Critical psychiatry and post-psychiatry

Critical psychiatry has become an international movement during the last couples of decades of the 20^th century and the beginning of the new millennium, due to changes in national policies on mental health care, and the emerging voices of user organiza-tions (Thomas & Bracken, 2004). Thomas & Bracken (2004), two spokespersons for critical psychiatry, describe a change in British mental health policies going away from paternalistic approaches in the health services in favour of more democratic health service that recognizes individual self-determination for the service user. In addition, the new British healthcare recognized social, cultural, and economical aspects of health issues. Thomas & Bracken (2004) argue that the rise of the user organizations and the change in health policies do not occur as singular events from within a vacuum, rather they are part of the globalized worlds of mass medias, with an emphasis on individual freedoms and consumerism.

One classical study made a critical point about the subjectivity of diagnoses that have been part of the inspiration for the critical psychiatry movement (as described in Double, 2002): In 1973, Rosenhan conducted a study in which eight pseudo-patients told they were hearing voices in prior of admission to different hospitals. At admission, and for the rest of the experiment, however, the pseudo-patients acted normally, answering honest to all questions. All of the pseudo-patients were attributed with psychiatric diagnoses, and seven out of eight were diagnosed with schizophrenia (Rosenhan, 1973).

Based on the findings, Rosenhan speaks rather critically about the directedness of the observing health professionals, and the centrality of the psychiatric circumstances for determining diagnoses:

It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals. The hospital itself imposes a special environment in which the mea-nings of behavior can easily be misunderstood. […] Where they failed, as they sometimes did painfully, it would be more accurate to attribute those failures to the environment in which they, too, found themselves than to personal callo-usness. Their perceptions and behavior were controlled by the situation, rather than being motivated by a malicious disposition. In a more benign environment,

one that was less attached to global diagnosis, their behaviors and judgments might have been more benign and effective. (Rosenhan, 1973, p. 257)

Further Rosenhan argues that the tremendous perspective on diagnoses goes in the way for the actual therapy: ‘The consequences to patients hospitalized in such an environ-ment – the powerlessness, depersonalization, segregation, mortification, and self-la-beling – seem undoubtedly counter-therapeutic’ (Rosenhan, 1973, p. 257). I agree with Rosenhan in that a mental healthcare that removes the attention away from the services users’ actual challenges, life situation, and resources, in favour of diagnostic labels, is not necessarily a healthcare that provides the best treatment as possible.

Thomas & Bracken (2004) give credit to Ingleby (1981) and colleagues as central to the rise of the critical psychiatry movement. About Ingleby’s (1981) work, Thomas &

Bracken (2004) states the following:

The underlying premise of Ingleby’s ideas is that mental illness is a political issue. Although he refers to Foucault, his book was written before Foucault’s ideas had made their full impact. Ingleby accepts the existence of states of profound suffering and alienation seen in psychosis, but questions the interpre-tations psychiatry makes of such states. He argues that we can best understand conflicting viewpoints about the nature of madness in terms of underlying philosophical systems, and that these systems of thought are ultimately driven by moral and political considerations. Thus, his analysis is conceptual rather than empirical. (pp. 362-363)

In the same way that postmodernist theories have criticized modernism, post-psychiatry challenges the bio-medical modernity that derived from the modern culture. Included in the critique is the view that the biomedical comprehension of mental illnesses is built on a narrow approach to science and knowledge, due to the empirically orientated understanding of truth, within modern discourses. Modern psychiatry is founded on positivism, which base knowledge on empirical observations and explanations of cau-sality, and is therefore not compatible with the understanding of the psychological world of human beings (Thomas & Bracken, 2004). In addition, for a long time the discoursive rules of causality seeking have not really acknowledged other theoretic models, which take into account different sides of the human existence. Researchers more in line with phenomenology and hermeneutics are perhaps more comfortable with the notion that not everything can be explained through universal causalities, especially not human beings. Instead of observing the behaviour of the service user, the phenomenologist is perhaps more interested in the essence of the experienced psychosis. The critical

theorist is perhaps interested in the repressing cultures that facilitate mental health challenges and difficult life situations for repressed groups of society, in favour of keeping the psychiatrists well positioned within the middle class. The postmodernist theorist may perhaps question the idea of the whole psychiatric institution per se, and perhaps discard the concept of diagnoses in favour of looking at individual human beings, with individual, local challenges, depending on social circumstances. Although superficial, and maybe even close to a caricature, at least the examples mentioned above depicts several reasons for including different perspective on both mental health and mental healthcare, more than what has seemingly been the case for the last century or so. And even though modern mental healthcare is not necessarily stuck within an all-in posi-tivistic bubble, I support the critical voices that call for a wider perspective on mental health and mental healthcare, in which person-centred approaches to recovery count at least as much as universal rules of causality counting on singular variables.

Inspired by critical and postmodernist theory, post-psychiatry seek to look past the seemingly neutral position of mental healthcare, in order to reveal that modern psychi-atry is a result of ruling discourses, in which a certain hierarchy is maintained:

Our essential argument is that the modernist agenda that shapes current thinking and practice in psychiatry serves to disempower patients, while justi-fying professional authority. Thus, there is a need for a fundamental rethink of psychiatric theory and practice if we are genuine about a move to ”user-cen-tered” or ”recovery-oriented” services. (Bracken & Thomas, 2013)

According to Bracken & Thomas (2013) there is fundamental need for new approaches in order to apply health services that offer the best treatment as possible. Post-psychiatry is part of the broader critical psychiatry movement, but with the ‘central claim that many of the problems of psychiatry rise from its identity as an enterprise of modernity’ (Thomas

& Bracken, 2004, p. 368). The post-psychiatry movement seeks to understand why and how psychiatry has come to its status quo, and seeks to make use of this knowledge to take mental healthcare into new directions.

Critical psychiatry, including post-psychiatry, is not an anti-psychiatric movement, but a movement that seeks to limit the bio-medical psychiatry, and make room for social and cultural understandings of complex mental health difficulties (Double, 2002; Thomas &

Bracken, 2004). Double (2002), another spokesperson for critical psychiatry, describe how certain diagnoses have skyrocketed in few years together with the use of phar-maceutics, and argues that the large amount of children diagnosed with ADHD is really a result of children being bored, frustrated, anxious, abandoned, or stressed. A study from Norway supports Duncan of his critiques towards the increasing medicalization

of children behaviour: out of half a million children, the researchers found significant correlations between subscriptions of ADHD medications and birth month (Karlstad, 2017). Children born in the first half of the year were diagnosed and treated more rarely with ADHD medications than did the children born in the autumn half of the year. The study reveals an unbalanced prevalence of ADHD diagnoses, which indicates that the social circumstances are an important variable in the question of ADHD; perhaps it is simply harder for the youngest ones in the classroom to sit still, pay attention, and com-prehend the content of the education. A Norwegian doctor and researcher, Ole Petter Hjelle (2018), argues that we often put diagnoses and prescribe medication, especially for ADHD, when it is obvious that physical activity is more effective: From an evolu-tionary perspective, Hjelle (2018) argues, children are really not made for sitting still.

The case of ADHD is only meant as an example, but it is a describing one, for what I believe that the critical psychiatry movement mean when they want to limit the increas-ing role of psychiatry in modern cultures. I do believe that symptoms correlatincreas-ing with ADHD can really be frustrating, and even painful, for those who struggle with them. And I do believe that medications can help in many of these cases. I still believe that we to often run to pharmaceutics, when 1) other interventions may be at least as effective, and 2) the symptoms are not necessarily biological founded, but rather a result of bio-logical bodies within specific cultural frames. According to Double (2002) there is also a development similar to that of ADHD when it comes to medication as treatment for depression, anxiety, social anxiety, PTSD, and OCD.

Thomas and Bracken (2004) (referring to Miller & Rose, 1986, two voices inspiring the critical psychiatry movement) make a point of how Foucault’s theory of government may be used as one way of understanding mental healthcare and diagnoses. We govern our selves within a language that is known for us, and we relate to the concepts we are familiar with. Terms found in mental healthcare are part of the ruling discourses that enable us to process ideas of mental health. This may be one of the reasons that clinical terms and diagnoses are used in the daily language, such as when people say that they are depressed when they are sad, and that they have anxiety when they are uncomfortable. Thomas and Bracken (2004) argue, in line with Foucault (2002), that such mechanisms of self government helps to maintain the power-relationships that exalt the status of the bio-medical psychiatry. If people mention ADHD each time a child is running around or finds it hard to sit still on a wooden chair, then this attitude helps to maintain the same repertoire of thinking. And as a consequence, the next hundred times children act the same way, it is easy to resort to the same pattern. If an ADHD diagnosis is what we think of, it is probably also what we look for, at least more than what comes ‘naturally’, if the term was not a big part of our daily language in which we comprehend the world.

Mental healthcare has changed throughout history, as we have also seen through the works of Foucault. And the modern bio-medicalised psychiatry has not always been regarded the best way to handle mental healthcare, although the status of the psychi-atrists have been somewhat stable since the beginning of the modern age (Bracken &

Thomas, 2013). What some critical voices wish, is that we go back to a mental health-care in which social and psychological perspectives are considered important aspects of both health and treatments:

Psychiatry needs to return to a biopsychological view to limit its excesses—

in other words, it needs to temper and complement a biological view with psychological and social understanding, thus recognising the uncertainties of clinical practice. Such an approach conforms to the new direction that has been called “post-psychiatry”. (Double, 2002, p. 903)

I support the critique of the modern mental healthcare brought by the critical psychi-atry movement, in terms of the argument that are outlined above. I also support the notion from post-psychiatry that the status of mental healthcare today is unbalanced in favour of a positivist bio-medical perspective, due to modern discourses of empirical observations and causality. I believe that we need to include social and cultural aspects of mental health to a much greater extent in order to provide mental health services that promote health.