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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
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
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.