Feature

Joined-up thinking

The division in psychiatry between care and control is being legally formalised by New Labour. Phil Thomas and Joanna Moncrieff explain why the coercive medical model should be rejected

New Labour’s ‘new’ look at mental health policy has some nasty surprises for those who had hoped for a new dawn of tolerance, understanding and social inclusion for those suffering from mental health problems. The government is proposing changes with serious implications for the rights of people who use psychiatric services. Although the National Service Frameworks contain positive developments, like home treatment, the government’s priority appears to be increasing coercion and control of those using mental health services.

The green paper reforming the 1983 Mental Health Act includes proposals for compulsory treatment in the community and is accompanied by a joint Home Office and Department of Health policy on people with so-called dangerously severe personality disorders (DSPD). If enacted, this would enable psychiatrists to detain such people indefinitely, even though they had committed no offence.

Compulsory treatment in the community and reviewable detention represent serious challenges to human rights, and these proposals have fuelled concern inside the profession. In January 1999, the Critical Psychiatry Network met for the first time in Bradford to discuss these issues. It has since made clear its opposition to compulsory treatment in the community and reviewable detention for people with DSPD.

The public is now more willing to question the role and authority of expert knowledge. As medicine has become more influenced by technology and science, it has lost contact with basic values of respect for the other person’s beliefs and preferences. This is particularly the case in psychiatry, where clinical neuroscience has driven a political agenda inflamed by distorted media coverage of high profile ‘failures’ of community care, and in which risk reduction is of paramount importance.

The result is legislation which attaches more importance to forcing people to take medication. Psychiatry has always been deeply split between care and healing on the one hand, and coercion and social control on the other. Government legislation, in shifting the balance away from care towards control, is making this split even clearer. No other medical speciality has the equivalent of the psychiatric survivors movement, confirmation of the coercive nature of psychiatry.

Critical psychiatry is part academic, part practical. Theoretically it is influenced by critical philosophical and political theories and it has three elements: it challenges the dominance of clinical neuroscience in psychiatry (but does not exclude it); it introduces a strong ethical perspective on psychiatric knowledge and practice; it politicises mental health issues.

Critical psychiatry is deeply sceptical about neuroscience’s reductionist accounts of psychosis and other forms of emotional distress. It follows that we are sceptical about the claims of the pharmaceutical industry of the role psychotropic drugs can play in the ‘treatment’ of psychiatric conditions.

Like other psychiatrists we use drugs, but we see them as having a minor role in the resolution of psychosis or depression. We attach greater importance to dealing with social factors, such as unemployment, bad housing, poverty, stigma and social isolation. Most people who use psychiatric services regard these factors as more important than drugs. We reject the medical model in psychiatry and prefer a social model which acknowledges the reality of living in a multicultural society characterised by deep inequalities.

The practice of critical psychiatry has important ethical implications. It is often difficult to work in the biomedical model in a way that respects and engages with the patient’s beliefs and preferences. What point is there in respecting the patient’s view if you believe that the main objective is to rectify a neuro-chemical imbalance in someone’s brain? The social model, on the other hand, recognises that the meaning of distress is culturally contingent, and that engaging with the person’s belief system and values is of paramount importance.

Critical psychiatry also brings a political perspective to mental health issues. The biomedical model locates distress in the disordered function of the individual’s mind/brain, and relegates social circumstances to a secondary role. This is problematic because it ignores the role of poverty and social exclusion in psychosis.

One of critical psychiatry’s most important tasks is the creation of a new dialogue between survivors, mental health service users and psychiatrists, a dialogue that recognises the value of different types of expertise. Psychiatrists are experts by profession, but service users are experts by experience. The best outcomes will only be achieved when the two types of expertise can work in alliance.

The government already recognises the importance of alliances between patient experts and health professionals in the area of chronic physical illness: it has established an Expert Patients’ Task Force to consider how professionals can work in partnership with expert patients.

We believe that this model must be applied to the field of mental health. We hope the government will not waste an excellent opportunity.

The Critical Psychiatry Network can be contacted via http://www.critpsynet.freeuk.com/