Slide 1 Title
Talk for RCPsych (Oct 28th 2008)
Introduction: Mental Health Revolution
I would like to first thank Dinesh for the kind invitation to address you tonight.
I joined this college as an inceptor in 1983, 25 years ago, and became a member in 1986. While I think I have always been a critical psychiatrist and have never been comfortable with many of the theories and practices of our discipline, I have always found this college to be a source of support and indeed encouragement. It is a genuine honour to be addressing you this evening as part of this lecture series.
And while I am aware that this audience is a mixed one, my comments will be addressed here to my medical colleagues. These lectures are, after all about how we as a profession, go forward.
I believe that a revolution is happening in the field of mental health.
Slide 2 Outline of lecture
In this talk, I want to first look at the idea of revolution, second try to identify what it is this mental health revolution seeks to overthrow and why, and third look at some ways in which we (as doctors) can participate positively in this.
The nature of revolutionary change
The word ‘revolution’ conjures up all sorts of images from our distant and recent history. When we use the word we usually think in terms of a political event, or a series of events happening in a short period of time. We think of the masses storming the Bastille, of Lenin and the October revolution in Russia,
Slide 3 Che Cuevara
of Che Guervara marching over the mountains of Cuba, organising a mighty military force as he went.
I was a teenager in the 1970s and, probably like many people here, I looked around at a world of oppression and injustice.
We saw power as something exercised from the top down, it was something held ‘over’ other people and was something in the hands of the bourgeoisie, the ruling class, the capitalists or simply the state. Revolution was primarily a political act: it involved taking power and using it to create a new society, one that would be defined in terms of different values, relationships and priorities.
We were part of a generation of students that felt that revolution was not only needed but immanent, just around the corner.
Of course, things didn’t work out the way we planned!
Instead we were witness to other forms of revolution:
The Thatcherite revolution in Britain, a fundamentalist revolution in Iran,
the ‘year zero’ revolution of Pol Pot and the Khmer Rouge in Cambodia
We learnt that even revolutions that set out with progressive ideals could lead to less liberty and less egalitarianism. The truth about the Bolshevik and Chinese revolutions emerged and we saw how quickly radical thought could become dogma, how quickly revolution could turn to reaction.
As the 20th century closed, the idea of political revolution had turned very sour!
Slide 5 John Gray quote
As John Gray puts it in his recent book Black Mass: "the world in which we find ourselves at the start of the new millennium is littered with the debris of utopian projects".
But if the late 20th century destroyed a simplistic faith in political revolution, it was also a time when our understanding of power itself began to change. We began to understand that power was not just something held by the state or the ruling class. We began to see how knowledge and power were intimately linked. For example, the women’s movement and the movement for gay rights showed that power is being exercised when any group has the authority to define roles, normalities, social priorities.
And, in line with this changing understanding of the nature of power, we started to see that we could really challenge power, not by taking over the state, but by challenging the ways in which roles were defined and by whom.
As we come to the close of the first decade of the 21st century, I believe that social revolution is still possible and still needed. But we must understand revolution as a process not as a singular event, as something to do with how we define ourselves as well as how we are governed politically.
Kuhn and the Structure of Scientific Revolutions
This links with how the philosopher of science Thomas Kuhn, used the word in his seminal work The Structure of Scientific Revolutions. Kuhn was not talking about social revolution but about the way scientific discourses change. He argued that when we study the history of different sciences we see that they do not develop simply through the steady accumulation of facts about the world. There are times when sciences go though periods of major upheaval. During these times of revolutionary science the fundamental assumptions, what he calls the basic paradigm, of the science is called into question.
One of the best known examples of paradigm change was the Copernican revolution that put the sun, rather than the earth at the centre of the solar system. Copernicus published his heliocentric thesis in 1543. However, many astronomers, including the famous Danish astronomer Tycho Brahe were not persuaded and continued to work with geocentric models throughout the 16th century. Much of this work was quite important in charting various aspects of planetary motion. Indeed it was a student of Tycho, Johannes Kepler, who ultimately gave us the laws of planetary motion.
This is a point that Kuhn stresses. He points out that it is hard for scientists who have worked through one paradigm all their lives to give it up, as it shapes not only their beliefs about the world but also their perceptions of that world, indeed how they experience that world.
Paradigms determine what we understand ‘the facts’ to be.
Slide7 quote from Kuhn
Indeed ‘when paradigms change, the world itself changes with them’ (p. 111).
The dominant paradigm in mental health
I now want to look at the world of mental health. Phil Thomas and I have argued that most work in this area has been guided by what we have called ‘the technological paradigm’. This underscores not just the medical model used in psychiatry but many of the alternatives currently being argued for.
Slide 8 technological paradigm underscoring other approaches
By the technological paradigm, we mean an approach to understanding experiences such as low mood, hearing voices, suicidality, self harm, fearfulness, elation that sees them primarily as technical problems that need fixing.
What do I mean by a ‘technical approach’?
I mean a way of understanding an issue with something like the following assumptions:
Slide 9: assumptions of technological approach
The only questions to be asked of technology are: does it work? And is it cost effective?
Listen to the following introduction to an article picked (almost at random) from the British Journal of Psychiatry, This is from a paper by Suzanne Beynon and colleagues published in January of this year:
Slide 10: Technical idiom: Benyon quote
‘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).
This quote is taken from a paper that examines the evidence as to whether alternatives to drug therapy are of use to people who have a bipolar tendency. My concern is not the content or conclusions of the paper but the language the authors use and the assumptions they make. Such episodes and experiences are understood to be due to a ‘disorder’. Drug treatment is the ‘primary tool’ used in its ‘management’. Psychosocial interventions are understood as discrete techniques that are to be ‘targeted’ at certain behaviours.
While the paper is actually about alternatives to drugs, the idiom is still very much technical. This idiom shapes and structures our current discourse of mental health not just in psychiatry but in other disciplines as well.
Slide 11 central preoccupations of 20th century psychiatry
In psychiatry, we see the technological paradigm shaping what have arguably been out three central concerns over the past 25 years:
classification systems (DSM etc), the search for causal processes (biological and psychological) in mental disorders and the application of the ‘evidenced based medicine’ approach in relation to interventions. I am not going to go into it in any depth here but, in many ways, evidence-based medicine, or EBM, is the epitome of the technical approach. It represents a quest to identify the specific technical fix at work in any medical intervention.
A key move of the technological approach is to push the non-technical, non-specific, aspects of mental health care to the margins. The technical approach does not ignore questions of relationships, values and meanings but it sees them as secondary issues.
This is reflected in the differential priorities afforded to these issues in publications, research agendas, teaching and training syllabi, service priorities, where we spend our money. It is very evident in our journals: any examination of our major journals will reveal that over 95% of the papers are technical in nature. Occasionally, there will be an editorial or commentary piece that raises some of these issues but these are adjuncts to the ‘really important’ technical stuff.
So this is the essence of the currently dominant paradigm. It guides not only our training, research and service agendas but crucially gives us our identity as psychiatrists. Before looking at current challenges to it, I want to quickly look at some of the supports for it.
Why is the technological paradigm dominant?
Slide 12: why technological paradigm dominant
First, are what I would call cultural factors. Phil Thomas and I have argued that psychiatry is historically very much a product of the cultural changes that happened in European societies in the wake of the Age of Reason or the Enlightenment. In this great cultural transformation the Western world started to turn from religious revelation to human reason as the path to truth and progress.
With this came a sort of veneration of reason and rationality and, in turn, irrationality became something to exclude and control on a systematic basis. The post-Enlightenment world saw the emergence of the lunatic asylums and within these: the birth of psychiatry.
Roy Porter, who was probably the greatest historian of medicine of our generation writes:
Slide 13: Porter, quote
‘.. 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’ (p. 17)
The focus on reason also gave rise to the emergence and consolidation of the human and social sciences. Humanity became the object as well as the subject of knowledge and human problems were now to be the proper concern of scientists and technical experts of different sorts. Once it emerged, the central concern of the new discipline of psychiatry was to establish itself as a bona-fide medical science and this quest still drives a great deal of our efforts and is, I believe, reflected in the priority we have given to classification, causal explanatory frameworks and the representation of mental health care as made up of discrete measurable interventions.
The point here is that the technological paradigm has always been at the heart of our profession and, in many ways, this continues to be nurtured by our society’s insistence that every problem must have a technical fix.
Slide 14 why dominance of technical paradigm
Secondly: Thinking about mental health problems as technical difficulties is attractive for many patients. Sometimes it is a great relief to regard one’s suffering as a ‘thing’, something almost separate from the self. As such it is something that can be passed over to an expert to deal with. It also allows the sufferer to give up some responsibility and to move into the ‘sick role’ for a period of time. This is sometimes needed and helpful.
3. The technical paradigm has obvious advantages for the practitioner whether doctor, nurse or therapist. It allows him/her to adopt the position of expert. Whatever technical model is used, the person who is trained in the logic and workings of this model will always have authority. They will be the ones to listen to.
4. One of the major supports for this paradigm is the enormous wealth of the pharmaceutical industry. The industry has worked to extend a technicalized way of thinking about problems to areas of life that previously would not be the concern of doctors, therapists and other professionals. It has often supported conferences and meetings that are not directly related to the marketing of drugs. For example the industry gave a great deal of support to the development of the DSM.
Slide 15: role of service users in technological paradigm
While in the technological paradigm there is a role for service user organizations and individual activists, this is advisory only. Just as patient groups can be allies in the field of cardiology or endocrinology, they do not change the assumptions or the science of the discipline. They are there in a consultative role only.
Their expertise will always be secondary to that of the technical expertise of the professional.
Why is radical change happening, needed and something we should support?
My argument is that we are entering a period of revolutionary change.
The technological paradigm is coming into question from developments outside the profession such as the rise of the user movement and also from within in the form of the emergence of movements such as recovery and critical psychiatry.
I am proposing that the technological paradigm has not served us (services users, carers and professionals) very well and we need to move beyond it.
In this slide, I have tried to represent the current situation. At present: we understand mental health as primarily a technical field. Other aspects of mental health are understood as marginal.
Essentially, the cultural, conceptual and scientific revolution I am suggesting is happening involves a reversal in how we see the world of mental health. It involves a shift to a situation where the mental health field becomes orientated around a very different discourse.
In this we do not dump our drugs, our therapies our service models out the window but we start to see them as secondary concerns, and (crucially) we start to determine how we construct them and use them according to the insights and priorities that emerge from a discourse that focuses on meanings, values and relationships.
I want to look briefly at why this might be happening, I will then look at why we should support this and I will then in the close of my talk, look at the implications for us as practitioners.
Slide 18: Why Happening?
First, Western economic realities and cultural priorities have changed. While in many ways we are still in thrall to science and technology, the postmodern world is less deferential to technical expertise, more questioning, less secure in its traditional sources of knowledge. We see many groups are seeking to put values back into our debates about social and personal problems. The rise of the organic and fair trade movements in the field of food production are examples of this.
Secondly, our understanding of technology itself is changing. We are beginning to get beyond an instrumental view. Instead, we are beginning to understand that we actually build values and priorities into the technologies we develop and promote. Think of how the sort of cars that are built in the United States reflect certain values that are prevalent in American culture, for example. In turn, the technologies we use serve to control, open up, limit, define whole areas of life. For example the ways in which teenagers communicate and form relationships has been significantly influenced by the development of mobile phone technology.
What is important is the idea that technology is not something independent of meanings, values and relationships. It is both shaped by these phenomena and in turn works to shape them.
Thirdly: there are signs that our profession is gradually freeing itself from the embrace of the pharmaceutical industry.
Recent debates led by journals such as the BMJ have indicated a willingness on behalf of doctors to start thinking seriously about the importance of an academic culture that is genuinely independent of industry influence.
Slide20 : empirical, conceptual, political and ethical
There are I believe a number of reasons why this revolution is justified.
Our major interventions in psychiatry are the use of drugs and psychotherapy. Orientated by the technological paradigm, we usually assume that these work by fixing some specific biological or psychological fault.
However, there is accumulating empirical evidence that what we call the non-specific aspects of our interventions are in fact the most important. This is the case in regard to both pharmacological and psychotherapeutic interventions.
Take depression for example. One of our ‘bread and butter’ conditions.
This year two widely reported meta-analyses have demonstrated that most (I am careful not to say ‘all’ as there is room for discussion) of the therapeutic benefit of anti-depressant drugs is due to the placebo effect.
How does the placebo effect work: well we are essentially looking at relationships and meanings.
Similar evidence has emerged from the side of psychotherapy. Several recent studies have shown that most of the specific features of CBT can be dispensed with without adversely affecting outcomes.
A comprehensive review of studies of the different components of CBT concluded that there is
‘little evidence that specific cognitive interventions significantly increase the effectiveness of the therapy’
Psychotherapy works. But, it doesn’t seem to matter very much what model or what specific techniques are used. What really matters is the quality of the relationship between patient and therapist, whether the patient feels respected and valued, whether the encounter is meaningful.
Slide 22 Why revolution justified
These conclusions have emerged from using the tools of the EBM approach, as I said earlier, the very epitome of the technological paradigm. Ironically, this is now throwing up empirical evidence that challenges that paradigm to the core.
A second level to my argument is philosophical: what is at stake here is the age old question of what it is we deal with as psychiatrists. What part of human suffering is it our job to confront?
Cardiologists deal with hearts, respiratory physicians deal with lungs, neurologists and neurosurgeons deal with the brain and the nervous system.
Psychiatry deals with ‘the mind’, with mental illness: the problems we engage with are to do with our thoughts, our feelings, our behaviors, our relationships.
The philosophical question is this: to what extent do problems in these areas behave in the same way that problems with our lungs, livers and brains behave? Can we analyze and research them in the same way?
I am not going to go over the arguments here, but I think there is a growing awareness amongst psychiatrists that that there are some fundamental issues here, hence the emergence of philosophy of psychiatry as an important academic development in recent years.
Slide 23: Philosophy of Psychiatry
Alongside this interest in philosophy we also see an increasing interest in culture, anthropology, history, spirituality and religion. What were marginal discourses are now playing an increasingly important role.
Slide 24 Why revolution justified
Turning to political issues. The question at stake here is the social position of those who experience episodes of mental illness. Has the technological framing of states of madness and distress helped to promote social inclusion and combat stigma?
I believe that there have been developments, that the lives of people with mental health problems are probable better now that they were 50 years ago. But for the most part, these developments have not come about through science but through social and cultural change.
Take an example from the field of learning disability: the case of Down’s Syndrome. While geneticists identified the fact that this syndrome was caused by a chromosome 21 trisomy some 50 years ago, this discovery did not bring about improvements in the lives of people with this disorder.
Such improvements as have been made are more the result of changing social attitudes towards people with learning disabilities and the resulting developments in social policy.
The last twenty to thirty years has seen massive investment in biological research in psychiatry. But, I would argue, very little of this research involving genetics, brain scans and neurochemistry has contributed anything to the practical lives of patients and their families.
Indeed, there is striking evidence from work on stigma that the more we promote the idea that mental illness is due primarily to some sort of biological dysfunction the less happy are members of the public to share social spaces with those endure episodes of mental illness.
The importance of the international service user movement
So far, I have looked at some of the reasons why a revolution might be happening and also why such a revolution is justified. However, to my mind the most profound development in the field of mental health in recent years has been the rise of the user movement. This is both a reason why revolution is happening, and a justification for us to join.
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.
Now it is important to be clear: many service users are happy with the technical paradigm, they seek a diagnosis and a treatment and are happy to understand their problems in a medical or psychotherapeutic idiom.
However, a growing number of service users are seeking different ways of thinking about, and working with, mental health problems. This is evidenced in the emergence of groups such as The Hearing Voices Network, the Self harm network, The Paranoia Network, the Evolving Minds group in Yorkshire and Mind Freedom International
To my mind, one of the most important movements has been Mad Pride. This summer, events were held all around the world under the banner of Mad Pride.
Slide 26 Mad Pride Cork
In my home city, Cork, a prominent service user and activist John McCarthy (who is here) organized an event in the central park of the city. Over 5000 people attended. I was there. It was a fantastic day with music, food, family events, clowns and talk: lots of talk about mental health taking place in a positive context. The event served a number of purposes but perhaps most importantly it challenged the public imagination about mental health.
In many ways, Mad Pride models itself on the Gay Pride movement: the message here is that madness (even though it may involve suffering) is not best understood simply as pathology. We need to seek other ways of encountering states of madness and distress and we need to recognize and celebrate the contribution that people who experience such states make to our society and our culture.
This is also the message of the Icarus Project in the US.
They have been meeting, writing and campaigning since 2002. At the heart of the project is an effort to redefine the meaning of bipolar experience:
Slide 27 Icarus
‘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’.
However, I’ve met the people in the Icarus project and they are not unrealistic. They know how destructive episodes of mania and depression can be. They are not dogmatic but they do promote self determination in relation to treatment decisions, including whether to take drugs or not and whether to use diagnostic categories or not.
Groups like Mad Pride and the Icarus Project are not anti-psychiatry, but they want a psychiatry that can think outside the language of psychopathology and that can respect the expertise that they have gained through their personal and communal struggles.
Challenge for Psychiatry:
I want to end by looking at what that might mean for us. How would our discipline have to change to become part of this revolution.
First of all, and following on from what I have just said about the emerging user-movement: we need to start thinking differently about the nature of mental illness. We need somehow to get beyond the framework of traditional psychopathology, to imagine a way of encountering states of madness, distress and dislocation that stays open to different interpretations and different priorities. We need to imagine a way of articulating our medical knowledge of how the body works with the meaningful world of human experience and suffering in a way that is adequate to the job.
From this will flow a different way of thinking the nature of expertise and what training should involve
I believe that this will come to have less to do with learning about theories and models and more to do with encouraging skills in the ‘non-specific’ aspects of mental health, skills in being able to tolerate ambiguity and ambivalence, skills with regard to negotiation around issues to do with framing and intervention. I see a substantial role for collaboration with service user organisations in this. In my experience, our junior doctors rarely meet with services users outside of clinical settings. This makes for a very limited and distorted encounter.
there are implications for our research priorities. A partnership and recovery orientated approach would emphasis collaboration between professionals and service users. There would be a greater focus on qualitative approaches that sought to tease out in much more depth the sort of issues that we have (up to now) regarded as secondary.
With regard to services:
I think there are two very important insights that emerge from the recovery literature. First is the realisation that recovery from mental health problems is often made by paths that are alternative to traditional routes such as medication and psychotherapy.
Research with service users indicates that things such as work, leisure, relationships, spirituality, creativity, friendship, sport, travel, acceptance are often of great importance in providing the context that allows people to move beyond a sense that their lives are stuck
Second, for many service users the loss of ‘social position’ that goes with using mental health services is profound. In fact, for some, this becomes a greater burden than the problems that brought the person to the services in the first place. This loss of social position is not something that can be overcome by users themselves or by professionals for that matter.
What both these insights point to is a need to think of mental health services that are not just ‘in the community’ but that somehow involve the community. There is a growing recognition of the importance of what might be called ‘community development’ approaches to mental health: working with local communities to develop a greater sense of ownership of the mental health agenda. A good example of this is the Sharing Voices Project in Bradford which was researched and reported on by the Sainsbury Centre a couple of years ago. If we take a community development approach to mental health seriously, we can expect to see very different sorts of services emerge in the years to come.
Most importantly, this revolution has profound implications for how we conceive of our relationship with the service user movement.
We will have to start moving from consultation to collaboration.
Positive implications for our profession
There is no doubt that there are real challenges in this agenda for us as a profession. The user movement is here to stay. Have no doubt about it! It might be unwieldy, unmanageable and contradictory at times. But it is growing and developing. In fact, it is going from strength to strength. Our society, our economy our culture are also changing.
I actually think that psychiatry is up for this challenge (in Britain and Ireland at least, having been in the US recently, I’m not so sure about the situation there). I have seen our college change dramatically in the 25 years I have been involved with it. Under the leadership of our recent presidents: John Cox, Mike Shooter, Sheila Hollins and now Dinesh there has been a growing acceptance that active collaboration with service users is important, an orientation towards a recovery agenda has emerged in many branches of the college, and there have been serious moves to reverse the penetration of the interests of the pharmaceutical industry into our meetings. I am also aware that in the real context of clinical work, many psychiatrists actually work with an orientation that is very close to what I have outlined.
I am not naïve. I know very well that there are forces pushing in the opposite direction.
One of the most positive advantages for practising psychiatrists from a partnership/recovery agenda relates to the question of responsibility. As long as we claim to possess a predictive science of the mind, a science modelled on the rest of medicine, and we de-emphasise the importance of contexts and social worlds, then it is not surprising perhaps that the public, the press and politicians see us as somehow responsible for the actions of patients we treat. I think this sense of being held responsible for things we cannot control is one of the greatest burdens of our profession at the moment.
Just as the historical task for surgeons was to find a way of safely opening the body without killing the patient, and the task for paediatrics was to develop a form of medical understanding that recognised the major differences between the developing body and the adult body, so too the historical task for us is to develop a medical discourse that is adequate to the nature and reality of the problems that we are tasked to deal with.
There is, I believe, a growing awareness that they will never be captured in the same logic and idiom of discourses that have to do with problems with our livers and kidneys.
If we accept this, then we are into talking about a new identity for the psychiatrist of the future:
a medically trained person who can negotiate with different understandings of madness and distress,
who is comfortable with un-predictability and ambiguity,
who has been trained in a range of technologies but who understands and is comfortable with their limitations,
who is able to bring the benefits of medicine to the lives of those who suffer mental distress without assuming that mental states can be grasped with the same causal logic that we use to understand the workings of our livers or lungs
who sees the importance of working locally with service users and their organisations to create a different sensibility about mental illness.