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

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 reasonFocus on the self The Great Confinement Sciences of the mind Depths of the interior Psychiatry Exclusion of Unreason Technical solutions to human problems Phenomenology Psychoanalysis

Technological Approach Medical model 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 Discourse centred 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