Thursday, April 30, 2020

Right to a second opinion for detained psychiatric patients

The Queen’s speech last December 2019 said work will continue to modernise and reform the Mental Health Act (MHA). This includes giving detained patients “better support to challenge detention” and a much greater say in their care.

I have been critical of the MHA independent review (eg. see previous post) for insufficiently promoting patients‘ rights under the Mental Health Act. We need to get back to the reforming spirit of the 1983 Act, which was lost with the 2007 amendments.

One reform introduced by the 1983 Act was the need for a Second Opinion Approved Doctor (SOAD) to review certain treatment decisions. In practice, SOADs now tend to “rubber stamp” the treatment plans of the Responsible Clinician, although I think when the Mental Health Act Commission (MHAC) first started this was not necessarily the case. The function of MHAC has now been taken over by the Care Quality Commission (CQC), which I think unfortunately means that a specific emphasis on the rights of detained patients has been lost, as CQC has the more general role of regulating health and social care.

Another problem is that SOADs are appointed by the CQC, so that the patient has no choice over which doctor provides the second opinion. Furthermore, it is uncommon for solicitors to obtain an independent medical report before a hearing to consider appeal against detention.

There is therefore much scope for increasing the independence of clinical opinion in the processes of detention appeal and enforced treatment. A patient ought to be able to have a second clinical opinion both about detention, and this can be given as evidence to the Mental Health Tribunal (MHT) and hospital managers, and about treatment, which should, as far as possible include any enforced treatment right from the start of detention. The Tribunal could be extended to make judgements about treatment as well as detention, but if not, or maybe if accepted by the patient, a decision can be made by the SOAD to approve any enforced treatment based not only on the evidence from the Responsible Clinician but also from the independent clinician. I think these improved safeguards at least need consideration by the government in its MHA reforms.

Monday, April 27, 2020

Reflections on postpsychiatry

I've mentioned Pat Bracken and Phil Thomas's work on postpsychiatry previously (see eg. previous post). I'm very pleased they've agreed to do this guest blog.

We would like to thank Duncan for the invitation to write a guest blog.

Our use of the term postpsychiatry began when we started to collaborate together in the 1990s. We were both working in Bradford and trying to change the way we encountered people with mental health conditions, how we understood their struggles and how we worked with them.

Employed as consultant psychiatrists, we were very conscious of working in a service that was very much ‘psychiatry-led’. We had come to realise how limited psychiatry was and how damaging its interventions could be; whether through the side-effects of drugs, demoralising diagnostic labels or theories that were sometimes little more than pseudoscience. We were sympathetic to the views of Thomas Szasz but were uncomfortable with, what we saw as, the binary nature of his thinking. We were also unconvinced by his characterisation of medicine as something that only had a legitimate role to play in relation to diseases that could be verified in the pathology lab, and were wary of his antipathy to any sort of collectivist politics.

After our training in medicine and our experience of work with different communities in different contexts, it was impossible for us not to see the ‘embodied’ and ‘encultured’ nature of all human suffering. It was clear to us that mind and flesh do not inhabit different worlds but exist as one. All experience of illness (whether we call it physical or mental) is complex. Thinking, feeling, relating to others are done by the same creature who sleeps, eats, has endocrine problems and gets old. And the same creature lives its life in the midst of language, culture and economy. We were interested in linguistics, anthropology and philosophy and had come to believe that states of madness, distress and dislocation were profoundly messy, and that no singular narrative, whether from psychiatry or anti-psychiatry, could account for it all.

This is what drew us to the work of Foucault, Bauman and others who might be characterised as ‘postmodern’. For us they offered a form of scholarship that did not see the messiness, contradictions and uncertainties of human reality as irritations that could be eliminated by more science, better science or more analysis and conceptual clarification. For us, postmodern thought was about facing and accepting the reality that there might not be solutions for all our problems, there might never be resolutions to all our ethical contradictions nor answers to all the questions we asked of the world. The word ‘postpsychiatry’ was used to signal our quest to imagine what a non-modernist medicine of the mind might look like. We wanted to think ‘beyond’ and ‘after’ psychiatry.

Crucially, we wanted a form of mental health medicine that worked towards the possibility of meaningful dialogue with the emerging ‘service-user’ movement. We saw that our job as critical psychiatrists was the creation of the conditions wherein genuine dialogue with this movement could take place. The main question for postpsychiatry was: how can we bring biological and medical insights to bear on mental suffering in a way that does not silence, distort and colonise the understandings that emerge from service users themselves both individually and collectively?

Of course there was no singular answer to this. In our work we looked for insights from post-colonial scholarship, feminist philosophy, queer theory, mad studies and critical pedagogy. Gayatri Spivak argues that educators and scholars who are genuinely trying to get beyond the legacy of colonial forms of knowledge must be engaged in ‘the unlearning of one’s own privilege. So that, not only does one become able to listen to that other constituency, but one learns to speak in such a way that one will be taken seriously by that other constituency’ (Spivak, 1990, p. 42). Postpsychiatry represented our attempt to unlearn, and to find a way of listening and speaking differently.

Pat Bracken & Phil Thomas are retired consultant psychiatrists. They were psychiatrists together in Bradford and professors of Philosophy, Diversity and Mental Health in the University of Central Lancashire. They co-authored Postpsychiatry: Mental health in a postmodern world (2005). They brought the group together that became the Critical Psychiatry Network.

Friday, April 24, 2020

Users and abusers of psychiatry

I said in a previous post that clinical psychologists may be more easily able to take an anti-reductionist position in mental health work than psychiatrists (see previous post). Critical clinical psychologists include Lucy Johnstone, Richard Bentall, Mary Boyle and Peter Kinderman amongst others. I see their work as part of the critical psychiatry movement. As I have said before (see another previous post), there are differences within the movement, and although mental health disciplinary training in itself does not necessarily create these differences, it can be a factor.

I just wanted to look at the work of Lucy Johnstone as an example. Her first book Users and abusers of psychiatry was first published in 1989. I wrote a review for the second edition and called it an "inspiring" book. The general lack of a whole person perspective can actually take responsibility away from people, so that they are encouraged to "rely on an external solution which is rarely forthcoming". The mental health system then can continue to blame them for their continuing difficulties and powerlessness. The personal meaning of people's distressing experiences and the psychological and social origins of their difficulties can be lost in psychiatric diagnosis, leaving them stuck in psychiatric treatment without alternatives.

Despite any differences I may have with Lucy about excesses and emphases, I totally agree with this critique of the psychiatric system. Clinical psychologists have tended to adopt the role of psychotherapists within mental health teams, but psychiatric practice is wider than this and includes detaining people if necessary under the Mental Health Act. As I keep saying throughout this blog, psychiatry needs to accept the limits of a mechanistic approach to mental illness and life in general.

I also did a review of Lucy's book, A straight talking introduction to psychiatric diagnosis. She makes an excellent case that psychiatric diagnosis is invalid, unscientific and not fit for purpose. Psychological formulation is necessary to understand people's problems (see previous post). Too often psychiatric diagnosis and the biomedical model effectively prevent practitioners from "seeing what is in front of their very eyes" (see eg. previous post).  I have argued that Lucy's argument about abandoning psychiatric diagnosis is at least potentially misleading (see eg. previous post). Nonetheless, psychiatry does need to move on from the facade it creates about biomedical diagnosis producing personal understanding.

More recently, Lucy has concentrated on the Power, Threat, Meaning framework, which she has created with Mary Boyle and others (see eg. previous post), and incorporated this in the 'drop the disorder' approach (see another previous post). I totally agree with Lucy that functional mental illness should not imply physical lesions in the brain (although this does not mean ignoring organic psychosis - see previous post). But I worry that the insistence on avoiding pathologising, again, can be misleading.

Nonetheless, I am keen to encourage further debate about whether psychiatry should become non-medical. Maybe my reservations about Lucy's expressions of the critical psychiatry position are because I am a psychiatrist rather than a clinical psychologist.

Thursday, April 23, 2020

Delusion as loss of intersubjective reality

Thomas Fuchs (who I have mentioned in a previous post) has an interesting PPP article on delusions. Delusions are failures of communication characterised by a disturbance of transcendental intersubjectivity. People do not "passively receive information from their environment which they then translate into internal representations. Rather, ... they constitute their experienced world or Umwelt through their ongoing sensorimotor interaction and embodied coping with the environment". Reality is constituted through active shifting of moving and multiple points of view reinforced by social perspective-taking.

Psychosis involves a radical subjectivisation of the processing of information so that understanding loses its intentional and decentering structure and the person adopts a solipsistic self-centrality. Basic trust in the shared world has been lost. A new sense-making is established fundamentally decoupled from the shared world (see previous post). "The possibility of intersubjective understanding is ... sacrificed for the new coherence of the delusion".

Monday, April 20, 2020

Overcoming the fairy circle of antiphlogisticism with traitement moral

Anti-phlogistic physicians saw disease as fundamentally a problem of inflammation and fever. The 'original' principle of phlogiston was posited by Georg Stahl (Taylor, 2006). Substances were flammable because they contained phlogiston, believed to be an elemental fatty earth. William Cullen was at the forefront of chemistry as well as medicine (see eg. previous post). For Cullen, phlogiston was not a metaphysical ‘principle’ of inflammability, but firmly in the world of ordinary matter.

As Searle (1835) said, in his Lancet article (Volume 23, Issue 594, 587-90), antiphlogistic treatment was "considered to be corrective of a phlogistic condition". As he goes on, antiphlogistic treatment by some was "not confined to inflammatory complaints, but ... [was] adopted in almost all other cases, with the view of preventing inflammation and fever" [emphasis in original]. Purgatives and emetics seemed to demonstrate the truth of Stoll's theory that most illnesses resulted from gastric impurities, especially bile. Bleeding, purging and making use of emetics, were all designed to counteract and to deplete the over-active, over-heated body.

From Phillippe Pinel's point of view in A treatise on insanity,
physicians have ... allowed themselves to be confined within the fairy circle of antiphlogisticsm, and by that means to be diverted from the more important management of the mind (p.4)
Pinel's approach which was called traitement moral (translated as moral treatment) gave preference to "ways of gentleness" and minimised the use of restraint. Essentially it involved the use of contrived situations, artifice and pious fraud. A variety of strategies were used to control difficult patients, including stern warnings, the manipulative use of food and privileges, and physical restraints, as well as various theatrical gestures designed to shock patients out of their morbid ways of thinking.

There are ethical questions about such techniques, but they at least focused on emotional factors, and such moral treatment can be seen as arising out of Pinel's conceptual understanding of mental disorders as "lesions of the function of understanding". As far as he was concerned, insanity has a "moral" cause rooted in ideas and the passions.  This did not mean the body was not implicated, as he took an integrated mind/body understanding, in that le moral and le physique were seen as interrelated. Standing out against many other anatomists, he was aware from his own dissections that insanity does not have a discernible brain lesion.

‘Anti-psychiatric’ voices that have haunted psychiatry

Sarah Kamens’ excellent article on post-colonialism and (anti)psychiatry shows how a discursive hierarchy in psychiatry subjugates certain communicative modalities while elevating others. As she says, we need to “gain a better understanding of those ‘antipsychiatric’ voices that have haunted psychiatry for all of these years”.

As I said in my previous post, anti-psychiatry is more to do with mainstream psychiatry wanting to dismiss criticism of the biomedical model (which ranges from radical reductionism to eclecticism). David Cooper, who coined the term, became an embarrassing figure who was very much out on his own in his later books (see extract from my book chapter). However, the rotten reputation of anti-psychiatry lingers on.

Anti-psychiatry at least overlaps with mainstream psychiatry in its emphasis on human rights, the therapeutic community and community care. Kees Trimbos (1975), one of the founders of Dutch social psychiatry, warned against imagining that anti-psychiatry was just a fad: "after all, anti-psychiatry is also psychiatry!"  There may be more benefit from looking for the continuities, rather than discontinuities, of anti-psychiatry with orthodox psychiatry.

Thursday, April 16, 2020

Now treatment-resistant schizophrenia is said to have a different neurobiology from treatment-responsive schizophrenia

Potkin et al (2020) argue that the underlying neurobiology of treatment-resistant schizophrenia (for which they give the acronym TRS) may differ from treatment-responsive schizophrenia. As the article indicates, clozapine's licensed indication is for schizophrenia in patients unresponsive to, or intolerant of, conventional antipsychotic drugs. The review is intended to facilitate the development of new pharmacological treatments.

Dopamine, glutamate and serotonin neurotransmitters are said to be potentially involved (as they have been implicated for schizophrenia in general). Dopamine supersensitivity has been suggested as the mechanism for tardive dyskinesia, and by extension it has been suggested that neuroleptics may cause a dopamine supersensitivity psychosis (DSP). I don't think the article makes as clear as it should do, that by suggesting that DSP may be the cause of TRS, it seems to be implying that antipsychotic medication causes treatment resistance.

Surely it's about time journals, including so-called Nature Partner Journals, stopped publishing such speculation as though it were science. It would also help if science itself gave up its wishful hope to explain mental illness in physico-chemical terms (see eg. previous post).

Was Foucault for or against the Enlightenment?

I'm very grateful to John Iliopoulos for providing this guest blog, following my criticism of Andrew Scull's recent History of Psychiatry article on Foucault (see previous post).

If we accept the standard interpretation that the History of Madness describes a continuous process of exclusion of madness which began in the Renaissance and lasted all the way to the late 19th century, then we are forced to deduce that the birth of the asylum which took place in what is called the Enlightenment, is a mere episode of this linear narrative, albeit one focused exclusively on insanity. In this case we are faced with a choice; if we side with the Enlightenment, we conclude that, after a long period of ignorance, prejudice and religious superstition, mental doctors finally reached a sufficient level of lucidity to insert insanity into the calm objectivity of science. No doubt an exclusion took place and harsh therapeutic methods were employed, but this was because psychiatry was still in its infancy. If, on the other hand, we consider the same narrative as anti-enlightenment and anti-psychiatric, we can conclude that the birth of psychiatry was the direct result of an oppressive rationalist and moral imperative to exclude and conquer Unreason. Lacking scientific rigor and being part of the larger project of suppressing madness, proto-psychiatry failed to treat insanity in accordance with the supposed humanitarian ideals of the Enlightenment.

This is the ‘blackmail of the Enlightenment’, that is, the question of whether one has to affirm or reject rationalism. Taking sides in this dilemma must necessarily rest on a value judgment and on ready-made concepts (for example, considering a priori exclusion as a social evil, or objectivity as the ultimate goal of science). Foucault, however, refuses to submit to this blackmail and decides to treat the Enlightenment in its own terms. For Foucault, the birth of the asylum is a unique, groundbreaking event in the history of western medicine, because the doctors of this period tackled madness first and foremost as a concrete anthropological problem. Part of a vast transdisciplinary domain in the late 18th century, alienism gave medical expression to the new anthropological mentality of the time, that is, the ‘strictly philosophical structure responsible for the fact that the problems of philosophy are now lodged within the domain that can be called that of human finitude’. Madness was the case of human finitude par excellence, the most alien experience, challenging ‘our very sense of what it means to be human’, as Scull rightly puts it, therefore it had to be assessed in its own, singular truth, free of all preconceived value judgments, naturalist or moral theories. If the alienists were ‘enlightened’, it was because they adopted a ‘limit attitude’ which permeated their theories and determined their practice. Let us follow Foucault’s historico-philosophical analysis of this phenomenon:

1) During what is called the Enlightenment, the criteria of rationalism, productivity and morality which had led to the Great Confinement, no longer applied, and the practice of massively and indiscriminately incarcerating individuals began to disintegrate. (Even if we accept that the great confinement never existed, there is ample evidence in the medical textbooks, the architectural planning, the legal context and the administrative framework of the time, that the French, English, or German early 19th century asylum was a novel and unique medico-anthropological institution). Also, the Enlightenment did not reinforce the scientific and experimental powers of man, which should normally lead to a continuation and deepening of the existing naturalistic and biological theories of the previous times. Instead, no new substantial naturalistic theories of madness were produced during this period, or at least they were minimal compared to the biological and psychological theories of the positivist (or scientistic) revolution 100 years later.

2) The exclusion of madness was primarily tied to a specific problematic of anthropological truth. To the political interests of the late 18th century (discipline, public hygiene), insanity presented a deep anthropological problem: why and how did madness pose limitations to the application of reason in society? (If certain individuals cannot be trained, educated or corrected, then there is an inhuman kernel in them resisting rationalization). The doctors of the time who were asked to respond to this question did not belong to an Enlightenment ‘movement’; they simply translated the general socio-political and philosophical anthropological problematic of their society, into medical language. They tried to examine, in clinical terms, the question: how can moral codes or psychological laws be applied to the mad individual who represents the impossibility of thought (Descartes)? Isn’t the study of the reasons why an insane individual fails to participate in the reasonable community of men, the condition of possibility for the empirical investigation of his ailment (Kant)? Thus, the alienists shifted the center of gravity from the age-old investigation of humoral aetiology to the anthropological examination of the mad subject and his truth and freedom. The result was a new nosographic and symptomatological field, a strict phenomenological description of signs and symptoms denoting experiences impervious to education, training or punishment - experiences at the margins of reason.

3) Importantly, this was the first time that medicine opened a dialogue with madness (reading Foucault’s two sets of lectures on psychiatry in the 70s, one has the sense that Foucault corrects himself or at least supplements his own earlier thesis on psychiatry’s ‘monologue on madness in the late 18th century’). The alienists were attentive to the truth that the mad discourse expressed. They isolated the mad individuals so as to listen, without distraction and outside interference, to their illusory, fantastic discourse, responsible for their alienation. (From the studies of Goldstein and Gauchet & Swain, up to recent research, it has been consistently shown how carefully the doctors of the time listened to the enigmatic speech of the patients, tried to decipher their discourse, manipulated their delirium (see for example, Huertas, 2014)). In fact, analyzing the methods of confinement and treatment in the proto-psychiatric period, methods which may appear unacceptable to the current psychiatric mind (Esquirol’s principle of isolation, Falret’s principle of the two wills), Foucault - especially in his Psychiatric Power lectures - shows no hostility or opposition; on the contrary, he seems to appreciate the rationale underlying those practices whose end goal was the revelation of the truth of delirium. The same goes for the ‘moral treatments’ of the time; attaching the mad individual to the procedures of discipline did not abolish the humanity and morality of Pinel, Willis or Tuke (unless we accept that disciplinary power is by definition enslaving); the aim was rather to identify and neutralize the insane beliefs using techniques whose application is possible only under conditions of protection and isolation.

Interestingly, Foucault’s criticism of psychiatry targets the post-anthropological, post-Enlightenment form that psychiatry has acquired since the late 19th century, a form which the rationalist optimists may view as the fullest expression of the Enlightenment: inclusion of madness instead of exclusion, increased scientific sophistication, humanitarianism, security. Foucault, however, sees in this process the intensification of rationalization and its inherent dangers, rather than the fulfillment of an Enlightenment ‘ideal’. Abandoning its anthropological focus on delirium as the heart insanity, psychiatry has sought to reduce illness to somatic localization, an effort which, instead of strengthening the epistemological status of psychiatry, has actually produced phenomena of lower scientificity and even abuse (perhaps even much greater than that which may be observed in the early 19th century asylums). Defining mental illness not as a disturbed relationship with truth, but in terms of its reality, that is, the voluntary and the involuntary, neurological disturbance and genetics, psychiatry has extended the scope of its application to all possible abnormal behaviors, becoming a science of abnormalities (today, one needs only to look at DSM-5 where more and more aspects of human behavior receive a medical comment, and the notion of the spectrum has officially entered the scene); genetics has been coupled with totalitarian and ideological practices giving justification to racism; the doctor-patient relationship is downplayed in favor of impersonal bureaucratic practices and the quest for the truth of illness in the laboratory; forensic psychiatry is asked to provide expert opinion on the danger of insanity, overstepping the epistemological boundaries of medical science, since dangerousness is neither a medical nor a legal concept.

By way of conclusion let us note the following:

a) The early asylum does not constitute the embarrassing past or the infantile beginning of psychiatry; but neither does it represent a romantic origin to which we should nostalgically return. As Foucault notes, quoting Nietzsche, things are not ‘most precious and essential at their moment of birth’. (Nietsche, Genealogy, History). Its genealogical value lay in its epistemological lessons: psychiatry can never escape its inherent connection with the philosophical problem of madness, just like medicine in general is intrinsically tied to the metaphysical problem of death.

b) Foucault does not deny the reality of madness (‘I have never said that madness does not exist, or that it is only a consequence of these institutions. That people are suffering, that people make trouble in society or in families, that is a reality. What I have tried to analyse are the ways these conditions, and the context in which this kind of suffering—delirium, persecution, etc.—are problematized as an illness, a mental illness, something which has to be cured inside such institutions and by such institutions.’ or ‘when I say that I studying the ‘problematization’ of madness, crime and sexuality, it is not a way of denying the reality of these phenomena. On the contrary, I have tried to show that it was precisely some real existent in the world which was the target of social regulation at a given moment (Fearless Speech)). The lesson he draws from the early anthropologists-alienists is that studying the reality of mental illness presupposes the study of its truth. This is because: 1) Diagnosis precedes aetiology. We look for somatic or psychic causality - but what is this causality the causality of? 2) the patient is part of the human species with a nature which can be studied anatomically and statistically. But only the concrete individual, with his delirious relationship with truth, ‘continues to tease and to bewilder us, to frighten and to fascinate, to challenge us to probe its ambiguities and its depredations.’ (Scull) 3) the doctor-patient relationship cannot be neglected, not for reasons of morality, but because, madness does not have only universal, somatic (not only cerebral) causes, but also a unique individual expression, a singular mode of existence, which can only be revealed in a specific milieu and in the specific relationship with the particular examining phychiatrist.

c) Scull’s assertion that ‘madness has social and cultural salience and importance that dwarf any single set of meanings and practices’, could be rephrased. Madness provokes a gigantic battle around truth, where multiple practices, knowledges and interests engage in the mutual construction of a single meaning: ‘in what way does a society define its relation to madness?‘

d) In fact, for Foucault, in the Enlightenment this belligerent relationship ‘between power, truth and subjectivity’, reached ‘the surface of visible transformations’; which is why it is ‘a privileged period for historico-philosophical work,’ and we should try to see whether ‘we can apply this question of the Aufklarung to any moment in history, that is, the relationship between power, truth and the subject’. In this sense, it could be argued that Foucault is actually for the Enlightenment, provided that the Enlightenment is conceived as a critical and diagnostic way of thinking and not as a moral and rationalist movement laying claims to Universality.

John Iliopoulos is consultant psychiatrist and chairman of the Department of Philosophy and Psychiatry at the Hellenic Psychiatric Association. He is the author of The History of Reason in the Age of Madness (2017)

Monday, April 13, 2020

Opening up the world of diseases of the nervous system

As Foucault (2008) noted in History of Madness, William Cullen (see last post) wrote in The Practice of Physic that:-
I [ie. Cullen] propose to comprehend, under the title of Neuroses, all those preternatural affections of sense or motion which are without pyrexia, as part of the primary diseases; and all those which do not depend on a topical affection of the organs, but upon a more general affection of the nervous system, and of those powers of the system upon which sense and motion more especially depend (Foucault, p.203).
This new world of diseases of the nerves opened up “a whole new pathological space“ (p.203). Medicine was able to move on from ‘metaphysical claptrap’ to integrating the soul and body. “A whole world of symbols and images ... [came] into being, where for the first time doctors enter[ed] into a dialogue with their patients” (p.204).

Constituting medicine on the basis of the doctor-patient relationship led to a reorganisation of psychiatric classification. As Foucault said, quoting Voltaire,
"We call madness that disease of the organs of the brain ... " The problems of madness revolve around the materiality of the soul. (p.208)
The world of the soul opened up an immense reservoir of causes for madness. Foucault quotes from Dufour (1770):-
The obvious causes of melancholy are all those elements that immobilise, wear out or trouble these spirits; great, sudden frights, violent movements of the soul resulting from transports of joy or intense affection, lengthy, deep meditation on a particular object, intense love, lack of sleep, and all excessive exercise of the worried mind, particularly at night; solitude, fear, hysterical affection, anything that impedes growth, healing (p.221)

The reforms of asylums (see previous post) matched the "prevalence and heterogeneity about the genesis of madness" (p. 221). Alongside dementia, mania and melancholia, hysteria and hypochondria were being increasingly associated, and for Robert Whytt, “in the mid-eighteenth century, the assimilation has become complete (p. 277). ... [A]t the close of the eighteenth century, almost without dispute, hypochondria and hysteria are firmly classed as mental illnesses" (p.278). They had been integrated into the domain of diseases of the mind.

Sunday, April 12, 2020

Origin of psychosomatic perspective

As I mentioned in my last post, probably the first person to speak of functional disorders was William Cullen (1710-1790), a key figure in the Scottish Enlightenment. As Sean Dyde says in his article,
While for ... Cullen the body could not be explained as if it were a machine, nor could ... [he] agree with the animism of Georg Stahl (1659–1734), that all bodily functions depended upon some rational principle or soul (see eg. previous post). 
As far as hypochondriasis is concerned, Cullen saw it as   
a disorder that affected some of the most important powers in the body. In other words, it was not its distinct nervousness which made hypochondriasis unique, but its combined effects on the vital and intellectual functions. 
Dyde goes on:-
However, by 1820 a change had come upon British physicians and surgeons. Many believed that Cullen’s medicine was in need of revision, that the motivating powers had no place in classifying disease, that medicine could be given firmer foundations.
It was said that the underlying disease was being missed too often. Illness or disorder was an “unhealthy state of the feelings or functions of parts”, and more attention needed to be paid to the “visible alteration in the appearance or structure of the affected part“. As Dyde says, “What had changed was the meaning of the term ‘disease’”. Pathological anatomy was starting to reform medicine.

As Dyde says,
For an ailment such as hypochondriasis, already on the cusp of medical understanding, pathological anatomy only made its ambiguities more prominent. ... [T]here was an acknowledgement that the time had passed when great figures like Cullen could survey the entirety of medical practice and encapsulate it within a single work. Where for Cullen the precise nature of disease was relatively unimportant, for pathological anatomy the question was all-consuming.
Dyde concludes:-
British physicians in the 1830s were little different from their colleagues in the 1760s: unable to distinguish the myriad of nervous ailments which they faced in medical practice, and fully aware that the conceptual tools at their disposal were unfit for the task.
But pathological anatomy had darkened Cullen’s reputation. Nonetheless, Cullen was “an astute physiological and medical thinker, as well as a remarkably influential nerve doctor” and “remains significant today for the warning ... [he] provides against reductionisms”.

Saturday, April 11, 2020

The opposition between psychogenesis and organogenesis of mental disorders

I mentioned Yorgos Dimitriadis’ History of Psychiatry paper in a previous post. This is part I of his ‘History of the opposition between psychogenesis and organogenesis in classic psychiatry’.

As he says,
Probably the first person to speak of functional disorders was the Scottish physician William Cullen in 1776 (Minkowski, 1935). According to Cullen (see Minkowski, 1935), these were diseases that were not caused by organic alterations of cells or of nerve fibres, but by anomalies in their functioning in various parts of the nervous system without any precise anatomical corollary – anomalies of an erratic and fleeting character, and in theory reversible. ... The term ‘functionalism’ (a word that in 1866 Louis Fleury opposed to ‘organicism’; Starobinski, 1999: 393) was also sometimes used, though it did not persist for long. ... [T]he term ‘functional’ was already present in Pinel’s followers, in particular Georget, who considered it to be a principle of mental alienation.

As I mentioned in a previous post, psychiatry expanded in the last third of the nineteenth century to include a broader range of what we came to call neurotic conditions. Traditional categories such as hypochondriasis, hysteria and melancholy tended to be incorporated into psychiatry as having a bodily cause. This way of viewing these illnesses created hypothetical disease entities, such as George Beard’s ‘neurasthenia’. As Dimitriadis says,
Neurasthenia ... was described by Beard in 1880 (see Minkowski, 1935) as a mainly somatic disease, with alterations of the blood, internal organs and the sympathetic nervous system, although it also came with psychical disorders such as feebleness of will, character alteration, irritability, and so forth. 
Hysteria was also considered a reflex neurosis, “that is, a disorder originating from the viscera, and more specifically from the genital organs, according to Hippocrates’s theory which was able to maintain itself for so long”.

Describing the psychical element of functional diseases began with
the study of hysteria by Briquet (1859), who imputed an essential importance to psychical and moral factors that deeply affect the human personality, while admitting that there are specific regions of the brain that serve as the basis for various disorders. The work of the Nancy school (Liébault, Bernheim) on hypnosis and suggestion (see Minkowski, 1935) impacted on the evolution of these ideas, establishing the effects of psychical factors on the nervous system, both somatic and visceral. ... Charcot stressed  the importance of affective factors that may strike the imagination or the feelings, with regard to the preparation, triggering and causal determination of neurotic disorders. 
He goes on:-
Babinski, previously the head of Charcot’s clinic, went further and reduced hysteria to  pithiatism, that is, to phenomena that can be triggered and eliminated through suggestion.  This had the effect, as observed by Ehrenberg (2004), of sealing off neurology from the unobjectifiable. His contribution, according to Ehrenberg (2004: 137), is ‘having established a boundary separating the neurological from the pathological, thus questioning our ability to understand mental states from cerebral ones’. Babinski thereby opposed Charcot who wanted, through the anatomo-clinical method and based on objective grounds (p. 137), to establish a physical semiology of hysteria (stigmata, for instance).

A further stimulus to the study of functional disorders came from the effect of trauma, emphasising
the presence of heightened affective irritability and of an increased influence of emotional factors on motor, sensitive and – even more importantly – on vasomotor and secretory innervations, that is to say on the vegetative nervous system.
Freud changed hysteria’s status to a condition resulting from psychological causes. “Likewise, Janet (see Le Gauffey, 1992a, 1992b) distinguished from Beard’s neurasthenia those cases in which psychological factors play a predominant role, and gathered them under the term psychasthenia.“

Dimitriadis moves on to note that:-
Jacques Vié (1934), ... observed that the term functional was used for two very distinct categories of events, either related to morbid processes, or else in continuity with normal functions ... [and that] functional disorders extend beyond the boundaries of organic pathology ... produced in the relation between the organ and the object of its function
He goes on:-
Von Monakow (see Minkowski, 1935: 17) regarded neuroses as prolonged affective reactions, generally psychical ones, arising from the personality against intense assaults.  These assaults, often repetitive and cumulated, target the personality’s instinctive sphere, that is, its most vital interests, and can affect the subject’s sexual life as well as his physical, psychical or moral integrity by way of trauma, disease, depravation, outrage to one’s prestige and honour, and so forth. 

As I said in my previous post, I’m very grateful to Yorgos Dimitriadis for making available in English this summary of the historical literature in French. It very much enriches my simplistic discussion of the nature of functional mental illness in another previous post. I look forward to reading the second part of his article.

Friday, April 10, 2020

Long-term outcome of depressive treatment

McPherson & Sunkin (2020) consider whether the independence of NICE (National Institute for Health and Care Excellence) may make it scientifically unaccountable, and use the debate about the depression guideline as an example. NICE is correct that there is limited available data on long-term follow-up, which, therefore, limits its usefulness for comparing treatment efficacy.

However, looking at outcome over the long-term does provide a different perspective from short-term trials, when even they leave room for interpretation about whether antidepressants are actually effective or not (see eg. previous post). Looking at how easy/difficult it is to treat depression in the long-term in an uncontrolled way shows that not everyone gets better and that recurrence is high (see previous post). Even so-called clinical improvement does not necessarily mean social recovery or complete elimination of symptoms. These sort of factors do need to be taken into account by NICE in any more comprehensive evaluation of the value of treatment in depression. Unless it does so, it may well leave itself open to judicial review.

The three periods of modern psychiatry

Yorgos Dimitriadis in a paper in History of Psychiatry points out that:-
Georges Lanteri-Laura (1998) divided modern psychiatry into three periods, or paradigms (inspired by Kuhn’s notion of paradigms). These were, respectively, ‘mental alienation’, ‘mental diseases’, and ‘psychopathological structures’. 
As he says:-
Pinel was probably the first person to consider mental alienation to be a disease in the sense of organic diseases, a disorder of the intellectual functions, that is, of the superior functions of the nervous system (see previous post). ... Pinel’s principles were adopted by his successors, Esquirol and Georget. ... Georget pointed out the distinction between symptomatic diseases, which stem from a known organic cause, and idiopathic disorders, the precise origin of which is unknown, but which evidently result from purely functional  disruptions and correspond to insanity in the strict sense.
He goes on, “According to Georget, in the case of insanity, the problem is entirely in the brain, which thus becomes the ‘diseased organ’.” It is true that, “Pinel and Esquirol [thought that] passions had their effects on the brain via the viscera” and that “[i]n contrast, according to Georget, the causes of both the passions and insanity should be sought in the brain”. 

The period paradigm of ‘mental diseases’ for Lanteri-Laura spanned from 1854 to 1926. “After Bayle’s (1822) anatomopathological work on general paralysis, the need for a characteristic lesion became necessary for the classification of diseases.” As no microscopic lesions could be found apart from general paralysis:-
This led to the development of a concept of dynamic, as opposed to anatomical, lesion. For example, this was described by Moreau de Tours (see Jeannerod, 1996: 153) in the  following  terms: ‘of a material and molecular lesion, however elusive  .  .  .  as can be for example the changes that occur in the inner structure of a rope moved in a vibratory motion’.
Detailed description of the various mental diseases, such as Falret’s ‘circular insanity’, became the “normative types representative of this period. ... Griesinger (1865), the father of German psychiatry ... was the origin of ideas later developed by Blondel, Jaspers and Guiraud.” Furthermore;-
In France, during this period, Morel (see Bercherie, 1980: 93) developed his ‘degeneration’ theory, which is more of a synthetic attempt than an analytical one. Morel was among the first to emphasize how organic factors, for example progressive heredity throughout successive generations, might interact with harmful experiences during infancy.

Towards the end of the nineteenth century, there was a further attempt to separate neurology and psychiatry, which began with Charcot’s work on hysteria and was taken up by Bernheim and Freud. “During the same period ... Kraepelin, influenced by the theory of degeneration, took an organic view of mental illness.”

The period paradigm of ‘psychopathological structures’ discussed by Lanteri-Laura included the challenge to the notion of specific mental disease by the epidemic of lethargic encephalitis that spread throughout Europe between 1917 and 1925. Furthermore,
[T]he introduction of a range of physical treatments strengthened the organicist conception of insanity. These included malaria inoculation (and later, penicillin) for syphilis, Sakel’s treatment (insulin [1932], cardiazol [1935], electroshock therapy [1938], psychosurgery through prefrontal lobotomy [1935]), and after 1950, neuroleptics, antidepressants and mood-regulating drugs (see Bercherie, 2005: 86). 
Alongside this, however, the 1920s saw the development of more ‘dynamic’  theories under the influence of the Gestalt  theory and of structuralism, and especially Gelb and Goldstein’s (Goldstein, 1983) neurological globalism (which rejected localizing conceptions and argued that the nervous system should be regarded im Ganzheit, ie. in its totality).
Focus on psychopathological elements led to, for example, Paul Guiraud  (1950), who
maintained  that  the disorders causing mental diseases were fundamentally disorders of the primordial psychic activity, that is, of the global psychical experience (éprouvé psychique global), the psychological aspect of the organic vital functions, mainly diencephalic in origin (see Follin, 1993).
Another example would be Henri Ey (2006), who “proposed an organodynamic theory, influenced by the work of John Hughlings Jackson (see Guiraud, 1950: 140–63)”.

I’m very grateful to Yorgos Dimitriadis for making this history summary available in English. What’s of interest to me is how it leaves out significant people which I have said figure in the history of critical psychiatry, viz. Ernst von Feuchtersleben, Adolf Meyer and George Engel (see my editorial).

Wednesday, April 08, 2020

Deep questions about mental illness

Patricia Churchland discussed the question 'Do we have free will?' as part of the attempt by New Scientist to tackle what it called the deepest challenges faced by science. Biology and social sciences, at least, haven’t escaped philosophy.

Churchland began her article with a case report. This 40 year old male patient displayed impulsive sexual behaviour with paedophilia, including sexually molesting his 8 year old step-daughter, and was found to have a right frontotemporal tumour. Churchland asked how different are normal humans from this patient where free will is concerned? I'm not convinced she gave the best of answers to this question.

Although the patient was orientated, there were neurological signs, such as marked constructional apraxia and agraphia. Poor impulse regulation and an acquired sociopathy do occur with adult-onset damage to the orbitofrontal cortex, although this case may be the first description of paedophilia as a specific manifestation of orbitofrontal syndrome. Signs of orbitofrontal lobe dysfunction may be quite subtle but do reflect an organic illness like dementia and delirium.

As I said in a previous post, organic problems are cerebral disease, which can be primary, or secondary to a systemic illness, or resulting from an exogenous toxic agent, or due to physical withdrawal of an addictive substance. In this case, the problem was clearly due to brain disease. 'Normal humans', as Churchland refers to them, do not have brain disease. Certainly issues of mental capacity apply to people with and without brain disease, but it may well matter whether it is brain disease that is affecting mental capacity.

Churchland says "brains make decisions" but it's actually people that do. Decision making capacity may well be affected if people have brain disease. Capacity may also be affected by whether people are psychotic for example, but actually delusional thinking may not be that much different from our ordinary thinking (see previous post). Of course there is a neurobiology of self-control, and as Churchland says, "the self is a construction of the brain". But it’s us that make sense of our world, not our brains. Neuronal processes are not meaning making and lack intentionality (see previous post). The sense-making activity of people also needs to be set into a context (see another previous post).

Jo Moncrieff in her recent PPP paper also starts from Churchland’s clinical case. She uses the example of a brain tumour causing behaviour to discuss the views of Thomas Szasz about the myth of mental illness. I’ve criticised before the view, like that of Szasz, that illness is only physical in nature (see eg. previous post). It’s only really since about the middle of the nineteenth century that we’ve had this perspective on illness, with the development of the anatomoclinical method, relating clinical symptoms and signs at the bedside to underlying physical pathology. Of course I’m not saying illness was not seen as bodily disorders, but how they were explained was very different from our modern pathological, including histological, understanding (see eg. previous post). We’ve always needed myths to explain illness (see eg. another previous post). For example, the theory of the four humours - blood, phlegm, black bile and yellow bile - remained a major influence in understanding the working of the body until well into the 1800s. Our modern biomedical understanding of disease helps us to make sense of symptoms in the same way as the humoral theory of disease did for centuries before. That doesn’t mean it’s necessarily true. And, here, I agree with Jo, Szasz was on to something by realising that what was called mental illness cannot be reduced to brain disease, in the same way as physical illnesses.

Of course, psychiatry, and medicine in general, had realised this situation well before Szasz. Its solution was to separate functional mental illness from organic mental illness (see eg. previous post). Trouble is that particularly over recent years, psychiatry too has adopted Szasz’s definition of illness and no longer makes a distinction between organic and functional mental illness, when it should (see eg. another previous post).

Jo’s right that psychiatry does need to look to philosophers, like Wittgenstein, for a critique of reductionism and positivism. For example, Pat Bracken & Phil Thomas in their version of critical psychiatry, which they called postpsychiatry, have already said this (see eg. previous post). As Laing (1979) pointed out in the New Statesman, there is little attempt to provide an in-depth analysis of the structures of power and knowledge in Szasz's perspective (see eg. Szsaz’s (2004) perspective on Laing in return). But it may explain why Jo needs to turn to a weighty philosopher like Wittgenstein to support her argument for Szasz. Szasz himself didn’t really do that.

As I keep saying (eg. see previous post) though, although Szasz contributed to critical psychiatry in the sense that he argued that the biological basis of mental illness is a myth, I don't think he's a good place to start to explain critical psychiatry. His trenchant views could actually be said to have detracted from the cultural critique of psychiatry and medicine in general (eg. see my book review).  Jo's right that we should make more of whether a brain tumour has caused a behavioural disturbance or whether that disturbance is functional. And we should give up trying to explain mental illness in physico-chemical terms, which modern psychiatry has always wished to be able to do but can't (see previous post). 

Tuesday, April 07, 2020

Not all psychiatrists are critical psychiatrists

Abdi Sanati, Chair of the philosophy special interest group at the Royal College of Psychiatrists, tweeted that anyone who is interested in critical psychiatry should read the article by Mohammed Rashed, that I commented on in a previous post. It worries me that Mohammed's article seems to be gaining such mileage, because as I see it, the article merely creates another way of marginalising critical psychiatry. The sentiment behind it seems to be that "we're all critical psychiatrists now". The argument seems to be that silly old critical psychiatry was attacking the straw man of radical reductionism and we've all moved on from that, haven't we?

This is a variant of the argument used by people like Anthony Clare to undermine the critique of so-called anti-psychiatry. As I've pointed out several times (eg. see previous post), what Clare did was suggest we didn't need to be ideological about psychiatry. Again, in a way, anti-psychiatry is seen as having attacked the straw man of the biomedical model, which people shouldn't be rigid about, and should instead incorporate the different perspectives in psychiatry in a wholistic way. Ok, there is some truth in this argument. Most psychiatrists are not rigidly biomedical, or at least some are less biomedical than others. But ultimately the vast majority of psychiatrists are very fearful about giving up the biomedical model, which I think underlies the motivation of Mohammed's article and its support from Abdi Sanati (and others).

Psychiatry is a cultural system like religion (see eg. previous post). Believe it or not, the biomedical model of mental illness is a model that does not necessarily define the real world. That's not the essential point for psychiatry. The model is needed to justify treatments such as medication and other physical treatments. It gives a way of operating for psychiatry that provides a framework to treat people in certain ways. Basically it provides a worldview. I can remember the trauma of giving up my belief in god as a teenager. Psychiatrists would be like theists giving up their belief in god if they gave up the biomedical model. Their personal essence is challenged by critiques of the biomedical model. That's why they're so sensitive to even the remotest indication that they may not have got it right. It creates the gravest anxiety if the way they've been operating is found to be no longer valid. That's why they have to cultivate what Clifford Geertz called the 'aura of factuality' about the biomedical model to sustain it and get all of us gullible people to believe in it. It's stupid not to believe it, isn't it (see eg. another previous post)?

I have mentioned before (see previous post), that Robin Murray has now accepted he made mistakes in his career, specifically, for example, promoting the neurodevelopment theory of schizophrenia. It's important not to be taken in by this. Robin would also like to say "we're all critical psychiatrists now". But the best he's become is 'semi-critical' and he hasn't pushed his critique of psychiatry far enough. As I said on my personal blog (see post), it's understandable he has taken the position he has in his career. He has been a professor in psychiatry and knighted for his research efforts, whereas I have tended to concentrate on my clinical work and been suspended twice (okay, maybe the second suspension wasn't definitely related to critical psychiatry, but the first was - see THES article).

I've pointed out before (see previous post) that a chapter by Manschrek & Kleinman (1977), which could be seen as one of the originating papers of critical psychiatry, divided psychiatrists into those that took either hubris or semi-critical positions. Things haven't changed much. There are still a few dogmatists about, despite what Mohammed says in his article. What we actually need is a critical rationality about psychiatry and it seems to be very difficult to create, because psychiatrists are so frightened about giving up their worldview and the power that goes with it.

Monday, April 06, 2020

Ganser syndrome amongst patients on remand in prison

I want to say a bit more about Julian Assange’s confusional illness (see previous post), from which I'm not sure he has recovered. In 1897, Sigbert Ganser delivered a paper entitled ‘A peculiar hysterical state’ in which he described four criminals (for three of which he gave clinical details) who developed transitory symptoms of mental illness and were brought to hospital, three of them from prison (see article). Ganser did not doubt his patients were "truly sick people". He didn’t really look into how they were being treated in prison. Scott (1965) in a commentary on Ganser's paper says Aubrey Lewis noted that Ganser syndrome is found typically in patients awaiting trial. This has led to the idea that Ganser symptoms are a dissociative reaction caused by an unconscious attempt by the patient to escape from an intolerable mental situation of potential prolonged imprisonment. All of Ganser's patients improved dramatically on being admitted to hospital and had no recollection of what had happened for a rather extensive period of time preceding. This state of clarity did not generally last and was interrupted by a deep depression and return of some symptoms.

The most striking aspect of the Ganser syndrome is ‘Vorbeireden’ or ‘approximate answers’ or ‘talking past the point’. Ganser actually used the term ‘vorbeigehen’ (‘to pass by’) by which he meant that interspersed with correct answers there are (a) approximate answers to the simplest questions which are incorrect but which show that the sense of the question has been approximately understood (like answers sometimes given by children), and (b) ridiculous answers showing an astonishing ignorance and deficit of knowledge which must definitely have been or still be in the patient's possession. He gave several examples such as:-
a conversation which was held with one of these patients : —Are you able to count to ten ? Yes. (But he does not, and is silent.) Well, then, count. (But he does not, and only counts on being prompted.) 1, 2, 3, 4. (Then he is quiet again.) What follows one? Two. Then? Twelve, 93 and . . . and after 93? (He continues in that fashion.)
Additional symptoms include hallucinations, disorientation and hyperaesthesia. Ganser characterised the syndrome as a “hysterical twilight state”.

I have no knowledge of Assange's current mental state or whether he still appears confused. I am unsure whether there are still elements of the Ganser mental state he demonstrated when he appeared in court last October (see description by Craig Murray). The extradition hearing to decide whether Assange should be sent to the United States is split into two parts, with the second half delayed until 18 May 2020, although Assange’s lawyers have said it is impossible to prepare his case for the second part because of Belmarsh being on lockdown because of the coronavirus crisis.

Reuters reported he was cleanly shaven and acknowledged supporters in the public gallery in court on Monday 24th February 2020. This was after his spokesperson said his health had improved after he was taken out of solitary confinement to the medical wing of the prison (Reuters). As in the Ganser cases, moving a patient to a medical setting can produce dramatic improvement, but this does not necessarily last completely. On 26th February 2020, Assange complained he was struggling to follow his extradition hearing. In particular he said he was as much a "participant in these proceedings as I am at Wimbledon (tennis)” because he was unable to communicate with his lawyers or ask them for clarifications. He said he was unable to communicate privately with his lawyers because of microphones in the dock and U.S. embassy officials in the courtroom. He said his legal team has been spied on and therefore he could not give comments to them in confidence. At one point, the judge asked whether his lawyers needed to check on him because his eyes were closed. On 27th February 2020 in the fourth day of the hearing the judge commented that it was quite apparent that Assange had had no difficulty communicating with his legal team despite him continuing to complain he was struggling to follow proceedings. He was given a pair of headphones to allow him to see if they would help him hear, but he took them off after about 30 minutes.

Chelsea Manning was released from prison on 19th March 2020 (see Reuters). Assange is of course wanted in the United States on charges of conspiring with Manning to hack into a Pentagon computer system containing classified materials, which led to the publication of the Iraq War logs, the Afghanistan war logs and the State Department cables.

I am unsure how much care has been taken to protect the health and safety of Assange in prison. I am also unsure whether the court wrongly thinks he is malingering. Before he went to the Ecuadorian Embassy, he took refuge at Ellingham Hall (see Beccles and Bungay Journal article). With the coronavirus crisis, why can't he go back there, even with a condition of psychiatric treatment?

Saturday, April 04, 2020

A history of critical psychiatry in four books

I hesitate to follow Tom Burns' example, when I've criticised him for not putting the history of anti-psychiatry properly in context by focusing on four books (see previous post). But at least he did highlight four essential texts. Here's what I think are the four essential texts of critical psychiatry.
1. Pathological child psychiatry and the medicalization of childhood (2002) by Sami Timimi
I've mentioned in a previous post how Sami Timimi felt indoctrinated in his psychiatric training. There is an orthodox medical approach to the problems of interpreting and treating mental disorders and any challenge to this orthodoxy tends to be suppressed by mainstream psychiatry (see my book chapter). I too struggled in my training but did my senior registrar training in the Sheffield University department of psychiatry (see my article), where Alec Jenner was Professor of Psychiatry and in tune with my views (eg. see previous post).

Child and adolescent psychiatry always tended to be a haven for those that found the biomedical overemphasis in adult psychiatry too difficult, as major mental illnesses do not really occur in children. Much of Sami's writing, including this key text, are about the increasing biologisation of child and adolescent psychiatry over our working lifetimes. For example, when both he and I trained, childhood depression was regarded as uncommon and different to adult depression (see previous post). Doctors have become much more ready to prescribe antidepressants in childhood and adolescence (see eg. my BMJ letter).

My review of this key text highlighted, as does Sami, how psychiatric diagnosis in childhood and adolescence oversimplifies children and young people's problems. Sami shouldn't have had to be in the position of resisting what he was being taught in his training. Psychiatry is a pseudoscience if it speculates beyond the evidence, and it is inevitably value-laden. The positivist reduction of mental illness to brain disease can't hide this fact. Read the book for a refreshingly honest engagement with the issues posed by psychiatry.
2. Post-Psychiatry (2005) by Pat Bracken & Phil Thomas
The term ‘postpsychiatry’ was coined for a series of short articles for OpenMind magazine from 1997-2001 (see previous post). Postmodernism is seen as a departure from modernism and challenges its basic assumptions. Psychiatry has been dominated by the biomedical model since the mid-nineteenth century, although the degree of its dominance has fluctuated, with the period 1900-1970 being one in which psychological causes of mental illness were relatively more likely to be entertained, if only because of psychoanalysis (see eg. my conference paper).

Postpsychiatry emphasises the importance of contexts, values and partnerships and argues for a new type of psychiatry. It suggests that society’s faith in science and technology has diminished. Values are important as well as evidence. The notion of objective reality is suspect. As far as medicine is concerned, it is now recognised patients have expertise themselves and need to come to an arrangement with doctors in which their expertise is shared with doctors' expertise. Fundamental questions remain about the legitimacy of psychiatry despite the onslaught of anti-psychiatry. Postmodernism was a fashionable movement and Pat and Phil tied critical psychiatry to it, although they did not mean this link to postmodernism to usurp other critical approaches.

Essentially postpsychiatry sees the modernist agenda of psychiatry as no longer tenable because of various postmodern challenges to its basis. As I said in my book chapter:-
These [challenges] include questioning simple notions of progress and scientific expertise. The rise of the user movement, with its challenge of the biomedical model of mental illness, is seen as being of particular importance. Recent government [new Labour at the time] policy emphases on social exclusion and partnership in health are viewed as an opportunity for a new deal between professionals and service users. Postpsychiatry is, therefore, context centred and takes its philosophical foundations from 'hermeneutical' philosophers such as Wittgenstein and Heidegger and the Russian psychologist Vygotsky. Such approaches give priority to meaning and interpretation rather than causal explanation.

Pat and Phil have moved on in their deconstruction of the authority of modern psychiatry (see previous post). They highlight five dimensions of the critical psychiatry project: ontological, epistemological, empirical/therapeutic, ethical and political. They also make clear that critical psychiatry challenges the technological paradigm, rather than just the biomedical paradigm, recognising that psychological, not just biological, understanding can also be mechanistic. Reductionism and positivism have dominated mental health practice and research too long.
3. Institutional racism in psychiatry and clinical psychology (2017) by Suman Fernado
Suman Fernando has written several books on racial inequalities in mental health services (see eg. previous post). Mental health is a global health priority (see previous post). It tends to have a systemically white perspective (see another previous post). Suman is the co-editor of an important book Global psychologies, that explores the diversity of perspectives in non-Western countries in relation to mental health and illness.

Human rights are violated globally in mental health services (see eg. previous post). Mental health problems are culturally embedded in the social, economic and political conditions of countries. The aim of services should be to reduce and eliminate ethnic inequalities in user experience and outcome.

I have commonly said that critical psychiatry has its origins in anti-psychiatry. However, anti-psychiatry had little to do with issues of race and culture. David Ingleby (see previous post), who originated the term 'critical psychiatry', is Emeritus professor of intercultural psychology at Utrecht University and his main interest has been in migration and health. In his book chapter, he explains why there is this important overlap between critical psychiatry and intercultural mental health. This is because of the importance of social context in the understanding of people's mental health problems and the unwarranted medicalisation of these problems. Low- and middle-income countries need to develop locally relevant approaches rather than follow the biomedical methods of high-income countries (see eg. previous post). Mental health service development should not be colonised by biomedical psychiatry.

My choice of this key text from amongst all Suman's writings is because it is explicit about institutional racism. For example, black people in particular are almost 4 times more likely than white people to be detained under the Mental Health Act. Black compared to white patients are diagnosed more frequently as schizophrenic by both black and white clinicians - although to a lesser extent by the former. Issues of racism need to be dealt with in society in general, not just in mental health services, and racial bias has always existed (see another previous post).

Institutional racism, and corruption in general, develop when systemic practices, which are legal, accepted and normative, nonetheless undermine the integrity of the institution. An essential message of critical psychiatry is that psychiatric organisations need to recognise and correct their own institutional racism and corruption (see eg. previous post). Mental health services need to change (see previous post). Critical psychiatry exposes the corrupting self-interests of modern psychiatry to support the wider acceptance of its focus on the person in mental health services.
4. The myth of the chemical cure (2008) by Joanna Moncrieff
Joanna Moncrieff is Professor of critical and social psychiatry at University College London. As a trainee at the Maudsley hospital, she set up a Critical Psychiatry Group, and I think the reason the Critical Psychiatry Network (CPN) adopted its name is more because of Jo than anyone else. She has been the co-chair of CPN since it started in 1999.

Critical psychiatry is not so much making a case for ‘the myth of mental illness’, as was Thomas Szasz (see eg. previous post), but for ‘the myth of the chemical cure’, as in the title of this key text. Critical psychiatry is prepared to engage with the evidence about psychiatric treatment. It takes a sceptical approach, emphasising the bias in the literature created by methodological problems with clinical trials, such as unblinding (see eg. my OpenMind article). Jo and I did an article together summarising the methodological biases in clinical trials. It is possible the general small effect size of trials could be explained by expectancy effects introduced through unblinding and other biases. For example, placebo amplification is seen as a valid explanation of the data in antidepressant trials (see eg. previous post).

Jo is at the forefront of this sceptical analysis of the evidence-base for psychotropic medication. Her The bitterest pills (2013) (see my review) focuses specifically on antipsychotics. She makes clear that the prescription of psychotropic medication can be more marketing-based rather than evidenced-based. Jo's drug-centred rather than disease-centred model of prescribing focuses attention on what psychotropic drugs actually do, rather than what they might be doing to correct any postulated abnormality, assuming they're effective in the first place. The problem is that mental health problems are too readily seen as brain disease, whereas treatments may well be inadvertent placebos.

Far too much of the emphasis in assessment in clinical trials is on short-term outcome. People may even possibly do better in the long-term if they work through their problems without psychotropic medication (see eg. previous post). Doctors tend to focus on short-term fixes, tend not to be psychologically minded, instead thinking they are treating a biological illness, and are too quick to peddle medication without discussing its limitations.

The question of the effectiveness of psychotropic medication is open to question and this key text, despite niggling overstatement at some points, shows how critical psychiatry engages with the data and its interpretation. It justifies critical psychiatry's scepticism of the effectiveness of medication. This does not mean that critical psychiatrists do not use psychotropic medication, but they prescribe within the uncertainty of the available evidence.
The choice of these four books is necessarily selective.  However, if you're asking me where I think you ought to start if you want to read about critical psychiatry, I would suggest you start with these four books.