Friday, September 26, 2014

From reductionism to hermeneutics

Pat Bracken in an article in World Psychiatry says psychiatry is in trouble and needs to move from reductionism to hermeneutics. He builds on the 'Bracken manfesto' paper (see previous post), as named by Peter Kinderman (eg. see another previous post), that the problem is the technological paradigm which dominates psychiatry. As Pat says, "Hermeneutics is based on the idea that the meaning of any particular experience can only be grasped through an understanding of the context (including the temporal context) in which a person lives and through which that particular experience has significance." Most medicine and surgery is concerned with the natural order, whilst psychiatry is mostly concerned with the human order.

Mario Maj in an editorial argues that the Bracken manifesto has gone too far in rejecting the technical aspects of care. He can't be as sceptical about the value of psychiatric medication or even that non-psychiatric medication could be just as ineffective (see previous post). He raises the spectres of the Italian reforms following the introduction of law 180 and the concept of the 'schizophrenogenic mother' to boost his argument of the dangers of a non-technical approach. However, evaluation of the influence of Franco Basaglia has been controversial. It is also obviously wrong and naive to blame families for causing schizophrenia. However, the problem with the reaction against the 'schizophrenogenic mother' idea is that it has undermined further legitimate family studies of schizophrenia. Maj also sees early intervention to reduce duration of untreated psychosis as a benefit of the technical approach without mentioning the critique of the early intervention approach (eg. see Jo Moncrieff's book The bitterest pills). Nor is it clear, as Maj suggests, that a non-technical understanding of psychiatric diagnosis necessarily leads to the abandonment of any attempt at classification (see previous post).

Still, it's good that there has been some mainstream response to the Bracken manifesto, rather than just ignoring it.


Anonymous said...

Interesting post. The "schizophrenogenic mother" caught my eye, must check out the Bracken manifesto and other links.

It caught my eye because I was accused of this in a tweet over a year ago by an old guy who overheard my conversation in a local cafe where I live:
Hadn't heard the term before so had to google it.

I've also believed that early "intervention" or support for psychosis is wise, since seeing my mother in an altered mind state, also my sons, in fact all of my close family, 8 of us through 3 generations. It's "normal" for us. Unfortunately the only treatment we could get was forced drugging and psychiatric labels, from the 1950's to this day.

I don't know if "technological" has to always mean drugs and coercion in psychiatry. Anosognosia and non-compliance. It made sense to me to resist psychiatric drugs/antipsychotics because they are disabling in the short and long term, more so in the latter. Antidepressants were even worse for me and mine, not lifting mood, causing suicidal impulse. I got clinically depressed because the antipsychotic made me so after bringing me too swiftly out of a psychosis. A gentler landing is what I was looking for.

As for "classification" I've seen no evidence of this being accurate for my family or for other folk I know. I've known service users who have had just about every label going and end up with BPD when all else fails. They pinned the schizo/phrenia/affective on to some of my family but we don't "hear voices" although we tell the "experts" this and aren't believed. More recently the third generation of us are getting the bipolar disorder one but I've had to battle for this outcome.

Some (many?) of us mad people will not fit into any of the DSM or ICD boxes, no matter how much they justify it in the "notes". Because they say it's so doesn't make it so. Anyway I have a resistance to psych labels and will do my best to prove them wrong. Recover from lifelong mental illness. Get off the lithium and get back on with my life. "Sticks and stones may break my bones but names will never harm me." But for some it may be more like how Eric Idle put it: "sticks and stones will break my bones, but words will make me cry by myself in a corner for hours.”

Ute Maria Kraemer said...

Appreciate Pat Bracken's 'Towards a hermeneutic shift in psychiatry' broadened outlook.

Good I read it before responding here.

Hermeneutics, isn't that the old and updated philosophers stuff (Gadamer, Habermas), being my initial reaction. In German humanistic psychiatry during the 20th century Heidegger's Daseinsanalyse (philosophy of ex-/insisting being in the world) was of huge importance, as well as 'existencialism'.

Pat Bracken, in the WP Oct 2014 article, does refer to Heidegger and Merleau-Ponty (but not the eminent hermeneutic philosopher Ricoeur)and thus, crucial in my view, reminds us of the 'affective' and 'embodied' dimensions of 'enacted meaning making' in shared social relationships and encultured contexts.
Another practicioner and thinker from Germany had written many books and spans the dimensions from embodiment (psychosomatics and dialectics of embodied perception) to theologies and religions for historically transcendant 'moral orientation': Viktor von Weizsäcker. The important contribution of von Weiszäcker was to articulate the interplay of the dimensions of embodied and socialized as well as 'geistvoll' - intellectual - human life conduct.

Heidegger and van Weizsäcker had been father figures of the German Society for Daseinsanalytische Anthropology and Psychiatry (which keeps changing name). Today its president is psychiatrist and philosopher Thomas Fuchs (Heidelberg) who has been making crucial contributions to embodiment and social relatedness of human capacities and experiences.

Neither hermeneutics, nor post-structuralism, but a transdisciplinary framework for human experiences are being elaborated (see also French Théorie de la Mediation by Jean Gagnepain, or, Vygotskian re-articulations by Daniels in England or by Anna Stestenko in US).

Eventually the decisive input of survivors' knowledge - as presented by Arnhild Lauveng, Jacqui Dillon, Rachel Waddingham, to name but too few, is necessary, if not sufficiant, for a paradigm shift beyond hermeneutics and post-isms.

Not a single publicaton by a survivor author and researcher through life and collective knowledge production is referenced in Bracken's '... to hermeneutics'.

May be the paradigm shift called for has to wait until survivor knowledge, truth and justice hit home to those who often posit as survivors' 'allies'... but much too often silence our voices and contributions when it comes to 'peer reviewed' journal discourse.

Do we really need refer to Foucault, and all 20th century liberation writers and activists, to highlight the turning point that collective survivor standpoint knowledge provides - far beyond hermeneutics; to awaken and transform academic discourse and 'paradigm shift wantedness'.

The author (Ute) is a Cultural Anthropologist MA and Psychiatric Survivor.

Ute Maria Kraemer said...

Way to go, may be: together. I like constructive proposals.

Here's one of my favorite allies who strenghtens and clarifies the survivor standpoint and co-production epistemology I am working on: Michelle Fine from CUNY and the Public Science Project.

Assumptions of the epistomology of critically engaged PAR (13.40 minutes ff in video

'Epistemology, a way of thinking about where is knowledge, where is expertise: 1rst assumption is that knowledge and expertise are widely distributed but narrowly legitimated. So we (academics) are seen as having expertise but the people we work with as co-researchers ... are not seen as having expertise. ...

1rst commitment: expertise is widely distributed and people who have endured the intimate scars of injustice have a very fine knowledge of the contours, the history, the structures and the consequences of injustice. For us in critical PAR that knowledge needs to be privileged when we generate research questions.'

3rd commitment 'Create contact zones in research camps to pull different knowledges together. ... and there are debates and figts worth having. ... On those contact zones one always has to address questions of power, of hegemony ... of condescendency... of building capacity of those who have been told they can not be co-researchers.'

4th commitment: Take strong objectivity (Harding), construct and contextual validity, generalizebility and sustainability serious. ... not leave validity to internal validity fetishists...

Epistemological gap between the gaited community of those of us who are doing research on injustice and the people who experience injustice ... no research honors without 'us': the disability rights community has done that, the HIV community, the indigenous community, and I think we need to mainstream (sic) that commitment into our work. -> so that's (strong) objectivity.

And then Michelle presents a lesson from teenage co-researchers from NYC... as well as provocative generalizability and sustainability.

Here's a collective way to go... for creating a useful knowledge shift... by adding psychiatric to injustice, oppression and power abuse.... and co-producing useful knowledge with commitment to investigate from the critically engaged standpoint of how psycho-social injustice, psychiatric oppression and iatrogenic harm are executed.

From Michelle Fine's keynote talk at the 2013 Biennial Conference of the Society for Community Research and Action in Miami. Introduction by Isaac Prilleltensky.