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
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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
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Psychiatry as a product of the
Enlightenment
The technological paradigm
Why we need to get beyond this
paradigm
Postpsychiatry: towards a posttechnological form of mental health
care
Roy Porter
Roy Porter
Kant
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‘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 thoughtprocesses, 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 moralistictheistic concepts to
definable naturalistic
mechanisms….’
Psychiatry and the Enlightenment
Age of Reason
Focus on reason
Exclusion of
Unreason
The Great
Confinement
Focus on the self
Sciences of the mind
Technical solutions
to human problems
Psychiatry
Depths of
the interior
Phenomenology
Psychoanalysis
Technological Approach
Medical
model
Cognitive
approaches
Technological Approach
Positivist forms of
social science
Main Assumptions of the Technological
Paradigm
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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
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‘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
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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?
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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
Social
position
Cultural
issues
Focus on
technology of
diagnosis and
treatment
relationships
Ethics and
values
Post-technological mental health
Training
priorities
Use of drugs
and therapy
Appropriate
Discourse
research
centred on:
-values/ethics
Service
-meanings/contexts
models
-relationships/power
Challenges to technological paradigm
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Postmodern culture
Changing understanding of technology
itself
Moves away from the embrace of
Pharma
Why Radical Change is Justified
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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
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Empirical evidence
Conceptual analysis
Political reasons
Ethical imperative
Psychiatry and Philosophy
Why Radical Change is Justified
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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
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‘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
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Rethinking psychopathology
A different understanding of
expertise
Training
Research
Service developments
Insights from Recovery Literature
1.
2.
3.
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
Relationship with service user
movement
From Consultation to
collaboration