Was Foucault an anti-psychiatrist?

John Iliopoulos in his book History of reason in the age of madness, which I have mentioned in a previous post, has a chapter entitled ‘Is Foucault an anti-psychiatrist?’. As I said in my book chapter on ‘Historical perspectives on anti-psychiatry’, Foucault’s Madness and civilisation is included in anti-psychiatry because Foucault is said to have viewed the Enlightenment as oppressive.” Actually, I think Iliopoulos’ position is correct that Foucault was neither for or against the Enlightenment.

As Iliopoulos says, Foucault stresses he was ignorant of anti-psychiatry at the time of writing History of madness. Iliopoulos corrects the position of post-psychiatry (see previous post) that “Foucault is engaged in an anti-psychiatric endeavour using counter-Enlightenment discourse” (p.101). Instead, Foucault accepted the validity of the anthropological project of the late eighteenth century with its phenomenological diagnostic approach to madness. Where psychiatry went wrong was its positivist reduction of mental illness to brain disease in mid-nineteenth century. In Iliopoulos’ words:-

[T]he subjugated, disempowered status of current psychiatry authority and the value-laden and pseudo-scientific definition of mental illness are not the result of the infantile epistemological level of psychiatry, its axiological nature or its inherently coercive role, but the product of a new, all-encompassing rationality denying and suppressing the anthropological kernel of psychiatric discourse. (p.98)

Reading Foucault’s History of Madness

Jean Khalfa, in his Introduction to his edited edition of Michel Foucault’s History of Madness, says that the book “has yet to be read”. Certainly I haven’t made an attempt to read it until of late. I have been too influenced by the “cursory caricature of Foucault’s work”, to which, as Colin Gordon suggested, even Roy Porter was prone (see Gordon’s review of History of Madness). Andrew Scull’s TLS review has been particularly misleading about the value of Foucault’s work (see, again, Gordon’s response to Scull). Even R.D. Laing’s enthusiastic reader’s report (see image above) for publication of the abridged version, Madness and Civilisation, may have given the wrong impression. Gordon wonders whether Scull has really read the book and Laing’s brief report (I presume this was all he submitted), again, makes me wonder whether he even read the abridged version.

Laing was right, nonetheless, that this is “an exceptional book of very high calibre”. As Gordon says, the book “is the work of a young genius, a work of masterful accomplishment and prodigious and prodigal energy, grasp and daring”.  More needs to be made of it (see previous post).

Holding onto delusional thinking

I went to a talk yesterday by Lisa Bortolotti in the Cambridge University Psychiatry department (see tweet). This was based on her chapter in a recent book. Delusions are not necessarily un-understandable, nor always "bad for us", nor even particularly an exceptional way of thinking.

Picking up this last point from a previous post, we believe all sorts of things, partly often because there isn't clear evidence one way or another for some of the things we believe, eg. belief in God. We also live in societies where power relations can determine what we believe. In fact, following Foucault (see previous post), psychiatry had its origins in the Enlightenment with a focus on human rights, the questioning of dogmatic beliefs and the development of science, particularly social science. Reason itself now questioned the rational foundations of what is accepted as reason. Alongside reflection on the state of the human mind, alienists identified unreason and madness as an un-understandably, different state. The madman’s delusional thinking is central to this fundamental distinction between reason and unreason. Lisa Bortolotti usefully reminds us that this distinction is not really so absolute. 

All this happened before the development of our modern understanding of disease (eg. see previous post). Although there has been progress since the middle of the nineteenth century in our understanding of physical disease, the functional rather than structural nature of mental illness has been difficult to appreciate in this context. The assumption that mental illness is due to brain disease, like delusional thinking, isn’t actually based on logic, but on faith, desire and wish fulfilment (see previous post). It seems to challenge our viability as psychiatrists to believe otherwise (see another previous post). This belief seems to be held onto almost with the same intensity as delusions.

Drugs culture

The Times had a leading article last week that took up from its news article the day before. It stated that "David Baldwin, a government adviser on the use of antidepressants, has resigned after a vituperative social media campaign against him". The leading article does mention the Public Health England (PHE) review set up by the Parliamentary Under Secretary of State for Public Health and Primary Care to review the evidence for dependence on, and withdrawal from, prescribed medicines, but doesn't make clear that Baldwin has resigned from this review. He's still Chair of the Royal College of Psychiatrists' Psychopharmacology Committee.

The Times says that scientists should not attack advocates of antidepressants because antidepressants are a "gain to human wellbeing". I'm not quite sure what it means by this, because there is an ongoing debate in the academic literature about the efficacy of antidepressants (see previous post). Instead The Times has already concluded that the "evidence base is impressive".

The leading article also makes much of the difference between clinical depression and everyday moments of low mood and sadness, although this distinction is of course relative and not absolute.  Medication has in fact always been used in the history of psychiatry but what happened in the 1950s was that tricyclic antidepressants were marketed as a specific treatment (eg. see previous post). These drugs were closely related to the chemical structure of chlorpromazine, the first marketed specific neuroleptic treatment for schizophrenia. Before then drugs tended to be used in non-specific ways.

The Times does recognise the value of talking therapy as well as medication. Helping people understand their problems and deal with them psychosocially has actually always been the mainstay of psychiatric treatment. And, of course, a multitude of different psychological therapies have developed after psychoanalysis - The Times mentions principally cognitive behavioural therapy and interpersonal therapy.

The Times quotes the statement made by David Baldwin (and Wendy Burn, President of the Royal College of Psychiatrists), which led to the complaint which I signed about antidepressant discontinuation problems being minimised (see eg. previous post). But it doesn't say that the complaint was signed by 30 people, not just psychiatrists and psychologists, but also people who have experienced antidepressant discontinuation problems. Instead it misleadingly says that 10 psychiatrists and a psychologist from the PHE panel complained. I'm one of the 10 psychiatrists that the leading article is referring to, but I'm not on the PHE panel!

I also signed a subsequent letter, as I was concerned that Baldwin's conflicts of interests could compromise his work on the PHE review group. The letter suggested he should be replaced with someone who had no such conflicts of interest (see Mad in the UK post). I'm not sure whether PHE had any concern about his declaration of interests. Certainly the Royal College of Psychiatrists had no such concerns (see press release). However, there are problems with institutional corruption within the Royal College of Psychiatrists (see previous post). Our complaint was not a personal attack on Baldwin but to ensure that the issues within the PHE group are discussed in as unbiased a way as possible. I'm sorry if David Baldwin felt distressed by the concern expressed about his role on the issue of antidepressant discontinuation but he is in a responsible position in the College.

What happened was that @Truthman30 became aware of Baldwin after the joint statement with Wendy Burns. He has produced a blog since 2007 on what he calls the Seroxat Scandal. This issue is much wider than just antidepressant discontinuation problems. This includes the role of paroxetine (original trade name Seroxat) in producing suicide and violence. Personally I'm more sceptical about these claims (see eg. my review of Peter Breggin's book) but @Truthman30 regards Seroxat as perhaps one of the most dangerous drugs ever made. He knows this from his personal experience and 10 years of research for his blog.

So @Truthman30's research into David Baldwin led to posts on his blog, which he described as being about David Baldwin's "long, incestuous, and financially lucrative relationship with the Pharmaceutical industry". This is where the term "pharma-whore" mentioned by The Times was used and @Truthman30 sought to defend its use. The "worse than Hitler" label comes from a comment on the blog by kiwi (not actually anonymous as The Times news article said, although the google profile has not been completed). @Truthman30 is unhappy that Baldwin described Seroxat in 1998 (the year @Truthman30 was first prescribed it) as "one of the safest drugs ever made" because of course this is not his personal experience, nor has it been backed up by the results of his research for his blog.

As The Times says, "Inflammatory and calumnious invective is unfortunately part of online discussion on many issues." I agree that scientific research should be based on evidence and I look forward to the report that will come out of the PHE review. I would like to see more discussion in the academic literature about antidepressant efficacy and discontinuation problems (see previous post). I would also like to see more academic discussion about the issues of safety raised by @Truthman30 (even though I tend not to agree with all he says). It's important to stick to the issues. It's also a privilege to be able to discuss these issues publicly on social media and this privilege should not be compromised. I'm glad to be able to do so on my blog.

Analysing the evidence about antidepressants and other psychiatric medication

Editorial in The Lancet Psychiatry helpfully calls for a “dispassionate analysis of the evidence” about psychiatric medication. It seems to be particularly concerned about what it calls “Hooked on happy pills” headlines that have appeared in British newspapers over recent years (see one example). 

By criticising these articles without dealing with the issues, the editorial could be taken as another example of minimising the significance of antidepressant discontinuation problems (see previous post). This issue does need to be taken seriously. 

Why doesn’t The Lancet Psychiatry commission a review of the evidence? Or more generally, why doesn’t it commission an analysis of the placebo amplification hypothesis of antidepressant efficacy (see previous post). Rather than platitudes in an editorial, it should be doing its job of analysing the evidence. There are too many issues about psychiatric medication that are being fought out in the press rather than psychiatric journals dealing with these matters scientifically.

The wish for a biological basis for mental illness will never go away

James Davies in his book Cracked (see my review), was surprised when Robert Spitzer, chair of the DSM-III task force, said no biological markers had been identified for functional mental illness (see recent @ClinpsychLucy tweet). Spitzer understood that organic mental illness is different from functional mental illness. It was DSM-IV, led by Allen Frances, that abolished the distinction. This was a mistake (eg. see previous post).

I have mentioned in a previous post how Sami Timimi couldn’t understand why he was indoctrinated in his psychiatric training. Similarly, I remember the discussions I had with Alec Jenner, my professor of psychiatry in Sheffield (see previous post), about why people believed what they did about psychiatry. The problem is that the belief in the biological basis of functional mental illness will never go away (see my tweet in response to @ClinpsychLucy). I’m not one who hopes for a radical, new psychiatry that will replace biomedical psychiatry. But we do need to break the dominance of the biomedical model and recreate a more pluralistic psychiatry. This situation is not helped by dissolving the distinction between functional and organic mental illness, which needs to be reinstated.

Running amok in American society

The New England Journal of Medicine (NEJM) has an article about how to stop mass shootings (see article). I've written before on this situation in the USA (see Psychiatry shooting itself in the foot and The omnipotence of the mental health system).

It isn't just in the USA where people have run amok (see medical definition of amok from Merriam-Webster). The NEJM article says that such US tragedies are "entirely preventable" by the implementation of policies requiring that firearm sales involve background checks on purchasers and also allowing courts to have firearms removed temporarily from people who pose an imminent hazard to others or themselves but are not members of a prohibited class. These policies may well reduce such incidents, but the article doesn't provide any evidence to suggest that their implementation will prevent mass shootings entirely. And there must be questions about whether they really go far enough.

Amok episodes normally end with the attacker being killed or committing suicide. Murders which are followed by suicide are most likely to be committed in anger by aggrieved people blaming others as well as themselves. Although amok was traditionally seen as a syndrome bound to cultures such as Malaysia and Indonesia, all societies, including American society, can subtly sanction such mass shootings (and perhaps also not so subtly sanction them - eg. How does NEJM publish an article like this that doesn’t properly consider removing guns from civilian possession). The American government and people need to understand the ways in which they themselves are doing this. Amok isn't just happening in other parts of the world.

Institutional corruption within the Royal College of Psychiatrists

I’ve commented before on institutional corruption within psychiatry (eg. see previous post). I’ve also pointed out how the Royal College of Psychiatrists can’t be relied on for its information about psychiatry (eg. see another previous post).

The College does need to do more to deal with institutional corruption within its own ranks. The American Psychiatric Association may be more blatantly corrupt (eg. see previous post), in that there doesn’t seem to be much attempt to hide commercial influence. However, this doesn’t mean there aren’t problems within the Royal College as well.

The College does prevent pharmaceutical company influence within College meetings. But many of the speakers have a conflict of interest. Declaring conflict of interests, even if it does make matters more transparent and honest, is insufficient to deal with the issue of conflict of interests (see previous post). If one thinks about it, declaring conflict of interests doesn’t purify the content of College meetings. In fact it does the reverse.

Peter Gordon’s campaign to make disclosing of payments from drug companies mandatory may help (see BMJ news item), but ultimately it’s up to the Royal College of Psychiatrists to deal with institutional corruption within its own organisation. The problem is that I don’t think the College agrees that conflict of interests compromises the work of its representatives.

We are all mad here

Peter Kinderman is giving a lecture at Salomons Centre in Tunbridge Wells this week entitled 'Our turbulent minds: why we’re all crazy, but none of us is ill'. I've mentioned Peter several times in this blog previously. For example, I’ve said he can express the essence of critical psychiatry better than me (see previous post), as he points out that explaining mental disorder in terms of the brain is no different from explaining all other behaviour and emotions in terms of the brain.

Despite all my agreement with Peter, I have been critical of some aspects of his book A prescription for psychiatry (eg. see previous post with links from that post). Obviously I don’t know exactly what Peter’s going to say in his Salomon’s talk. He might start with a quote from Lewis Carrol in Alice in Wonderland (see tweet):-

“But I don’t want to go among mad people," Alice remarked.  

"Oh, you can’t help that," said the Cat: "we’re all mad here. I’m mad. You’re mad." 

"How do you know I’m mad?" said Alice. 

"You must be," said the Cat, "or you wouldn’t have come here.”

Of course we’re all crazy in this sense. We believe all sorts of things which it might be very difficult to justify. Our very existence relies on having a worldview that protects our viability as human beings. It’s particularly difficult to give up these kind of beliefs. For example, it was quite traumatic when in my late teens I gave up my belief in God. Similarly psychiatrists find it very difficult to give up the biomedical model. They may feel that their very existence as psychiatrists may fall apart if they do.

Yet I worry that Peter may mislead by going on to say that no one is ill. I do understand what he means. Illness since the nineteenth century (although not really before) has been understood as having a bodily tissue pathological basis. I agree with Peter that functional mental disorder does not have a physical basis in this sense. For example, no physical pathology has been established for psychotic disorders, such as schizophrenia or bipolar disorder. True, with the amount of psychiatric research that is done, many people assume that a physical basis has been established for these conditions, but this is wrong.

However, this does not mean that psychosis does not exist. It’s not surprising Alice may not have wanted to go amongst psychotic people who are out of their minds. We all have the potential to lose touch with reality and this is different from believing our normal everyday crazy ideas which sustain our worldview. Of course, the psychotic person’s delusions and hallucinations are sustaining their worldview in this way, but it’s idiosyncratic and the rest of us find it very difficult to understand why they’re out of their mind.

Personally I’m happy to see mental disorders as ‘illness’, as the 19th century anatomoclinical understanding of disease in terms of physical pathology has never incorporated functional mental illness. We’ve been misled by defining illness so narrowly. That definition allowed Thomas Szasz to say that mental illness is a myth.

But we need more historical undestanding of the origin of psychiatry. Of course mentally ill people were looked after by the state in poor law arrangements. And it was once the state started to intervene in this way that it identified there was a group of people that were mentally ill. They weren’t necessarily responsible for their poverty, as they were mentally ill and needed treatment. Psychiatry developed the role of identifying this group. What psychiatrists now call phenomenology is the process of identifying psychological abnormalities. Peter’s right that there may well be disagreement about what counts as an abnormality. But the fact that people were prepared to question the beliefs that they had led to psychiatry having the role of identifying insanity. They were alienists, identifying mental alienation.

This proto-psychiatry existed before the introduction of anatomoclinical thinking in medicine. Much of the thinking about the origins of mental illness was in fact very physically based. For example, there were ideas about the brain being oppressed by blood and several early psychiatrists were phrenologists. Yet incorporating the anatomoclinical way of understanding disease into psychiatry has eclipsed a more psychological understanding. This is why we need a critical psychiatry to point out that psychiatry can be practiced without believing that mental illness is due to brain disease.

Realising the right to mental health

The European Psychiatric Association (EPA) has expressed "great concern and disappointment" in a position paper about what it sees as "the misleading and false portrayal of psychiatry ... as well as the lack of any evidence or statistics supporting this opinion" in a report from the UN Special Rapporteur, Dainius Pūras, who I mentioned in my last post. I actually thought the report was very good (see previous post).

EPA is particularly concerned by what it sees as the ignoring of evidence for the effectiveness of psychotropic medication, which it says "risks harming people" by encouraging avoidance of treatment. It defends the biomedical approach and does not see it as "a source of neglect, abuse and coercion" or as "the key factor explaining the current unsatisfactory status of mental healthcare". Rather, it sees inadequate government funding as the primary obstacle to mental health.

The EPA position paper is helpful in clarifying points of disagreement. I've always emphasised the need to avoid polarisation in the debate about psychiatry. However much I think the biomedical view is wrong, I am aware that it will never go away.

Recognising the bias in the evidence for psychotropic medication is not unscientific. In fact, I've always said psychiatry needs to be more scientific in its interpretation of the evidence (eg. see previous post). It is true that biomedical theories are used to encourage people to take their medication (eg. see previous post) but I've always found that patients are able to understand that a physical basis for mental illness has not been established.

I do see the dominance of the biomedical approach as an obstacle to the realisation of the right to mental health. We need a more balanced perspective. The tendency to reduce people to objects, which the biomedical approach can encourage, hinders understanding of peoples' problems and may prevent helping them deal with their problems. Of course some patients take a biomedical perspective but imposing such a view on people is a misuse of psychiatric power. The EPA should encourage further debate on these issues.

Institutional corruption in psychiatry

I've commented before on corruption within psychiatry (eg. see previous post). Dainius Pūras, the United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, who I have mentioned before (eg. see previous post), produced a report last year on corruption and the right to health, with a special focus on mental health. The World Psychiatric Association (WPA) objected strongly to the report (see letter sent to Dainius Pūras) and seems to be particularly complaining about the specific focus on psychiatry.

Robert Whitaker and Lisa Cosgrove in their book Psychiatry under the influence highlighted the institutional corruption due to over-marketing of stimulants for ADHD, the expansion of the notion of depression, the extension of SSRI antidepressants for other neurotic conditions besides depression and for children, and the promotion of mood stabilisers (see previous post). Perhaps WPA need to read this book to find the evidence for the statements in the Special Rapporteur's report.

There is no doubt that psychiatric power is misused for private gain. It seems reasonable that the Special Rapporteur should have a focus on corruption in mental health in this report, taking into account the context of his previous report, which raised the issue of the global burden of obstacles that persists in mental health care systems globally and how this hinders the realisation of the right to mental health. These obstacles include (1) the dominance of the biomedical model and the overuse of biomedical interventions, in particular psychotropic medications (2) power asymmetries and (3) the use of biased evidence.

Institutional corruption develops when systemic practices, which are legal, accepted and normative, nonetheless undermine the integrity of the institution. Disclosure is insufficient to control conflicts of interest (see previous post). In fact, there is little attempt to hide the commercialisation of psychiatry. Ironically being open about commercial interests does not purify psychiatric science but rather exposes its self-interest (see another previous post). The WPA does need to recognise and correct its own institutional corruption. The corrupting self-interests of psychiatry demand change in psychiatric practice.

Anatomoclinical understanding in psychiatry

In the introduction to The birth of the clinic, Michel Foucault contrasts the views of Pomme from the middle of the eighteenth century and Bayle less than a hundred years later. Pomme believed that baths for ten or twelve hours a day for 10 whole months desiccated the nervous system and its sustaining heat, and observed in a patient after this treatment that:-

‘membranous tissues like pieces of damp parchment… peel away with some slight discomfort, and these were passed daily with the urine; the right ureter also peeled away and came out whole in the same way’. The same thing occurred with the intestines, which at another stage, ‘peeled off their internal tunics, which we saw emerge from the rectum. The oesophagus, the arterial trachea, and the tongue also peeled in due course; and the patient had rejected different pieces either by vomiting or by expectoration’. 

Such “language of fantasy” was not used by Bayle when he described the encephalitic lesions of general paralysis. Foucault describes such new pathological understanding as a “mutation in discourse”.

Such anatomoclinical understanding, relating symptoms to their underlying physical pathology, was a major advance for medicine in the first half of the nineteenth century and still underlies our modern understanding of disease. But the enthusiastic search for anatomical localisation in psychiatry still led to fanciful notions later in the nineteenth century. For example, Theodor Meynert (1833-1892) delineated various ‘fibre-systems’ in the brain and deduced functions for these ‘pathways’. Despite his skills in brain dissection, his theories were not based on empirical findings. They were eventually attacked and labeled as ‘brain mythology’, particularly after his death. To quote from Auguste Forel, who studied with him:

He [Meynert] was certainly brilliant and full of ideas, but his imagination made leaps that were ten times as bold as mine. The longer I remained, the more I lost faith in his encephalogical schemata, and the fibrous connections which he perceived in the brain. … I could not always see what Meynert saw.

Modern neuroimaging studies also have the tendency to be interpreted as facts despite the inconsistencies and confounders in the data (eg. see previous post). Meynert’s research may have appeared so successful because it seemed to give a material explanation of the basis of mental illness, in the same way as brain scanning does for us now. Its empirical truth is a lesser concern in whether the results are believed or not.

Equality in the Mental Health Act

Race on the Agenda (ROTA) and Race Equality Foundation (REF) have made their submission to the Mental Health Act (MHA) Review 2018. I have shown support by signing up on the ROTA website and hope others will as well.

I have blogged before on the MHA review (eg. see previous post). I have questioned how open this review is (see previous post). I hope it doesn’t boil down merely to ‘watering down’ community treatment orders (CTOs), because I think that will be a missed opportunity to create a more rights-based focus for mental health work in England and Wales.

Anti-discriminatory principles and the acknowledgement of institutional racism do need to be made explicit in any new Mental Health Act. I understand historically why mental illness was not defined in the 1983 Mental Health Act, but I think this difficult issue needs to be grappled with in this review. For example, even alcohol intoxication seems to have been misunderstood as a disorder that is liable to detention (see twitter conversation). However much this may be against the spirit of the MHA, there is clearly confusion and a clearer definition of mental disorder that is liable to detention is required. More stringent criteria are required to avoid cultural misunderstandings and racial bias. It should be explicit that diagnosis must take account of the person’s social and cultural background. In practice, detention may only be justified for psychosis, with loss of mental capacity, and for personality disorder which is treatable. And there need to be rigorous standards to avoid misdiagnosis of psychosis because of cultural and racial bias. And if people are going to be detained for personality disorder or psychosis, the degree of risk should not be exaggerated because the person is "big and black". Mental health professionals should have the skill to appreciate cultural diversity in diagnosis and treatment and this needs to be legislated for by stipulating that Approved Mental Health Practitioners (AMHPs) and Responsible Clinicians (RCs) can only be approved (and their approval renewed) when they do have these skills. A similar process needs to apply to independent mental health advocates (IMHAs).

The interim review does say it will look at improving the Mental Health Tribunal (MHT) (see extract). The MHT should be able to deal with specific appeals against failure to take account of the person’s social and cultural background, with expertise from Black and Minority Ethnic (BAME) interests on the panel and the ability to call evidence from outside sources. MHTs need to be able to seek additional information on cultural background of the detained person. Their decisions need specifically to take account of cultural diversity and institutional racism. People appointed to MHTs need to have experience of race and anti-discrimatory practice. Personally I think the MHT has become too legalistic and has lost sight of its role as a safeguard in detention. I think there is a case for wholesale reform of the MHT. I would actually change its name to the Mental Heath Rights Tribunal. This is putting the R back into the acronym of MHRT, but inserting the word 'rights' rather than 'review', as it used to be.

As I said in my previous post, I was surprised that the interim report did not mention the statutory responsibility of the Care Quality Commission (CQC) (after taking over the role of the Mental Health Act Commission (MHAC)) to interview detained patients and investigate their unsatisfactorily dealt with complaints, as well as deal with any other complaints in relation to detained patients. This was a significant safeguard introduced by the 1983 Act and its significance seems to have been lost with MHAC's assimilation into CQC. The CQC should be reducing the use of detention and racial inequalities in practice. It needs to reinforce its inspection of cultural competence of mental health professionals and address racial bias. It also needs to be fulfilling its role to prevent ill treatment under the Optional Protocol to the UN Convention (OPCAT) (see duties under National Preventative Mechanism). Personally I think the Mental Health Act functions of CQC need to be taken out of CQC and taken over by a new body. Maybe this could be a new single Mental Health Rights body, which also incorporates the MHT functions. Second Opinion Appointed Doctor (SOAD) functions also need to be strengthened so that they are not merely a rubber-stamping exercise.

As a member of the Critical Psychiatry Network (CPN), I was against the introduction of CTOs. CPN was an original member of the Mental Health Alliance that campaigned against the reforms that eventually led to the 2008 amendments to the Mental Health Act. CPN was the first group of psychiatrists that was part of the Mental Health Alliance, which was subsequently joined by the Royal College of Psychiatrists. CPN resigned from the Alliance when it looked as though the Alliance was going to compromise on the introduction of CTOs, which in fact proved to be the case. I am not opposed to CTOs because I don't realise there has always been provision within the MHA for enforced community treatment, in the form of guardianship orders. I think at the time of the 2008 amendments there was a supervised community treatment provision, which was never used as much as community treatment orders. I'm not proposing returning to supervised discharge arrangements. Too many CTOs are currently technically unworkable because of non-compliance and even those that seem to be workable the person consents to the treatment, so there may be a question about why the CTO is needed. Quite commonly people are recalled just for breaching conditions, which is actually an insufficient reason for recall within current legislation but there is no safeguard. I'm pleased to see that the interim report of the MHA review has said that CTOs will be reformed or replaced. My personal option would be to go for replacement, perhaps building on the current provision within guardianship.

I'm also not one that necessarily thinks it would be a good idea to replace the MHA with Mental Capacity legislation. The trouble is that mental health professionals tend to define people who do not make very rational decisions as lacking in capacity. Mental capacity legislation makes clear this is incorrect but ensuring its implementation may in fact be more difficult than reforming the MHA, as RCs and AMHPs have got used to interpreting the spirit of the Act. That spirit of the Act needs to be reinforced in reformed legislation to make it even more rights-based.

Global critical psychiatry

The Mad in Asia website has recently been launched. It’s part of a global network (see links). I’ve posted before on global mental health: eg. Mental health as a global health priority, Global human rights violation in mental health, Human rights and mental health worldwide, Think about investing in intercultural mental health and How to get money for global mental health research.

I have always encouraged critical psychiatry to be a broad church (eg. see previous post). However, I do worry that this may dilute the essential message of critical psychiatry that mental illness should not be reduced to brain disease. Critical psychiatry needs to be a genuine global movement. And, it needs to be concerned about its systemic whiteness.

The true situation about antidepressant discontinuation problems

I’ve mentioned before (see previous post) that I signed a complaint to the Royal College of Psychiatrists about a statement made by Wendy Burns, the President, and David Baldwin, the Chair of the Psychopharmacology Committee, that discontinuation problems on stopping antidepressants resolve within two weeks for the vast majority of patients. I do not think this statement is evidenced-based. The complaint has been dismissed by the College as unfounded (listen to MIA Radio podcast)

Minimising the significance of antidepressant discontinuation problems doesn’t seem to matter to the College. I’m not convinced the College membership fully agrees with this unwillingness to engage with the evidence and I am ashamed as a member of the College about this apparent lack of concern. As I said in my previous post, there is a history of antidepressant discontinuation problems being minimised, even denied, and this situation just seems to be being perpetuated by the College.

On the other hand, I guess we shouldn't be too surprised that the College is unconcerned about the truth of a matter of this sort. It finds it difficult to acknowledge the political and ethical implications of psychiatric practice. However neutral and objective the College may like to think it is, it exists, actually, as an institutional structure to justify psychiatric treatment, such as antidepressant medication. So, it would want to minimise problems caused by medication, wouldn't it? More generally, the validity of what it promotes as science does need to be challenged (eg. see previous post). We should not assume that the College has full and absolute legitimacy in truth over psychiatric matters and this has been demonstrated by the way this complaint has been handled.

Let's hope Wendy Burns and David Baldwin are prepared to discuss these matters further now that the complaints procedure is over.

The origin of critical psychiatry

The origin of the term 'critical psychiatry' was probably in an edited book Critical psychiatry: The politics of mental health by David Ingleby (1980). My own edited book Critical psychiatry: The limits of madness (2006) deliberately echoed David's use of the term, and, of course, the name was adopted by the Critical Psychiatry Network (see previous post). David also contributed a chapter to my book.

In the preface to the second impression of his book (2004), David commented that "the notion of mental illness as a brain disease has become even more widely accepted than ever before" (p. 5). The essential position of critical psychiatry can be said to be the critique of this notion. Mental illness should not be reduced to brain disease (eg. see previous post). Even Thomas Szasz contributed to critical psychiatry in this respect, as he regarded the biological basis of mental illness as a myth (eg. see another previous post).

There are, of course, implications of taking this conceptual position. How critical psychiatry's essential understanding is taken forward does lead to differences within critical psychiatry (see previous post). In his introduction to the book, David suggested that, "One premise shared by all contributors to this book is that mental illness is, in fact, a political issue" [his emphasis] (p. 8). In fact, Franco Basaglia (eg. see previous post), one of the contributors to his book, tended to be less concerned about whether mental illness had an organic aetiology. His primary motivation was to abolish the asylum as, as far as he was concerned, its main purpose was to segregate the under-privileged (see extract from my book chapter).

David made it clear that "mental illnesses ... do exist" (p. 18). He, thereby, moved critical psychiatry on from Szasz's theme of 'the myth of mental illness', in the sense that Szsasz did not believe that the concept of mental illness is valid (see previous post). David also notes how some critical psychologists and others have questioned whether mental health problems "really have much to do with medicine in the first place" (p.8). However, he also quotes Peter Sedgwick, who argued that "mental illness was, after all, a medical problem" [his emphasis] (p. 9).

David juxtaposed 'positivist psychiatry', defining positivism as "the paradigm of studying human beings as if they were things' (p. 13), with 'interpretative' approaches, by which he meant "[u]nderstanding people's 'symptoms' in terms of their social situation" (p.52). Mental illnesses are "meaningful responses to difficult situations ... [but] in many conditions a 'residue' remains refractory to commonsense understanding" (p.13). Here he turned to psychoanalysis to interpret the 'residue' in terms of unconscious meanings.

David concludes his chapter by saying that “until the political component of our disagreements is brought out into the open, we will never go beyond the phoney synthesis of psychiatric ‘eclecticism’” (p.71). His book was written at the end of the period of conflict know as 'anti-psychiatry'. He does mention (on p.7) Anthony Clare's book Psychiatry in dissent, which, as I have said previously, many have seen as the compromise outcome of the anti-psychiatry debate. Clare reinforced an eclecticism in psychiatry by avoiding any clear conceptual basis for psychiatry (eg. see my Psychiatric Bulletin letter). Manschrek & Kleinman called this kind of position in psychiatry 'semi-critical' (see previous post). In many ways, psychiatry is still in this situation (see eg. previous post). The critique of psychiatry does need to go further. Critical psychiatry, in very much the sense originally used by David Ingleby, does need to be seen as a valid solution to the anti-psychiatry debate.

Mind-body relation

Further to my previous post in which I mentioned Charles Myers, I came across a lecture he gave in 1932 entitled ‘The absurdity of any mind-body relation’. (1) What he meant by this was that life has direction and is more than blind mechanism. And, “[c]onscious mind is essentially a specialization, a distillation of that directive activity” (p.8). So mental activity and living bodily activity are identical and it doesn’t make sense to talk about a mind-body relation.

Physical concepts of mechanism are incomplete for a total description of nature (see previous post). The primary distinction is between life and inanimate matter, not life and consciousness (see previous post). To quote from Myers’ lecture, “In no form of life is directive activity wholly absent.” (p.21) As Kant said in the Critique of Judgement,

there will never be a Newton of the blade of grass, because human science will never be able to explain how a living being can originate from inanimate matter

Directive activity is still inherent in plants, even though, as Meyers said, “locomotion and plasticity are minimal” (p.25). This doesn’t mean that there can be no causal explanations for an account of the physical nature of organic matter. But, mechanistic explanations are insufficient for an account of the totality of human and living nature. As Myers concludes, “There is no separable mental or vital force: and the mental must be regarded as identical with the vital.” (p.26) Psychiatry needs to recognise its mistake in reducing mental illness to inanimate brain disease.

(1) Hobhouse memorial lectures 1930-1940 OUP: London

The roots of medical psychology

I’ve mentioned before (eg. see previous post) that I am doing a PhD in psychology at Cambridge University. It’s probably just as well that I’m in the psychology department rather than psychiatry, considering how critical I’ve been of some of the emphasis within the psychiatry department (eg. see previous post).

What may be of interest is that it was actually the psychology department that first started psychiatric training at Cambridge University with the setting up of a Diploma in Psychological Medicine (DPM) course in 1912. It only lasted until 1927 (although no students had enrolled on the course for two years before it was abolished). But the intention had been to make Cambridge the “national centre for the education of psychiatrists” (Forrester & Cameron, 2017: 248).

One of the main driving forces was Charles Myers, who set up the Psychological Laboratory at Cambridge. After the war, he wanted to develop the medical, educational and industrial aspects of psychology. He left Cambridge in 1922, at least partly because of opposition from an emphasis on experimental psychology.

Cambridge psychology needs to be reminded of this root in medical psychology. The British Psychological Society closed the British Journal of Medical Psychology in 2001 and continued it as Psychology and Psychotherapy: Theory, Research and Practice the following year. The first editorial of the newly titled journal said that “the term ‘medical psychology’ is itself becoming anachronistic”. I’m not convinced psychology should be quite so dismissive of this aspect of its history.

Psychiatry should be more scientific

An advertisement article in the Guardian paid for by the Royal College of Psychiatrists uses Mary-Ellen Lynall (who I've mentioned in a previous post) to promote young doctors coming into psychiatry. I'm not sure if it really improves recruitment by speculating that "brain inflammation may be a cause of depression and in five or 10 years we could have a blood test to detect whether that inflammation is present", because this is merely misguided wishful thinking (eg. see previous post).

What worries me is that the apparent motivation for this campaign is that newly qualified doctors don't think psychiatry is very scientific. That's not surprising considering what's promoted as apparent advances in psychiatry, including seeing brain inflammation as the cause of mental illness (eg. see another previous post). Junior doctors are right to laugh at psychiatry if that's all that's on offer.

Psychiatry isn't just about physical disease, as the advertorial indicates. It's a human science, and not just focused on the brain. Nor is the rest of medicine just focused on the body and psychiatry needs to promote itself as a truly patient-centred scientific medical discipline (eg. see another previous post).

Defending Engel's biopsychosocial model

Linda Gask has an essay in The Lancet Psychiatry entitled 'In defence of the biopsychosocial model'. Progress does need to be made on clarifying George Engel's biopsychosocial model (see previous post).

Engel’s model promotes a holistic psychiatry in the same way as critical psychiatry and is a challenge to biomedical dogmatism. His original Science paper was written in response to a paper published in JAMA by Arnold Ludwig (1975) called ‘The psychiatrist as physician’.

Ludwig was concerned about the state of psychiatry, which he saw as under attack from what we now identify as 'anti-psychiatry'. His response was to accept that modern-day psychiatry is vulnerable to such charges. His solution was to retreat to the medical model. As far as Ludwig was concerned, psychiatry should deal with medical illness, including neuropsychiatric and medicopsychiatric disorders, rather than nonpsychiatric problems, which are more appropriately handled by nonmedical professionals. This position is what has more recently been called a 'remedicalised psychiatry' (see previous post). Ludwig was clear that psychiatry's viability was dependent on an understanding of mental illness as due to known, suggestive or presumed brain dysfunction. Interestingly, he predicted, “I am not optimistic that there will be any sudden and dramatic resolution of these issues” (p. 604). Subsequent history could be said to have proved him wrong in the sense that psychiatry has become more biomedical since the publication of DSM-III in 1980 and the development of brain imaging. Modern psychiatry has become more biomedical than even Ludwig anticipated.

Engel, by contrast, was not happy with Ludwig's proposal for change. As far as he was concerned, all medicine, not just psychiatry, was in crisis. He believed doctors had become insensitive to the personal problems of patients and preoccupied with procedures. In short, medicine is too disease-oriented rather than patient-orientated. For Engel, the biopsychosocial model has real advantages, by taking account of cultural, social and psychological considerations as well as biological. Furthermore, it avoids the polarisation between biomedical reductionists, amongst which Engel would have included Ludwig, and exclusionists, like Thomas Szasz, who deny mental illness. Szasz, in fact, had the same biomedical understanding as reductionists of the nature of illness as physical lesion, but did not believe in mental illness because a biological basis has not been established. I have always tried to be clear that there are aspects of Szasz's views which do not coincide with my views about critical psychiatry (eg. see previous post). My views are more identified with Engel's.

What is of interest is that both Ludwig and Engel were trying to salvage psychiatry in the context of ‘anti-psychiatry’. This is why this situation is relevant to critical psychiatry, which has its origins in anti-psychiatry (see my book chapter). I am suggesting that Engel’s biopsychosocial model is a viable form of critical psychiatry.

Many psychiatrists, like Linda in her essay, would say that their approach to psychiatry is biopsychosocial, taking into account psychosocial factors as well as biological. I agree that most psychiatrists are pragmatic in their approach. However, even though most psychiatrists are not narrowly biomedical, they are still biomedical (see previous post), in the sense that they generally believe that mental illness, or at least major mental illness, such as schizophrenia and bipolar I disorder, is due to brain abnormalities, even though the evidence is against this conjecture. More than the empirical evidence, the philosophical argument about the relationship between mind and body is against such speculation. Psychiatrists now rarely become involved in this conceptual debate because they expect that brain research will find the solution to mental illness.

As pointed out by Linda, the biopsychosocial model has been critiqued as being too eclectic by Nassir Ghaemi, leaving psychiatry with no overall theoretical structure as "all theories are possible and all perspectives are valued" (p.1) (see my book review). I agree that psychiatry can be eclectic with, for example, biological and psychotherapeutic treatments being combined without any systematic theory to support such a therapeutic strategy. There is also commonly a split in the aetiological understanding of mental illness, with major psychotic illness being seen as biological in origin, and more minor, neurotic illness seen as having psychosocial causes.

The real origin of eclecticism in modern psychiatry, though, is not in the biopsychosocial model but in the mainstream response to ‘anti-psychiatry’. Anthony Clare’s Psychiatry in dissent, mentioned by Linda, was a response to anti-psychiatry (see previous post). It eschewed a well-defined theoretical basis for practice. In this way, Clare avoided the worst excesses of reductionism and the objectification of patients that caused particular concern to anti-psychiatry. This approach is what is now often labelled as ‘biopsychosocial’ and I worry that Linda is using the term in this way. Most psychiatry is only semi-critical in this sense (see previous post). The true meaning and implications of Engel’s biopsychosocial model have been diluted.

Valid psychiatric diagnosis is unreliable

It's touching to see Paul Salkovskis & Irene Sutcliffe apparently hankering after DSM-III in their The Mental Elf blog post. For some reason they associate DSM-III with ICD-9, which was actually very similar to DSM-II not III. Surely ICD-9 still had some of the "notoriously unreliable" diagnostic definitions Salkovskis & Sutcliffe seem to so dislike. True, they do recognise that biological research has failed to substantiate reliable diagnostic categories, as in DSM-5 (see previous post).

What I'm objecting to is the way Paul Salkovskis & Irene Sutcliffe seem to follow Robert Spitzer in his view that "assuredly an unreliable system must be invalid" (Spitzer & Fleiss, 1974). As I said in my talk (see powerpoint slides), psychiatry should not be panicked by the unreliability of psychiatric diagnosis. If psychiatric diagnosis is going to be meaningful, there will be inevitable inconsistencies. In fact, paradoxically, increasingly internal consistency may well create an overly narrow measure that does not measure the construct optimally, which is called the attenuation paradox.

I'm not against Salkovskis & Sutcliffe encouraging debate about whether psychiatric diagnosis is finished (see previous post). But they speak against the Division of Clinical Psychology (DCP) position statement encouraging people to give up the disease model of mental disorder, which is actually what I think should happen (see previous post).

Most of The Mental Elf post is about the Power Threat Meaning (PTM) Framework, on which I have also blogged (eg. see previous post). Personally I'm not worried that DCP spent money on the launch of the Framework, as it needs to do something with its money. I agree with Salkovskis & Sutcliffe about the Framework being hard to follow, but I've tended to assume it will get easier once I've got used to it. Maybe though it does need a more user-friendly version.

I actually think the summary by Salkovskis & Sutcliffe of the document is quite good. What worries me though is that they seem to still believe in scientific positivism in mental health. They need to accept more the limitations of psychiatric diagnosis (see previous post), and take the PTM Framework more seriously. Lucy Johnstone, one of the main authors of the Framework, is merely arguing for service users to have more choice as to whether they take on a psychiatric label as part of their understanding of their problems (see my book review). Some service users may well find the PTM Framework helpful.

Maybe Foucault understood critical psychiatry after all

Further to my previous post about postpsychiatry, I have found that I like the view of John Iliopoulous that Foucault was not necessarily for or against the Enlightenment (see his PhD thesis (2013) and subsequent book (2017)). The Enlightenment is not so much about the "principles of humanism, liberalism and positivism" (book p.18) but the point when reason itself started to question "the rational foundations of what is accepted as reason" (book p.7). It was this "critical engagement of reason with itself which brought psychiatry as a discipline into existence, and it is the same conflict, the same battle which fuels current debates in psychiatry" (thesis, p.7).

Foucault draws on Kant's philosophy. "Kant's method of questioning the pretensions of rationality, and reflecting on the limits of who we are through reason, inspired Foucault to analyse the birth of the human sciences, and especially of psychiatry" (thesis, p.21-2). In the late eighteenth century, alienism identified certain individuals who were "agents of an experience whose content eludes understanding" (thesis p.167). The insane were separated from places of confinement and placed within asylums.

Madness thus became separated from where it was within medicine in the sixteenth and seventeenth centuries. At that time, "'[m]aladies of the spirit' existed and theories of humours were used to explain mental disorder" (thesis p. 99). From the middle of the nineteenth century, the idea of madness was then "inserted into positive medical knowledge" (book p.20). But, incorporating positivism led to psychiatry losing "its scientific rigour and its validity" (book p. 22).

Iliopoulous also has an article, from which I have produced a tweetorial, that takes this situation forward to the twentieth century. With the development of community care, psychiatry has become accountable to the public.

What I like about this historical narrative is that it fits with my view that there has always been a critical psychiatry perspective since the origins of modern psychiatry (see previous post). Critical reflection is not confined to a particular historical period. Although it may be unrealistic to expect a paradigm shift in psychiatry (see previous post), "Foucault argues that verification and positivism have excluded, set aside and subordinated other modes of truth production" (book p.123). Such critical perspectives are important.

How does a Cambridge professor of psychiatry get away with this?

As a young doctor, Ed Bullmore did not want senior physicians to start thinking he was bonkers, but now he’s long in the tooth it doesn’t seem to matter. He’s written what his publisher calls a “game-changing book” on depression (see book website).

Bullmore reminds me of Henry Cotton (1876-1933), an eminent and notorious American psychiatrist, who believed that the cause of mental illness was the systemic effects of largely hidden chronic infections (see my book review). This is because Bullmore has the same enthusiasm for so-called scientific medicine and advises depressed patients to ask their doctor to consider whether there may be a low-grade inflammation causing their depression. For example, he suggests trying a new dentist in case periodontitis (gum disease) has been missed. You might think this advice may well get him into trouble with the GMC. But, at least Bullmore doesn’t advise removal of teeth or tonsils or even the colon, like Cotton.

To give Bullmore his due, he does admit that finding periodonitis will not immediately make much difference to the treatment of depression. But, he is seriously asking us to consider his theory, which is actually about inflammation in general not just periodonitis, if only, because he is currently leading an academic-industrial partnership, whilst working part-time for a pharmaceutical company, to develop anti-inflammatory drugs to treat depression (see Neil MacFarlane’s review). Initially Bullmore wants to use these drugs for depressed patients that also have a physical illness and then for those depressed patients with raised inflammatory markers.

Don’t be confused into thinking that Bullmore is quite the critical psychiatrist. True, he doesn’t believe in the serotonin theory of depression. His history of the origin of antidepressants with Nathan Kline is actually quite good, although he doesn’t mention Roland Kuhn (see previous post). But, then he takes the radical step of saying that “rheumatoid arthritis is not primarily a disease of the joints” (Loc 963). This does sound bonkers, and what he means is that it is instead a disorder of the immune system. By analogy, we’re not really supposed to view depression as a psychological disorder, but as an inflammatory disease.

I’ve already said in a previous post that this hypothesis doesn’t make much sense. To me, Bullmore seems to compound this situation by confusing feeling sick with feeling depressed. He mentions several times that he had a root-canal filling at the dentist in 2013, and this made him feel blue. The link between inflammation and sickness cannot be disputed, but that inflammation causes depression is just plain wrong and not worth investigating any further. I just think Bullmore, like others, wants to develop an antibody for depression because anti-TNF antibodies for autoimmune and immune-mediated diseases have made billions of dollars over the years. This is despite the only trial of a TNF inhibitor in depression being negative. Bullmore should be put out of his misery.

Also, don’t think Bullmore is a good philosopher because he makes much of Descartes. Sceptics of his theory like me are dismissed as Cartesian, which I’m not. And he doesn’t spell out that his position is reductionist (eg. see previous post). True, he admits he likes such a point of view because it’s simpler. But I’ve made a point in this blog of emphasising that it’s important to integrate mind and brain (eg. see previous post) and medicine and psychiatry (see eg. another previous post). Bullmore could also learn from the philosophy of biology (see previous post).

Let’s conclude with quotes from Bullmore himself, “[I]mmunology has made no difference whatsoever to any patients with depression, psychosis or Alzheimer’s disease” (Loc 443). Nor should it! As Bullmore also says, “Voltaire and Molière filled theatres with their dark comedies about medical buffoonery” (Loc 1243). Bullmore is laying himself open to similar treatment from a modern satirist.

Taking the Independent MHA Review forward

Akiko Hart has a MIA blog post about the interim report of the Independent Review of the Mental Health Act (see eg. previous post). As she says, it may be difficult to see how changing legislation in itself could necessarily address rising detention rates and racial disparities in detention.

The interim report is disappointing because it does not specifically mention institutional racism (see previous post). Nor is reference made to the rights-based report of the UN Special Rapporteur, which takes into account the Convention on the Rights of People with Disabilities (CRPD) (see previous post). It’s also difficult to know what the interim report means when it says “We are  not  persuaded that CTOs [Community Treatment Orders] should  remain in their current form“, when CTOs probably should never have been introduced in the first place.

What is central is the dignity and respect of detained patients. The Independent Review has heard plenty of evidence of unacceptable, including abusive, treatment. The interim report does not specifically mention the Mental Health Act Commission (MHAC), whose functions have been taken over by the Care Quality Commission (CQC). Its statutory responsibility is to interview detained patients and investigate their unsatisfactorily dealt with complaints, as well as deal with any other complaints in relation to detained patients. I guess it could be said that CQC has not been fulfilling this statutory function and changes need to be made.

Opposing increased coercion in reform of the Mental Health Act

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

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

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

What’s happened to Harvard psychiatry?

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

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

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

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

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

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

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

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