Postpsychiatry: reaching beyond the technological paradigm in mental health care

Pat Bracken

Clinical Director, West Cork Mental Health Service, Ireland

Psychiatry: A Crisis of legitimacy

Efficacy and safety of anti-depressants and anti-psychotics in question

DSM 5 under attack Concern at the medicalization of ordinary

life Promises of neuroscience not delivered Corruption of academic psychiatry by Big

Pharma Rise of the service-user movement

Outline of Lecture

Psychiatry as a product of the Enlightenment

The technological paradigm Why we need to get beyond this

paradigm Postpsychiatry: towards a post-

technological form of mental health care

Roy Porter

Roy Porter

Kant

‘Enlightenment is man’s emergence from his self-incurred immaturity. Immaturity is the inability to use one’s understanding without the guidance of another. This immaturity is called ‘self-incurred’ if its cause is not lack of understanding but lack of resolution and courage to use it without the guidance of another. The motto of the Enlightenment is therefore: Sapere aude! Have courage to use your own understanding’

Roy Porter

"… the enterprise of the age of reason, gaining authority from the mid-seventeenth century onwards, was to criticize, condemn and crush whatever its protagonists considered to be foolish or unreasonable. All beliefs and practices which appeared ignorant, primitive, childish or useless came to be readily dismissed as idiotic or insane, evidently the products of stupid thought-processes, or delusion and daydream. And all that was so labelled could be 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" (Porter, 1987, pgs 14-15)

Roy Porter

‘Indeed, the rise of psychological medicine was more the consequence than the cause of the rise of the insane asylum. Psychiatry could flourish once, but not before, large numbers of inmates were crowded into asylums’

Roth and Kroll

‘The advance of science has helped societies in their thinking about aberrant behaviours to move from moralistic-theistic concepts to definable naturalistic mechanisms….’

Psychiatry and the Enlightenment

Age of Reason

Focus on reason Focus on the self

The Great Confinement

Sciences of the mind Depths of the interior

Psychiatry

Exclusion ofUnreason

Technical solutions to human problems

PhenomenologyPsychoanalysis

Technological Approach

Technological Approach

Medicalmodel

Cognitive approaches Positivist forms of

social science

Main Assumptions of the Technological Paradigm

The problem to be addressed has to do with a faulty mechanism or process of some sort

The mechanism or process can be modelled in causal terms, ie described in a way that is universal, a way that works regardless of the context

Technological interventions are instrumental. They are not to do with opinions, values, relationships or priorities.

Technical idiom

‘Bipolar disorder is a complex, recurrent mood disorder, and its impact on everyday life can be devastating. Although pharmacological interventions remain the primary tool in its management, medicines cannot control all aspects and consequences of the disorder. Psychosocial interventions target issues untouched by pharmacological treatments, such as medication adherence, awareness and understanding of the disorder, early identification of prodromal symptoms, and coping skills’ (Beynon et al, 2008).

Modernist Psychiatry

Primary discourse is technical: focused on diagnosis and classification, causal explanations, evidence-based interventions (EBM)

Other issues become secondary: ethics, values and priorities, meanings and contexts, relationships and power

Why is Technological Paradigm dominant?

Cultural support: continuing dominance of ‘modernism’ within medical world

Patient expectations Underscores professional roles Pharmaceutical industry

Marketing Bipolar Disorder in Children

Role of Service-user Organisations in the Technological Paradigm

-consultation-help with fund-raising and recruiting

subjects for research -their expertise secondary to that of

the technical knowledge of the professional

20th Century Psychiatry

Focus on technology of diagnosis and

treatment

relationships

Ethics and values

Social position

Cultural issues

Post-technological mental health

Discoursecentred on:

-values/ethics-meanings/contexts-relationships/power

Appropriate research

Service models

Training priorities

Use of drugs and therapy

Challenges to technological paradigm

Postmodern culture Changing understanding of technology

itself Moves away from the embrace of

Pharma

Why Radical Change is Justified

Empirical evidence Conceptual analysis Political reasons Ethical imperative

CBT

‘little evidence that specific cognitive interventions significantly increase the effectiveness of the therapy’ (Longmore and Worrell, 2007)

Why Radical Change is Justified

Empirical evidence Conceptual analysis Political reasons Ethical imperative

Psychiatry and Philosophy

Why Radical Change is Justified

Empirical evidence Conceptual analysis Political reasons Ethical imperative

Ethical

if we say that we are working to

develop user-centred services, training and research programmes then it is simply unethical to carry on as if the user movement did not exist.

Icarus Project

‘we shared a vision of being “bipolar” that differs radically from the narrow model put forth by the medical establishment, and wanted to create a space for people like us to articulate the way we understand ourselves, our “disorder”, and our place in the world’.

Implications for Psychiatry

Rethinking psychopathology A different understanding of

expertise Training Research Service developments

Insights from Recovery Literature

1. Recovery often made through paths that are alternatives to drugs and psychotherapy

2. Importance of loss of social position that comes with being a service user

3. Community development approach

Relationship with service user movement

From Consultation to collaboration