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This book contains both a critique of psychiatry and its use of power and authority, and then a discussion of that critique. The first part of the book consists of chapters by various authors who contributed to a 1996 conference on which it is based. They explain their perspectives on psychiatric power, illness, the process of diagnosing, racism, hearing voices, mental health workers' perspectives and involvement with psychiatry. The second part of the book addresses a more theoretical and philosophical argument for classification and the responsible use of power in psychiatry, with the final chapter giving persuasive criticism of the first part.
The different authors give an interesting slant in tackling the history of psychiatry, how the construction of power and authority evolved, and the rules of the language game. Thomas Szasz argues that psychiatric power has remained essentially constant for almost 300 hundred years when it began with troublesome persons being confined in madhouses (p.46). He asks what if anything has changed. Ron Coleman goes along similar lines but suggests that for users to gain power they should no longer hide behind the illness and remain a victim of the system but should instead take responsibility for their own lives. However, as he is well aware, that is easier said than done, when you need, as he states, brass to have power! What if you cant get a job or support yourself then maybe it is easier to be a victim?
Mary Boyle writes about the process of diagnosing and the way in which a diagnosis can be a valid and reliable concept. Suman Fernando discusses the racist consequences of labelling on those of ethnic origin. Again these issues incorporate the use of language and the implications of diagnosing to decide what a person is like as judged by a psychiatrist according to a certain set of criteria. This critique of diagnosing is in itself powerful, and should be taken into account within psychiatry. Fernando argues that psychiatry is basically and fundamentally racist (p. 83) and gives evidence for this, especially in regard to the over-diagnosis of black people with schizophrenia and the use of compulsory treatment. He suggests, "the imperialism carried over from slavery and colonialism is now being manifested through psychiatry
," and a way to start reforming psychiatry may be to examine the psychiatric system in a bid for the struggle of black people to survive it.
Hearing voices by Marius Romme discusses a different approach to traditional psychiatric intervention with those who experience psychosis, and an alternative explanation to the illness concept. He concludes from his study that it is the way an individual copes with his/her voices that can create psychopathology and suggests that these symptoms may be the cause of illness, and not the other way round.
Shulamit Ramon tackles the issue of understanding the ambiguities and ambivalences that mental health professionals live with. She suggests that there needs to be participation between professionals, users and relatives in new alliances for a change where she "would like to see created professionals who are genuinely engaged in partnership with clients
who are ready to give up their power in this process"(p.109), in order for the professionals to be able to live more comfortably with the ambiguities and uncertainties that can not always be resolved when working with people with mental health problems. Finally, Alec Jenner argues that the authority of psychiatry "depends on an almost hegemonic vocabulary and language" (p.121). He further suggests that society defined madness first, and this definition was taken on by the profession of psychiatry.
The counter-arguments to the provocative first part of the book reflect differing positions about power and authority. Chapter 10 reviews the context and power in family meetings to examine the balance of power between service users and staff. These authors have attempted to erase authority from their practice with an example of emancipation based on reflective practice. Chapters 11, 12 and 13 discuss different therapies, one from the work of R.D. Scott, another regarding the philosophy of district services centres, and the other looks at therapeutic households providing a compressive treatment that is individually tailored. This second part of the book concludes with a persuasive critique of the first.
The Construction of Power and Authority in Psychiatry makes an important contribution to the way we should consider psychiatry. It includes many arguments and perspectives and it is up to the reader to judge them. I do not necessarily agree with everything written; for example Parsons and Armstrong (chapter 14) suggest that the power and authority that proceeds from psychiatric diagnosis would be of benefit to the majority of those who use psychiatric services, and also, to society in general (p. 221). However ideal this may seem, I believe they are being somewhat naive and obviously have not been on the receiving end of psychiatric services?! It is true that as human beings we classify all the time and that it may be helpful to have psychiatric classification, but I agree with Boyle that currently "psychiatric diagnoses are unreliable" and are invalid because of their construction (p.73). As Coleman states: "weve got a theory about diagnosis in voice hearers
If youve got a straight face youre schizophrenic. If youre smiling when you see him youre a manic-depressive. And if he doesnt like you youve got a personality disorder" (p.65).
So what are the answers? This book provides thought provoking suggestions to stimulate ideas. It should be remembered that power is not always a negative thing as is assumed in this book, and that changes could possibly be made if professionals used positive power. Although this review stresses mainly the issues around diagnosis, the book does incorporate interventions and other elements involved in mental health. Ramon would like to see professionals who are genuinely engaged in partnership with clients. This may be a start, but will we ever totally escape the use power and authority in psychiatry? I dont know, and I believe that the authors dont know either
it's something to think about! A quote from Sadler et al (1994:86) sums up my personal view in this area:
The nosologist searching for universal features of disordered personhood is laying essential foundations for a more moral and scientific humanism. But the one who never really sees the patient and his or her actual problems and possibilities because of nomothetic commitments to the presumed disease or disorder is neither physician nor scientist. (Sadler, JZ; Wiggins, O.P, and Schwartz, M.A. (1994). Philosophical perspectives on psychiatric diagnostic classification. The John Hopkins University Press: Baltimore & London.)
Deborah Tallis is a Ph.D. student at Anglia Polytechnic University, Cambridge with research interests in personality disorders, especially in relation to the process of attribution.