Lecture for the Mind Conference, November 2002

There were two compelling interviews on radio 4 with two survivors of mental health services in the same week in February 2001. One was with Rufus May, interviewed by Fergal Keane on his programme 'Taking a Stand'. The other was with Kay Sheldon, interviewed on 'Women's Hour' by Jenni Murray .

The edition of 'Taking a Stand' won two of the nine Mental Health Media Awards in October 2001 (www.mhmedia.com/press/awards2001.html). These were for the Factual Radio Award for the programme and for the Survivor Award for Rufus May. A record number of people apparently contacted the BBC after the programme.

Rufus May is a clinical psychologist in Bradford. At the time of the interview he was working in Tower Hamlets in London. When introducing the interview, Fergal Keane suggested that a clinical psychologist that takes a stand against the widespread use of medication in mental illness is not perhaps all that unusual these days. However what was unusual was that Rufus May had taken this stance for his experience of mental health services as a patient. In the programme he told how he had kept quiet about his experience of mental health problems to be able to undertake his clinical psychology training.

He also recounted some of his experience as a survivor. Asked to explain his mental health difficulties, he said:-

Rufus did not minimise the significance of and risk involved in his experiences. He talked about when he once left hospital to go down to the railway:-

Kay Sheldon was also candid in her interview on 'Woman's Hour'. Kay received an out-of-court settlement of £58,000 from Norfolk Health Authority after being wrongly treated for schizophrenia over a period of almost 15 years (www.mind.org.uk/press-room/press_page.asp?ID=96). She was detained several times against her will under the Mental Health Act. Kay knew that she did not have schizophrenia and that her treatment was wrong, but she could not get people to listen. The only course of action she found she could take was a medical negligence claim.

Simon Foster, Mind’s Principal Solicitor when commenting on this case said:

The fact that both Rufus and Kay were able to talk about their experiences as survivors is inspiring. What they have in common is that they are willing to use their stories as a basis for changing mental health services for the better.

To quote from Rufus:-

Similarly for Kay, in her own words:-

This is the kind of thinking about psychiatry that I want to encourage in this lecture. I have called it "critical thinking". However, I do not want you to misunderstand me. The word "critical" tends to have a negative connotation. It tends to imply being antagonistic. This meaning may be the first one that you will find in dictionaries. In this sense, critical means "inclined to find fault, or to judge with severity."

However, 'critical' also has other meanings, such as being "characterised by careful, exact evaluation and judgement." Also, it may have something to do with a crucial turning point, in this sense meaning "of the greatest importance to the way things might happen."

It is in these later senses that I am using the word 'critical' in relation to psychiatry. Not that I am saying we should not think negatively about psychiatry at times. Psychiatry is not always the solution to mental health pronlems; it may be part of the problem itself. However, critical psychiatry wishes to avoid the polarisation that was encouraged by regarding criticism of psychiatry as "anti-psychiatry". The language of opposition has obscured how much there has always been a strand within psychiatry that has attempted to avoid objectifying the mentally ill.

I am a member of the Critical Psychiatry Network (www.criticalpsychiatry.co.uk) that was formed in Bradford in January 1999. The network exists to provide a forum to develop a critique of the contemporary psychiatric system - critique in the sense I have just defined. Essentially, we believe that it is not necessary to justify psychiatric practice by postulating brain pathology as the basis for mental illness.

The problem is that psychiatry has become so dominated by biomedical thinking that the stance of the Critical Psychiatry Network is seen as almost heretical. The assumption is commonly made that schizophrenia and manic-depressive illness are diseases of the brain, just like Parkinson’s disease and Alzheimer’s disease - without always being absolutely clear what this statement means. It is very widely accepted that mental illness is due to a chemical imbalance in the brain.

For example, the guide for patients and their families on major depressive disorder, called Treatment works (http://www.psych.org/clin_res/MajorDepressive.pdf), produced by the American Psychiatric Association from its practice guidelines, states that:-

This statement in fact leaves open the possibility that chemical imbalances may be results rather than causes of depression. This subtlety may be lost in the simpler message that chemical imbalances cause depression. Moreover, the guide goes on to make clear that:-

So even if the guide is not going as far as saying that chemical imbalance is the cause of depression, which it may wish it could do, it is sure that correcting the imbalance is what reverses the depression. Nothing could be simpler. This statement is made with the authority of the American Psychiatric Association.

However, it seems that the facts may at least not be as clear and simple as this. Moreover, there are implications for the doctor-client relationship. For example, Kenneth Silk, a psychiatrist speaking at the 2000 annual meeting of the American Psychiatric Association at a symposium led by the outgoing President of the Association (www.psych.org/pnews/00-06-16/tool.html), advised psychiatrists that:-

So it seems that not all members of the American Psychiatric Association agree with the basic emphasis on chemical imbalance as the cause of mental illness. Personally, I would ask you to consider an alternative hypothesis to brain pathology. The kinds of processes that underlie mental illness at the biological level may be no different from those that produce thoughts, feelings, and behaviour among "normal" people. The explanatory model of mental illness that is used in mental health work is important and does affect the way people are treated.

What I am suggesting is that the biomedical hypothesis is uncritically accepted by too many people. The notion that mental illness is caused by a chemical imbalance which can be corrected by medication needs to be looked at critically.

Over recent years, it has become popular to regard critical thinking as something that can be taught. Critical thinking is seen as the art of taking charge of your own mind. If we can take charge of our own minds, the theory is that we can take charge of our lives; we can improve them, bringing them under our command and direction. Critical thinking involves getting into the habit of reflecting on our inherent and accustomed ways of thinking and leads to action in every dimension of our lives.

There are said to be universal intellectual values in critical thinking. These are clarity, accuracy, precision, consistency, relevance, sound evidence, good reasons, depth, breadth, and fairness. Everyone falls into poor habits of thinking. What matters is finding ways out of them and setting higher standards for our thinking. We need to overcome the obstacles to effective thinking in our lives and direct our thinking towards our most important goals and purposes. The views of experts need to be critically assessed. There are practical techniques for making more intelligent decisions that can be learnt. Furthermore, applying critical thinking to life's key decisions has ethical implications.

How could we go about applying these principles to psychiatry? Let's return to the case of Kay Sheldon to find an example. One of the pieces of advice she was given was the following:-

Kay now has two healthy children and lives with her husband. She ignored medical advice. She started from the first principle of critical thinking, which is to critically assess what the experts are saying.

Wherever does the advice come from that she was given? It is commonly believed that schizophrenia, which was the diagnosis that Kay was given, is a genetic condition. This is because schizophrenia runs in families. By this is meant that schizophrenia occurs more commonly than average in families of people who have a diagnosis of schizophrenia.

We need to use our critical faculties to realise there may be a common logical fallacy here. A widespread mistake is to implicate genetic transmission merely because mental illness runs in families. Genetic transmission is not the only way in which traits are passed on from one generation to the next. We learn in families and imitate others. How we are now is determined by experiences we have had in the past. Environmental factors are important, not just genetic influences.

So there is no necessity that Kay would have defective children, even if she was correctly diagnosed as schizophrenic. Children who are presumed to have a genetic tendency for schizophrenia because one of their parents had the diagnosis, may well be alright if brought up in an undisturbed family. In fact there is evidence for this state of affairs from adoption studies.

The example of the advice given to Kay Sheldon also highlights that the application of critical thinking has ethical implications. Uncritical dogmatic statements have led to the association of research into the genetics of schizophrenia with eugenic campaigns to prevent the propagation of the apparent genetic predisposition to schizophrenia. The advance of political correctness has obviously not led to such views being too far from the surface. I know that Kay Sheldon is not the only user of mental health services who has had similar advice from psychiatrists over recent years.

I want to take our analysis of critical thinking one stage further. We need a theoretical approach. We need to ask why people are so ready to adopt the biomedical model in psychiatry. We need to see how that system of collective beliefs legitimates various power structures.

Critical theory has distinguished itself through its critique of science as positivism. What I mean by this is that there is a tendency to believe that natural science is the only valid mode of knowledge. Psychiatry is said to have advanced over recent years in its understanding of the mind and mental illness. It suits people's expectations to think that psychiatry has found the solution to mental illness.

Scientific abstractions have been enormously successful in producing technological advances, so it may not be surprising that a prominence is placed on the scientific scheme of objective fact. However, verifiable knowledge about the mind is as essential as natural facts. The importance of human self-knowledge should not be undermined in tyrannical thinking about the brain.

The primary aim of psychiatric assessment should be to understand the user of mental health services as a person. The danger of saying that mental illness is a brain disease is that it reduces people to brains that need their biology cured. Critical theory promotes an approach to personal and social analysis that recognises personal and social problems and promotes personal and social change.

Let us return to the case of Rufus May for an example. Rufus is very keen to make sense of people's psychotic experiences. This is how he works as a clinical psychologist. As far as he is concerned it may be possible to make sense of the most disturbed of experiences.

Psychotic experiences may seem meaningless and incomprehensible. This is why we are inclined to regard them in an impersonal way. We tend to attribute them to a disturbed brain, as they seem 'other' and separate from the person. To avoid engaging with someone, who it seems could not possibly be so mad and crazy, we impute a chemical imbalance or some other brain abnormality.

Rufus' attempt to deal with problems at a personal level leads to him looking for alternatives to medication to help people. In the radio interview he talked about when he managed to come off medication himself.

We all want to have easy answers to our problems. Expectations that medication will help are understandable. I do not think Rufus would necessarily recommend his way of coming through his psychosis and coming off medication to other people.

A critical frame of mind is required to question the evidence of clinical trials and to take on the forces of the medical establishment and the pharmaceutical industry. Challenges to the orthodoxy of mainstream psychiatry are suppressed. A critical stance in psychiatry demands going to the root of the foundations of its practice. Such an approach may be seen as a threat, but it is also an opportunity for growth and a recognition of the potential for change.

What I am arguing in this lecture is that psychiatry needs to be self-conscious, self-critical and non-objectifying. Psychiatry needs to be open to the uncertainty of human action, rather than seeking to fix it in its biological substrate. I am trying to release psychiatry from its institutional constraints, so that free of the power strongholds currently vested in biological psychiatry, opportunities for improvements in the treatment of psychiatric clients can be provided.

This may sound like an idealistic agenda. And I think there is a sense it which it could be seen as naïve. Psychiatry has always had a biological bias. Historically there has always been this tendency. However, I think the ideological basis of psychiatry has swung even more strongly towards the biological side over recent years. This imbalance does need to be redressed.

We need a renaissance of what I call a biopsychosocial, rather than a biomedical, understanding of mental illness and its treatment. This approach looks at the whole person, their life and circumstances, and not simply into their brain. Surely it is not such a radical agenda to propose a more complete assessment of people's mental health problems and more recognition of the social and psychological aspects of those problems in the treatments we offer. Of course there is a biological component to mental illness, as there is in all behaviour, whether ‘normal’ or ‘abnormal’. The point is that the kinds of processes that underlie mental illness at the biological level may be no different from those that produce ‘normal’ thoughts, feelings and behaviour among people without a diagnosed mental health problem. That is a very different working hypothesis than mainstream psychiatry's reductionism and has implications for mental health practice.

The implications for clients are that services should become more personal and more attempt should be made to understand their problems. Treatments should become less reliant on physical approaches, such as ECT and medication. The expertise of users and survivors of mental health services will be acknowledged. There will be more awareness of how a biomedical orthodoxy imposes a particular worldview.

Anti-psychiatry came to have a poor reputation. Critical psychiatry needs to recognise its roots in ant-psychiatry but to move on to its positive agenda.

One of the ways in which there may be a shift in the directions I have described is to recognise the value of critical thinking. I have tried to make this case in this lecture. Critical thinking should be seen as a positive force. We can learn how to think critically, and as a theory we can rethink the basis of psychiatric practice. I hope I have managed to encourage you in your critical thinking about psychiatry.