A few years back, I used to be something of an anti-psychiatrist. I could smugly quote Laing, Foucault, Szasz, Goffman. I could hold forth on “social labelling”, “biological reductionism” and the evils of “scientism”. I could deconstruct, for crying out loud.
Nowadays, I don’t feel that way about psychiatry. I’m not saying that Laing, Goffman, Szasz etc didn’t get anything right. Of course they did, and to some degree yes, mental illness is a social construct designed to deal with ways of thinking and behaving that society finds disturbing or unacceptable. And yes, the history of psychiatry is one riddled with stories of neglect and abuse.
But…and here comes the big But…well, the author of Pole to Polar: The Secret Life of a Manic Depressive has put it perfectly:
All I want, all I believe, is that bipolar disorder is real. As for the medications? If you make informed decisions and are supported, and if they help you, that’s the important thing. I am sick of the anti-med bandwagon. I rolled on it for such a long time. The churlish, “ddddduuuuh mental illness is fake!” belief just reinforces the stigma of mental illness. The most important thing to me is that people with mental illness, behavioural disorders, whatever the hell you want to call it, aren’t marginalised and discriminated against for something that- yes, even if they’re aware of it- feels out of their control. I have said time and time again here that I always felt that what was happening to me was biological. I fought the good fight. I went on the diets. Changed my scene. Did the mindfullness techniques. Had the therapy. Stopped the booze. Settled down and lived a quiet, careful life. And I am still a manic depressive. I still suffer intense depression. I still suffer highs and mixed episodes. And I even have the “broken home”, the “unstable background”. And yet, I’m okay with that. My broken home and unstable background is populated with people and experiences I cherish. It didn’t destroy me. It never will.
I don’t care if they’re a cluster of symptoms defined in an outdated manual. To me, they are real. They do not define me as a person. And knowing that, hanging on to that, is what gets me through when I feel I am losing the fight.
What the quote above illustrates to me is a thought that’s been growing in my mind for a while…that in some respects anti-psychiatry can sometimes represent just the same sort of rigid, dogmatic and downright tyrannical attitude that its proponents accuse psychiatry of. Saying to someone, “You have a mental illness, caused by a chemical imbalance in the brain, which can only be solved by medication” may well be a rigid, simplistic, condescending statement that pigeonholes people into narrow boxes, but so too is, “You do not have a mental illness but are being categorised into a social construct for which medication is not the answer.”
About a year ago I found myself sharing an evening class with an archetypal coffee-shop intellectual. Like me he had read Szasz, Laing, Foucault. He had a sort of stilted, nasal laugh “uh-HUH-HUH-huh” that he would use when he believe he’d said something witty and clever. This would usually be accompanied by a twitching of the nostrils and a tilting back of the forehead. He was also completely unemployable and was sponging off a rich woman while he wrote some shit novel that he probably believed was the next winner of the Nobel Prize for Literature.
He would tell me, at length, whether I wanted him to or not, “But psychiatry is stuck in reductionist ideas, and you’re still using barbaric practices like ECT…uh-HUH-HUH-huh…when RD Laing proved that schizophrenia is a logical response to power-plays in family dynamics…uh-HUH-HUH-huh.” *nostril twitch* *tilt back forehead*
Listen, you over-educated dole scrounger, much as I still love RD Laing’s writings, and still think he made a lot of valid criticisms, he didn’t prove anything. He suggested it. Psychiatric research didn’t stop in the 1960s just because Laing wrote a book.
As for Thomas Szasz, despite his qualification as a psychiatrist I regard him as being pretty much in the category as the nostril-twitching forehead tilter above who knew everything about how to deconstruct but had never set foot in a psychiatric ward. Szasz may be a psychiatrist, but there’s nothing in his CV to suggest he’s attempted to apply his theories to deeply psychotic people. It’s one thing to say that what we call mental ilness are merely “problems in living” and that there should be no compulsory detention or insanity plea when all you’re doing is psychoanalysing stressed-out Manhattan stockbrokers. It’s quite another to do so when talking to somebody who is in mortal terror because he believes that the neighbours are telepathically controlling his thoughts.
“What? Your thoughts are being controlled by the neighbours? It’s just a social construct! You’ve just got a problem in living! You can make your own informed, rational choices about what you want to do about it! Snap out of it, man!”
I haven`t read any Laing, Foucault, Szasz or Goffman. I never frequent coffee shops and I don`t lose much sleep about “biological reductionism”.
I`m simply dissatisfied with the psychopharmacoligical and physical interventions upon which psychiatry is so reliant. Once the interventions – be they chemical, electrical or surgical – improve then my hostility will dissipate immediately.
I wholly respect your decision to work in a secure unit. We do have to pay the bills. However, it isn`t the optimum learning environment ( I have been there ). Having said that it is an excellent chance to closely monitor the longer term impacts of the psychiatric model. It will be very interesting to see how you feel about this post in a years time.
Oh don’t get me wrong, I’m worried about those things too: particularly about the long-term side-effects of psychiatric medication, and also about the lack of availabity of psychological approaches. I don’t dispute any of that.
But what I’m objecting to is the idea that mental illness is merely a social construct: an argument that’s usually made by people whose only talent is the ability to bray loudly at dinner parties.
For me the problem is not what explanation works for service users, but that various authorities on Mental Illness act like they know what the cause is. Nobody has a definitive explanation and I think its really important to remember that. Your high pitched friend sounds as arrogant with his social constructivist view as those who advocate the biological cause. The only thing that matters is what the service user believes and how we work with them to help them make their lives better.
That doesn`t make sense, Malcolm. There is no definite explanation of the problem and therefore we cannot have a definitive solution. Medication, though, is treated as a definitive solution as such a high percentage of service users are on prescriptions. What the service user believes is of obvious importance but the quality of potential interventions has to be of equal importance. We need to remember that there may be chemical solutions to these problems. They won`t be found whilst Big Pharma are allowed to cling to the discredited dopamine and serotonin hypotheses. For me anti-psychiatry is mainly about putting a rocket under the arse of Big Pharma. Doctors cheerfully prescribe almost anything so there shouldn`t be a problem with a trickle down effect when better products hit the market.
Zed, it isn`t just about the side effects. It`s distresing to see people, perceived as being better, when the reality is that their delusions are still quite fixed and the variable is their motivation and physical ability to act on them.
Of course the views of service users are important but we can’t ignore the fact that some believe in sitting under a blue chrystal or astral healing! That’s always been my problem with self management programs where every opinion is given equal weight. Give me a dose of Ami Sulpride anytime.
Tell me more OSB, cause it makes perfect sense to me….
OSB, I don’t really dispute any of what you’re saying, but that’s not really the point I’ve tried to make with this post. More the point that a hardline social constructivist approach can be just as blinkered and unhelpful as a hardline medical-model approach.
To me, all the different models of psychiatry (medical, psychosocial, psychodynamic, cognitive-behavioural, humanistic, social constructivist…) are like the old proverb of a bunch of blind men standing around an elephant. One feels the trunk and decides it’s a snake; another feels its leg and announces that it’s a tree, a third feels the tail and sayis it’s a rope hanging down…
All the different models are just aspects of the truth. All are needed to some degree or another, but there needs to be a balance between them.
I suppose I`m just looking at things from another angle. The other public sector blogs seem highly adept at identifying the problems they face and then applying some pressure for change. In the mental health world we just seem adept at getting lost. Smokescreen after smokescreen billows forth and we process in circles.
We face a whole host of problems but the most significant one has to be the medical model. It does a dis-service to the overwhelming majority of service users and it absorbs vast amounts of resources. Now a “hardline social constructivist approach” may well be unhelpful but if we are prioritising effectively it doesn`t stand comparison.
Big Pharma and the Medical profession are content with the status quo, their primacy is assured. If nurses aren`t at the vanguard of the movement for change then the show won`t hit the road. We need to be focussed.
The answer is choice. Medication works wonders for some of the people some of the time, and the same can be said of some forms of ‘talk therapy.’ However nothing works for all of the people all the time. Our job is to identify the difficulties people are having in their lives, explain the options for dealing with it, and help them come to an informed decision about which ‘therapy’ they would like to go with. It goes without saying that the NHS cannot provide all of the possible options, so these are generally limited to those that are evidence based.
Let me make this as simple as I can.
If the man who makes Amisulpiride was saying to Ariel” I`m really glad Amisulpiride works for you but I think I can do better. I`m going back to my shed, I`m going to look at psychosis from every conceivable angle and I`m going to do my utmost to develop a much improved anti – psychotic medication”. Then I wouldn`t be making a fuss.
Unfortunately, the man who makes Amisulpiride is actually saying to Ariel, ” I`m really glad Amisulpiride works for you. I`m selling lots of it and I`m making a good profit. I`m going back to my shed for a kip. When I wake up I will try and get it licenced for the treatment of OCD. I may also try and develop a similar molecule which has a less unpleasant side-effect profile”.
That`s not good enough. That`s why we need an anti – psychiatry movement. Let`s hurry the bastards along, shall we ?.
OSB and CPNurse. Have to agree with OSB. His is an argument for change while CPNurse is an argument for maintaining the status quo.
Its not real choice, if its only what we in the NHS can do, and limited by our own professional knowledge of what Mental Illness is. Real Choice is about freedom & responsibility, outcomes and consequences, making mistakes and learning from them. Not a single activity but a life-long process.
CPNurse
It goes without saying that the NHS cannot provide all of the possible options, so these are generally limited to those that are evidence based.
I’d add to that not only “evidence-based” but also “resource-based”. One of the reasons for the dominance of the medical model is simply that medication is readily available and psychological interventions…..well, aren’t. We’ve all seen the ridiculous waiting lists to see a clinical psychologist, assuming the psychologist will accept the patient onto his/her waiting list in the first place.
What’s the solution to that? The likes of NHS Blog Doc will scream “quacktitioner” at this, but the only way we’ll realistically do it is to upskill more RMNs into nurse therapists via training like the Thorn course. The last clinical psychologist I spoke to seemed very in favour of this.
There’s always talk about not providing psychological services – but there is a great misunderstanding of this. Yes, there usually is a huge waiting list to see a psychologist, but they are not the only ones who provide psychological therapy! I provide psychological therapy as an EMDR therapist and take referrals from other members of my team for this input. Other RMN’s are trained in CBT and other recognized ‘psychological therapies’. This is not providing the work of a psychologist on the cheap, it is freeing them to use their expertise on the more difficult clients.
And having said that…I can’t see how I can be accused of maintaining the status quo!
Interesting. I’m in an unusual (or usual – I don’t know) position of being a working RMN who bipolar, stable on medication. (Good old valproic acid if you must know).
I started suffering from mood disorder when I was around 14, swinging from super low to mildly high. No one really noticed the highs, just the lows and I got taken to the GP. Nice guy, his comment was to try and forget about giving me the dreaded mental patient status being so young – this was the 1970′s. Forget the shit they tell you about lables in Uni now, it really meant something back then. Trouble was my mood swings were pretty intense and I started self medicating with booze. It helped, and I struggled on. I joined the Army when I was 17 and found aggressive/competitive social drinking was positively encouraged, which again, hid any psychiatric problems I had. Any irrational stuff could be easily explained away – I was drunk, as per Queen’s Regulations. I carried on this way, not being able to settle in relationships, unable to stick at jobs. By the time my third marriage broke down in the early 2000′s my liver must have been as big as, I dunno, a really big liver. Blotchy. By this time I was working as a staff nurse, having followed the porter-auxilliary-student route, basically my life turned into a total shitstorm, too preoccupied to go out drinking and being a hearty chap – thus keeping a lid on it – I went high as a kite and got hospitalised. Well, the drinking was the easiest thing to break out of, believe it or not, and I’ve never drunk alcohol since! Don’t miss it either. I got offered various options, lithium (no) carbamazapine (ha!) then to try depakote. Good stuff. I’ve taken it ever since and only really ever had one episode when the mania broke through. What has been the best is that the horrible darkness, the depression that always lurked there has died away. I look back on my life with a bit of regret, wonder what I might have achieved if I could have made my brain work a bit better. As it is, the Trust that threw me as bait to the NMC and gave me full pay to be off work for three years (ta lads!) while I shaped my crap up (and did bank in nursing homes) now treats me with something approaching a bit of respect. So, yes, medicate me. I’ll thank you for it.
I met Szasz once, we went for a drink after he gave a lecture. He reminded me of my Jewish great uncles- a lot of what he says is like when they twisted my ears, a sort of tease but with a bit of an edge to it (it hurts!).
The point is, some of this anti-psychiatry is meant, or best understood, as a provocation not as a dogma, and it’s very useful taken that way. So, when someone talks about the dopamine hypothesis or the genetic basis of schizophrenia, or why patient X will certainly relapse if he ever stops his depot, its always worth listening to that little voice which says ‘yes but you don’t KNOW that’- while at the same time being able to hand out the tablets if you really can’t think of anything better to solve the problem in front of you. But academics got hold of the ideas and ran off up their own arses.
Its also true Szasz isn’t a practitioner as we understand it- he takes the view that the only interaction one should have as a psychiatrist is to take money in return for a desired service, and to keep coercion outside the clinical encounter. Patient doesn’t get anything he recognises as help, he doesn’t pay, end of story. There is some value in that approach- imagine how services would be if the patients not the PCT had the cash (let’s see if direct payments and the ‘choice agenda’ ever get that far). But it doesn’t help those of us who think coercion has a place in society (I don’t regard being a judge, a police officer or a prison officer dishonourable professions per se, not to mention a parent) & need a coherent way of applying it.
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