Postpsychiatry: reaching beyond the technological paradigm in mental health care

1. Postpsychiatry: reaching beyond the technological paradigm in mental health care Pat Bracken Clinical Director, West Cork Mental Health Service, Ireland

2. 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

3. 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

4. Roy Porter

5. Roy Porter

6. 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’

7. 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)

9. 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’

10. 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….’

11. Psychiatry and the Enlightenment Age of Reason Focus on reason Focus on the self Depths of the interior Exclusion of Unreason Sciences of the mind Technical solutions to human problems Phenomenology Psychoanalysis The Great Confinement Psychiatry

12. Technological Approach Cognitive approaches Positivist forms of social science Medical model Technological Approach

13. 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.

14. 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).

15. 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

16. Why is Technological Paradigm dominant? • Cultural support: continuing dominance of ‘modernism’ within medical world • Patient expectations • Underscores professional roles • Pharmaceutical industry

17. Marketing Bipolar Disorder in Children

18. 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

19. 20th Century Psychiatry Focus on technology of diagnosis and treatment Social position relationships Ethics and values Cultural issues

20. Post-technological mental health Discourse centred on: -values/ethics -meanings/contexts -relationships/power Appropriate research Training priorities Service models Use of drugs and therapy

21. Challenges to technological paradigm • Postmodern culture • Changing understanding of technology itself • Moves away from the embrace of Pharma

23. Why Radical Change is Justified • Empirical evidence • Conceptual analysis • Political reasons • Ethical imperative

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

25. Why Radical Change is Justified • Empirical evidence • Conceptual analysis • Political reasons • Ethical imperative

26. Psychiatry and Philosophy

27. Why Radical Change is Justified • Empirical evidence • Conceptual analysis • Political reasons • Ethical imperative

28. 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.

29. 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’.

30. Implications for Psychiatry • Rethinking psychopathology • A different understanding of expertise • Training • Research • Service developments

31. Insights from Recovery Literature • Recovery often made through paths that are alternatives to drugs and psychotherapy • Importance of loss of social position that comes with being a service user • Community development approach

32. Relationship with service user movement From Consultation to collaboration