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.

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