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PostpsychiatryReview - Postpsychiatry
Mental Health in a Postmodern World
by Patrick Bracken and Philip Thomas
Oxford University Press, 2006
Review by Bradley Lewis, M.D., Ph.D.
Aug 29th 2006 (Volume 10, Issue 35)

Patrick Bracken and Philip Thomas are two U.K. psychiatrists whose important new book expresses a deep concern, and a hopeful optimism, for the future of psychiatry. Their concern comes from their first hand witness of the growing gap between the priorities of contemporary psychiatry and the needs of service users. They find that most of contemporary psychiatry has so over-identified with science and technology that it cannot meaningfully connect with human concerns: psychiatry's "primary discourse is scientific, mainly around biology and positivistic versions of psychology. Issues such as meanings, values, and assumptions are not [completely] dismissed but they are relatively unimportant, secondary, concerns (p. 5)."

This contemporary scientistic approach not only alienates psychiatry from human concerns, it is historically rooted in the ever increasing need to exclude and control the psychically different. Quoting Roy Porter's work on the history of psychiatry, Bracken and Thomas point out that with the rise of the Enlightenment, "foolish or unreasonable people" were "deemed inimical to society or the state--indeed could be regarded as a menace to the proper workings of an orderly, efficient, progressive, rational society (p. 8)." Porter, like Michel Foucault before him, argues that "the Great Confinement" was the Enlightenment's response to those it found to be outside reason. The emergent discipline of psychiatry was consequence of this mental incarceration (p. 87). Once the mentally different were excluded and confined, a scientific discourse with expert authorities was needed to legitimize and intervene in the asylum.

These newly formed psychiatric experts set out "to discover the universal laws underlying human behavior and to develop causal accounts of how these laws operated (p. 9)." Their scientistic and technical approach is a direct forerunner to today's dominance of Diagnostic and Statistical Manual and to the recent "decade of the brain." By framing mental difference in an exclusively technical idiom, psychiatry has erased all other forms of understanding, whether it is spiritual, moral, political, or traditional.

Bracken and Thomas argue that one of the primary problems with the emergent technical idiom is "methodological individualism." Enlightenment approaches--and here psychoanalysis is as guilty as biopsychiatry--so focus on individual "pathology" that they become blind to the social and political dynamics of psychic life. Individualized approaches, in other words, fail to access the basic wisdom of the alienated, oppressed, and denigrated--the personal is always also political.

In view of these deep and serious concerns about contemporary psychiatry, how can Bracken and Thomas still be cautiously optimistic? It is because they also see a growing groundswell of people who are resistance to dominant technical approaches. Service users, contemporary intellectuals, and critical psychiatrists are all finding alternatives to the mainstream approach. Service users are becoming increasingly organized and they are articulating their own discourse on psychiatry. One empirical study by service users that Bracken and Thomas highlight finds that, of 512 people interviewed, only 12 % were pleased with their psychiatrist. Nearly 40 % found their psychiatrist's attitudes to be reserved, detached, godly, complacent, or condescending. And Bracken and Thomas's reading of Speaking Our Minds--an anthology of critical service users--reveal consistent concerns that psychiatrists ignored the context of psychic difficulties, were so enthralled with technical proficiency that they were unable to connect with people, and that psychiatrists power to confine and coerce people (who they very poorly understood) led to tremendous pain and trauma.

In addition to the rise of critical service users, Bracken and Thomas see reason for hope in the synergy between service user complaints and the critiques of modernism in contemporary scholarship. These critiques of modernism can be loosely labeled under the term "postmodern." By postmodern, Bracken and Thomas refer to writers who are "coming to terms with the downside of the modernist Enlightenment dream: a world ordered according to the dictates of reason; a world shaped by science, technology, and the primacy of efficiency" (p. 6-7). Using postmodern thinkers as their guide, Bracken and Thomas identify two problematic themes of modernism that are also very much problematic themes for psychiatry as well. First, modern thinkers believed that "primitive" traditional and religious beliefs were the cause of many of the world's problems. The advances of science and reason, they thought, would overcome inadequate folk superstitions and would result in progress and advancement for humankind. Second, modernist thinkers believed in and developed the sciences of man to explore the different aspects of what it is to be a person. Central to these sciences--particularly medicine, psychiatry, psychology--was the primacy of the individual.

These two modernist preoccupations (the superiority of science and reason and the primacy of the individual) became the founding assumptions of modern psychiatry. These founding assumptions, still very much in place today, tend towards the exact complaints voiced by service users. Psychiatry's faith in science and reason leads to such a preoccupation with order, control, and the technological imperative that it makes it hard to form empathic human connections. In addition, psychiatry's near exclusive focus on the individual leaves the social, cultural, and political dimensions of psychic life invisible. Service users and contemporary postmodern intellectuals seem to have a lot in common, and their common energies may very well contribute to significant change in psychiatry.

Finally, Bracken and Thomas have reason to be optimistic because they are part a group of UK psychiatrists, the Critical Psychiatry Network (CPN), who are working toward reform in psychiatry. CPN first met in 1999 to oppose the government's plans for extended community compulsory treatment. CPN works against the ever increasing medicalization (psychiatrization) of daily life and the rapidly increasing pharmaceutical influence in psychiatry, and CPN is an important source of mutual support for colleagues "who dare to think differently" in psychiatry (4).†† †††

Moving beyond critique, Bracken and Thomas use their book to articulate a fresh vision for psychiatry. They term this vision "postpsychiatry" because of its resonance with contemporary postmodern thinking. Postpsychiatry, for Bracken and Thomas, is less of a new model of "mental illness" and more of a new attitude for looking at existing models. This attitude leaves behind a modernist idealization of science and reason to place ethics at the heart psychiatric care and support: "To us, postmodern thinking does not involve a rejection of Enlightenment values and ideals, but instead reflects a concern to understand their limitations (7)." Postmodernism does not reject modernist insights. "It simply rejects their claims to be foundational and universally valid. It does not dismiss their insights... but posits their truths as partial, contingent and local (7)."

†Bracken and Thomas take care to differentiate postpsychiatry from an "antipsychiatry" that would be against psychiatry or even against science in psychiatry. Bracken and Thomas argue that although the antipsychiatry movement of the 60's involved a heterogeneous set of psychiatrists, psychologists, and sociologists, the commonality of this group arose from a basic sense that psychiatry is a form of oppression that crushes the individuality and subjectivity of patients (p. 86). But Bracken and Thomas use Foucault's later writings to argue that the consequences of psychiatry are more complicated: "Psychiatry and its allied disciplines control deviance through their interventions and treatments, but they also provide us with the narratives through which we understand ourselves and our problems (p. 99)." Psychiatry may very well have been part of the great monologue of reason that silenced psychic difference, but at the same time it has provided a discursive frame where "organizations like Mad Pride, Mad Women, the Hearing Voices Network and the Self Harm Network are demanding a return to dialogue (p. 99)."†† †

Because of these and many other paradoxical effects of psychiatry, postpsychiatry has no need to be for or against psychiatry--neither "propsychiatry" or "antipsychiatry." Postpsychiatry understands that many people find ways to benefit through contemporary psychiatry, but, at the same time, many people are also left out, alienated, and even traumatized by current reductionistic practices. Indeed, Bracken and Thomas devote two chapters to reductionism in psychiatry. They use insights from Wittgenstein and Heidegger to argue against "the modernist urge to frame all our problems as technical, all our sufferings as medical, ultimately something open to cure through some expert intervention or another (p. 168)."

This opens space for Bracken and Thomas to articulate a basic motto of postpsychiatry that runs throughout the book: "Ethics before Technology." Bracken and Thomas argue that most good mental health work, including most psychopharmacology, "is actually based on meaningful relationships between helpers, clients, professionals and patients. In other words this work involves in some central way a human encounter focused on issues such as hope, trust, dignity, encouragement making sense, empowerment, empathy and care (168)."

Postpsychiatry is not against psychiatry so much as it is for reprioritizing psychiatry. Postpsychiatry "does not mean an abandonment of science, technology or even control, but it does mean a reversal of the traditional order of priorities (189)." Rather than making science, technology and treatment the first priority, "the first move in mental health work should be an exploration of we, as a community, want to care for one another in states of madness, distress and alienation. This is primarily about what values we wish to attach to such states of mind. This is not a technical issue but and ethical one, and so one that should be open to democratic debate and discussion"--rather than simply controlled by expert authorities under an idealized modernist rubric of value-free science (189).

Bracken and Thomas argue that a main goal of their critique is to turn down the volume of scientistic approaches so that it is possible to hear voices that are usually drowned out. That means, quiet simply, that they want to hear less from the "experts" as currently defined and more from the people who are struggling; the people psychiatry is supposed to be helping.

In Bradford, England, the city where Bracken and Thomas work, hearing to these alternative voices means learning about the roles of social and cultural contexts for people's difficulties. Bracken and Thomas find that "Sharing Voices Bradford" and "Evolving Minds" are two particularly good sources of wisdom in their community. Sharing Voices is a community development project set up to engage Bradford's Black and minority ethnic communities. Evolving Minds is a peer support program that creates public space--monthly meetings in a local pub--where different understandings of distress can be explored and where social justice in relation to mental health can be advocated.

Sharing Voices and Evolving Minds are very different but they share a common approach rooted in local practices and beliefs. "Both are collective and accountable, and assume that madness is a concern to everybody. The Great Confinement was physical, ideological and political. Evolving Minds and Sharing Voices challenge this by taking madness back into the heart of the community. They refuse to accept that madness is the exclusive domain of the psychiatrist and mental health expert. Both propose that we have a collective responsibility to engage with madness and distress, and to see such states as part of a range of understandable response to conflict, abuse and trauma (p. 247)" †

Having outlined the content of Postpsychiatry, I would now usually offer my critique of the book. Here I must point out my own situated perspective on these issues. Like Bracken and Thomas, I too am very concerned about the future of psychiatry, and I too am looking for reasons to be hopeful. My own recent book, Moving Beyond Prozac, DSM, and the New Psychiatry: Birth of Postpsychiatry, also picks up the term "postpsychiatry" and uses it as a wedge to open modernist psychiatry to alternative perspectives. I adopted the term from Bracken and Thomas, and I consider them to be kindred spirits in the movement to reform psychiatry. From that position, I have no critique of Bracken and Thomas. I only feel gratitude for their efforts.

Working against the grain of mainstream approaches, while at the same time remaining actively engaged in mainstream systems, is an extremely difficult task. It means finding a way, completely unsupported by the field, to educate oneself on a critical discourse that can be used to unpack the problematic aspects of the field, while at the same time not alienating oneself from the field. Few people have achieved this accomplishment as well as Bracken and Thomas. I take my hat off to them for their work. We can all benefit from their efforts. ††††††††††††††††††††

My critical comments, then, are not for Bracken and Thomas. Rather, they are for mainstream psychiatry. It is past time to open the door to new and alternative approaches to what is generally considered mental illness. Critical voices both inside and outside psychiatry are growing and gaining momentum. These voices tell of people involved in mental health whose needs are being lost. The appropriate response--especially for a helping profession--is not to ignore these voices. The appropriate response is to take them seriously.†

†††††††††††

© 2006 Bradley Lewis

 

Bradley Lewis, Ph.D. is author Moving Beyond Prozac, DSM, and the New Psychiatry: The Birth of Postpsychiatry (University of Michigan Press, 2006).† He is an assistant professor at the NYU Gallatin School of Individualized Study.†


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