 2017, one of the main intellectual figures in the PA. He was also one of the founders of the Guild of Psychotherapists, with Ben Churchill and Peter Lomas, who also took a critical view of psychoanalytic theory and practice. Laing, although radically criticising the psychiatry of his early years when heavy use of ECT and lobotomy were common, and patients often spent years incarcerated in psychiatric ‘bins’, was not so clear in his critique. Laing brought together the philosophy of Sartre and the existentialists, with psychoanalytic ideas, notably from Winnicott and the “Middle Group” at the Institute of Psychoanalysis. Heaton in contrast took psychoanalysis to task for reification and objectification of ideas such as the unconscious, projection, transference, but vitally our more general ideas about the ‘mind’, the nature of thinking or feeling, and what might count as psychotherapy and training in psychotherapy.

Heaton was a member of the British Phenomenology Society, and a regular attender and contributor to the annual Wittgenstein conference in Austria. He published several books including Wittgenstein and psychotherapy: From paradox to wonder and The talking cure, which explicate his thinking in relation to how we conceptualise and practice psychotherapy, very much influenced by the ‘therapeutic’ move in understanding Wittgenstein’s philosophy. Heaton comes to see therapy not as a rule based activity (not that anything goes) but a relationship in which someone is helped to make sense of her life in new ways perhaps freeing herself from a weight of fixed ideas and ways of perceiving things. Psychotherapy is not a technical process, but an exploration, and language, however at times difficult to find, is ordinary.

Importantly, especially in finding other ways of thinking about symptoms or the ‘unconscious’, Heaton emphasised, following Wittgenstein, that while psychoanalysts as well as neuroscientists might insist that ‘experience’ is private and mediated in the brain, many questions can be asked here. When it comes to making sense of ‘experience’ we depend on language which cannot sensibly be private, or just ‘in my head’. Wittgenstein, well before developments such as systemic family therapy or attachment theory, suggests that we learn to speak of our pain as children surrounded by adults who give us the words to use. Words at first are part of the expression of pain, and not a description, and replace crying or screaming, unless we are in extremis.

This distinction between language as expression, and language as description is missed in psychiatry, leading to deep confusion about the nature of so called ‘mental states’. Psychiatrists tend to assume there is some mental object, a mood, an hallucination, that must be accurately described, although mainly for diagnostic purposes. Currently in psychiatry, there is little attempt to understand what drives the torments, whether thoughts, voices, moods, although psychoanalysis, as well as Jaspers, traditionally has wanted and attempted to do just this. Psychiatry still distinguishes between the form and content of psychiatric symptoms for nosological purposes and orthodox psychiatrists are often very suspicious of the search for meaning in the terrifying experiences of those they are confronted by.

While Jaspers and Freud both set a limit on trying to understand psychosis, a phenomenological approach is exploratory but not dogmatic about what might be found. Interestingly, Roger Boyes, a Times journalist who experienced hallucinations after coming out of intensive care for Covid-19 (see article), apparently a common experience, talked of these as ‘his brain’ trying to make sense of what happens when you are so ill and in an induced coma for some time. Working with young people I have seen, sometimes at least, hallucinations disappear, not when made sense of directly, but when the young person makes sense of their often traumatic or abusive experiences in other ways. Hallucinations may be experienced when things don’t make sense; when language in some way reaches into someone’s experience, the hallucinations might fade away.  

We can ask therefore, what could psychiatry be like if it was recognised that there was no such thing as a ‘mental state’, certainly not the reified object it is taken to be, and that what patients need is to be able to express themselves, in whatever way comes to them? Art and music are vital ways of expression, whether or not they are part of a therapeutic method. Recognising this is important as children who were abused are often not given words by concerned adults to express their pain. The abusing adult more often insists on secrecy and silence. Hence the inchoate nature of someone’s pain that may end up being expressed through illness, of whatever kind. We now know that trauma is non-specific in its effects and can be part of ‘mental illnesses’, ‘physical illnesses’, the rather horribly named ‘medically unexplained symptoms', as well as for some a push to do extraordinary things. Finding expression through speech or in any other way is not necessarily a cure, there is no cure, but may allow some form of liberation.

Wittgenstein said the philosopher seeks to find the liberating word. Liberation itself is a word that leads to many domains, not least questions of race, gender and class. This is the subject for another blog, but having recently, in spite of ‘knowing’ about it before, woken up to the hidden ways racism works even when the protagonists are not overtly or deliberately racist, it needs acknowledgement. It is common knowledge that poverty is linked with poor health outcomes in all domains, it is also common knowledge that BAME people have more mental illness than white people and are imprisoned and hospitalised using the MHA more. That BAME people die more from Covid-19 is also linked. How do we talk about this knowing how painful it is, how difficult it is for BAME people to be constantly the whistleblower (whistleblowers are still more likely to be discriminated against, sacked from their jobs, and further persecuted in some way), how difficult for white people to acknowledge that even without intention our actions, social structures, regulations, stop and search or policing of social distancing can be racist?

Intersectionality³ is a broader way of thinking about people’s position than existentialism, which claims universality from a European context, showing that non-European value systems are equally valid, and making explicit how race, gender, class and sexuality interrelate in the subjectivity and position of people of colour. However the idea of situation in existentialism still has a lot to offer to psychiatry and psychotherapy in thinking about meaning, value and position. Sonia Kruks in Situation and human existence  discusses the social aspects of situation, mutuality and freedom. Alfred Kraus’ idea of a phenomenological-anthropological approach in psychiatry covering all aspects of the personal, social, cultural, meaning world of the subject derives in part from this idea of situation.⁴ We are not determined by our situation, freedom is fundamental, situation is however our starting point. Situation, and the meanings attached, move between or beyond notions of the inner world and particularly horrible, ‘external reality’. External to what? Another question is whether we can ‘transcend’ our situation by our own efforts, or do we require a revolution, a social movement, politics? Can psychotherapy address all of this? Whether we have the potential for change in relation to the areas considered by intersectionality, whether racism, sexism, ableism, class, not to mention the climate emergency, is at the heart of our current dilemmas.

The PA tries – what does this mean exactly? – to put all this in question: theory, position, situation, subjectivity, power structures. But there is a limit. And we are bodies, as Merleau-Ponty lets us know, and merely human. If we ‘meet’ in some sense, see each other, experience through our limited speech something of the terror we face, the hurt, the loss, our ‘thrownness’ into this world, our despair, our futility, our ravenous desires and destructiveness, our rage at the world and at death … is all this universal, cross cultural, beyond intersectionality? Doubtless not, but there is the necessity that we meet, and find ourselves not in isolation but in the face of, in the presence of the other.

¹ Karl Jaspers quoted in Thomas Fuchs, Brain mythologies; Fuchs, Breyer and Mundt (eds) Karl Jaspers’ philosophy and psychopathology, Springer, 2014.
² Maurice Merleau-Ponty, The Visible and the Invisible, Chapter 4 The Intertwining, the Chiasm. Northwestern University Press, 1968.
³ Patricia Hill Collins Intersectionality as critical social theory. Duke University Press, 2019
⁴ Alfred Kraus. How can the phenomenological-anthropological approach contribute to diagnosis and classification in psychiatry. Chapter 13 in Nature and narrative, eds Fulford, Morris, Sadler and Stangellini. OUP 2003

Miles Clapham is a phenomenological psychotherapist at private practice in psychotherapy and psychoanalysis, having retired as an NHS consultant child and adolescent psychiatrist. He trained with the Philadelphia Association in psychoanalytic psychotherapy and is a member of its training committee.