Postmodernism and psychiatry

We have found that ‘post-psychiatry’ ¹ tends to challenge our patience more than it does our ontological security. We agree with Bracken & Thomas ² in that ‘an increasing number of psychiatrists are seeking to work with different frameworks and to engage positively with the diversity of the user movement’. However, we doubt that post-psychiatry has much to contribute to this effort. Holloway's commentary ³ is generous with regard to the philosophical basis of the article. We believe that the application of the confused and confusing ideas that are known as postmodernism to psychiatric practice is deeply misguided and counter-productive.

The key contention in Bracken & Thomas's article is that organised psychiatry's recent attempts to form an alliance with service users and carers are inauthentic. A true alliance, according to them, requires that we abandon the biomedical perspective in general and descriptive psychopathology in particular in order to allow us to preferentially engage with radicals within the service user movement.

They briefly mention more conventionally minded service users and carers, but effectively dismiss their point of view. This apparent lack of respect for the diversity of opinion within the service user movement is entirely consistent with the postmodernist convention that everything, including ‘facts’ and ‘truth’, is relative. Where all perspectives are equally valid, the postmodernist is free to reject objectivity as an illusion, and to confine dialogue to the like-minded. For those of us who cling on to older humanistic ideas, the challenge in getting alongside patients is to take service users’ experiences and views seriously whether or not they coincide with our own. Choosing to align ourselves with one particular perspective is patronising and simply repeats the mistakes of the past.

There is an inappropriate modishness (not to mention a lack of self-awareness) in Bracken & Thomas's free use of the term ‘madness’. The word remains offensive to many service users, despite the fact that a minority choose to reclaim it. It is one thing for service users to define themselves as ‘mad’. It is quite another matter for mental health professionals to use such terminology. There is a parallel here with the reclamation of racist words by some Black people. There is no degree of alignment with anti-racism that makes it OK for White people to use these terms. Similarly, it is hard to see how the interests of people with mental illness are furthered by urging psychiatrists to embrace the language of bigotry.

Bracken & Thomas sustain their argument by caricaturing the biological-mechanistic approach and suggesting that it is the primary conceptual framework of psychiatry. They make assumptions as to how the profession might respond to the challenges of the more radical parts of the service user movement, but they do not reference these responses, presumably because no one has made them. Although this type of argument is common in postmodernist writing (the discourse is implicit, so the lack of explicit reference to it is irrelevant), it is hardly likely to be persuasive to anyone with a reasonable level of independent mindedness.

In a fine piece of postmodern doublethink, post-psychiatry seems to want to be both part of psychiatry and separate from it. Bracken & Thomas deny being anti-psychiatry, anti-medical or anti-scientific but they reject the existence of any objectivity that transcends a particular paradigm and they regard descriptive psychopathology as oppressive. The logical corollary of their rhetoric is that when we are helpful to patients, it is despite the fact that we are psychiatrists, not because of it. If this is the case, why involve doctors in the care of people with mental illness at all? It is simply implausible and logically inconsistent to suggest that a Royal College of Post-Psychiatrists would somehow shrug off the encultured baggage of the doctor-patient relationship to lead us to a better place where the biomedical is replaced by something which is unspecified, but nicer.

A significant part of mainstream British psychiatry has long been working to develop a more humanistic, relevant form of practice that seeks to help people to solve problems in their lives rather than simply fixing problems in their minds or their brains. Biological research and treatments in psychiatry are necessary in this endeavour, although it would be foolish to deny that there is a problem when they dominate. Indeed, it was the then president of the American Psychiatric Association (not himself a post-psychiatrist, we believe) who complained that too much psychiatry followed a ‘bio-bio-bio model’. ⁴

Post-psychiatry is a tendency within the Critical Psychiatry Network, a small group of psychiatrists united mainly by their dissatisfaction with the status quo. We accept that there is a great deal wrong with the status quo, but we choose to put our faith in ordinary mental health professionals and service users who have worked steadily to change attitudes and to try to develop better, more user-friendly psychiatric services. This seems more fruitful to us than self-righteous separatism.

Psychiatry is having something of an identity crisis at present. Under rather different circumstances, Gramsci ⁵ wrote: ‘The crisis consists precisely in the fact that the old is dying and the new cannot be born; in this interregnum a great variety of morbid symptoms appears’. Despite its good intentions, there is little chance that post-psychiatry will achieve much by suggesting that a set of inconsistent and logically flawed ideas can renew the profession. Like Sokal, ⁶ we believe that ‘truth’ and ‘facts’ are important because they are one of the few weapons that the weak have against the strong. Post-psychiatry is a distracting irrelevance. The real task is to shift the intellectual centre of gravity of the actually existing profession.