28 de agosto de 2008

The London Society of the New Lacanian School
Psychoanalysis in Conversation
Towards the “Rally of the Impossible Professions: Beyond the False Promises of Security”

London, 20th September 2008

Joanna Moncrieff in conversation with Roger Litten

Joanna Moncrieff, psychiatrist and one of the founder members of the critical psychiatry network [1], talks to Roger Litten of the London Society of the New Lacanian School

RL: Perhaps we can start by sketching out 3 questions: your own position and how that led you to the Critical Psychiatry Network, how that Network came about, and some of the issues that this work has led to.

JM: Well, in common with many people, I went into psychiatry because I found medicine boring and tedious. Psychiatry offered me the possibility of something more philosophical, political, and sociological to think about - how we view madness and how we classify disturbing and deviant behaviour. So I20was reading Thomas Szasz and R.D. Laing when I was at medical school 8 0 they were the only ray of interest I could find in the subject area. What led me to the Critical Psychiatry Network was the complete disparity between my experience with patients and what the text-books had led me to expect. The books and journals said ‘there are this number of discrete mental disorders for which you give this specific treatment and then people get better’. This was just not my experience. For example with anti depressants, I saw people who had been taking them for years and didn’t seem better. I couldn’t find any evidence that these were actually helpful to people. Soon the whole evidence base for psychiatry seemed to me to be up for question.

RL: This was before ‘evidence base’ had become a widespread notion.

JM: Yes, this was in the 90s and one of the reasons that I was so successful with my early publications was because the=2 0notion of Evidence Based Medicine was just coming in and20the Cochrane collaboration had just started. I was able to publish because of the enthusiasm for EBM. It certainly worked in my favour in the early days. But it is a double edged sword. The more I looked into the research literature the more holes I saw in the standard accounts of psychiatric treatments. So I wrote some papers on lithium and drugs for alcohol treatment – the latter were being pushed by the pharmaceutical industry and they were really changing the whole area of addictions. This was an area where psychotherapy and therapeutic communities had been the main approach, but there had always been a very strong biomedical school of explanation for addictions. Nevertheless the main forms of treatment were psychological and psychotherapeutic. I could see the pharmaceutical industries coming in, capitalising on the want that people had for a biological explanation, which was reinforced by the availability of medication. The very idea that there is a physical treatment available reinforces the belief that addiction is caused by discreet identifiable biological abnormalities…

RL: … which is like a model of supply and demand. If the supply is there it creates the demand. We20almost need a strong marketing paradigm to expla in the persistence of some of these ideas.

JM: I would say we need a political paradigm: the psychiatric profession needs to justify their medical training; the pharmaceutical industry needs a biological explanation to sell their drugs; and to a certain degree the State prefers it because it avoids bringing this degree of complexity into the political and democratic arena.

RL: These are three major factors that bolster what counts as a scientifically validated basis of mental illness. JM: Ben Goldacre [2] who I met with briefly recently wanted to emphasise how it is the public that often demand biological explanations and medical treatments, but I think the main impetus has come f rom the institutions mentioned, who have helped shape public attitudes and expectations.

RL: Can we hook that around the development of the Critical Psychiatry Network?

JM: Yes, as I said, there was a discrepancy between my experience and the literature, and when I moved to the Institute of Psychiatry I linked up with five or six others who had similar views - three in particular. We began by organising a series of talks: Simon Fernando, Nikolas Rose, the Maudsley User Group came along, and that’s how it started in London. We had informal meetings based at the Institute of Psychiatry where we discussed papers and books. It sounds ironic, but it’s a very mixed place and some of the senior people are quite sceptical and were quite sympathetic to us. My boss Anthony Mann was supportive and even Robin Murray likes having a debate - he thought it was good that there was another point of view. He didn’t come to our meetin gs, but he20was supportive. So in some ways it was quite a facilitating place, I never felt censored there. So we started them once a month for about a year, and then we were contacted by Phil Thomas and Pat Bracken in Bradford who were part of a little group of like-minded people. They got in touch because the Labour Government were going to review the Mental Health Act. It had been on the cards for a while, but the Conservatives hadn’t got around to it. The Government wanted the new Act to introduce compulsory treatment in the community. We wanted to oppose that idea. We felt it was important that the ‘case against’ was articulated, and to make the point that the objection was coming from within psychiatry. Shortly after this was announced there was the case of Richard Stone – the man accused of killing a woman and her daughter in Kent. He had been released from psychiatric hospital just prior to that because he was deemed to be an untreatable psychopath. That set in motion a whole line of activity in The Home Office who needed to find a legislative way to approach the problem. They came up with Dangerous Severe Personality Disorder – a category that could be dealt with under mental hea lth legislation.

RL: Who came up with it?

JM: The Home Office invented this concept – I don’t know that it’s included in any diagnostic manuals, but they came up with this concept of DSPD, presumably in conjunction with forensic psychiatrists who were liaising with them, advising them. And they set up a review to work out how people with a dangerous, severe, personality disorder could be detained or imprisoned using mental health legislation of some sort, and that process was merged with the MHA review. There then follows the attempt to medicalise DSPD, and a wish to use psychiatric legislation to introduce indeterminate detention with out trial.

RL: That whole que stion of the intersec tion of legislation with the clinic is very interesting. The diagnostic category was invented in the law first, then filtered through to the medical level without addressing the question of aetiology or treatment.

JM: Yes, the MHA review process brought it in: there was a bill published which had quite a lot to do with this category of DSPD, but the bill didn’t get through parliament in the end.

RL: You also get the idea that this theme has been generalised more broadly with the contemporary questions of risk and security. So there seems to be a link between the compulsory community treatment, and the shift towards preventative measures - a move away from dealing in detail with specific instances.

JM: Yes, a lot of sociologists have written about the risk culture: Bauman and Beck, for example. I think it is very much part of this. You can show that there are escalating numbers of people being detained under the Mental Health Act. The number increased a lot in the 1990s but people were not being discharged in any greater numbers by tribunals so there were more and more people being detained in hospitals…

RL: …at the same time psychiatry hospitals were being cut down...

JM: …yes, beds are being cut down. So the emphasis in psychiatry has changed considerably since I started. Now there’s a much stronger emphasis on risk prevention, or social control as it used to be called.

RL: In your own work you’ve identified quite precisely the redistribution of the role and status of psychiatry, the relocalisation of psychiatric treatment. You’ve looked at the effect of legislation on the status of those who are treated, and you’ve shown how this has involved a profound reorganisation of that whole domain in the last decade…

JM: … Stefan Priebe has traced this: ordinary psychiatric beds have been cut, but beds in secure units have increased, particularly in the private sector. So there’s a privatisation of social control going on. That has helped this whole political attempt to muddy the issues, and this mirrors, I think, the idea at the base of psychiatry: ‘Let’s hide this issue of social control, lets pretend its medical treatment, and if you privatise it as well it’s even more difficult to pin down.’

RL: … so it appears less political, it appears more arms length. I came across your 1997 paper, ‘Psychiatric Imperialism and Medicalisation’. It’s a nice summary of very complex themes. Let me quote you from the opening paragraph on the rise of institution of psychiatry: “Its function was to deal with abnormal and bizarre behaviour which without breaking the law did not comply with the advance of the new social and economic order. Its association with medicine concealed that aspect of social control by endowing it with the objectivity and neutrality of science. The medical model obscured the social process of deviance by locating problems in human biology …” In three sentences you have condensed a remarkably powerful nucleus.

JM: I wrote that when I was an SHO, a junior doctor. I wrote it for Soundings, which was then a new Open University magazine. It makes me feel sad as I sit here now in UCL! No-one would ever encourage me to write a paper like that today. I’ve got to write papers that get into the Lancet for the Research Assessment Exercise, so it’s difficult to find time and the outlets to write things like that which need to be written, which do actually get to the fundamental core of the issue…

RL: … and remain as valid if not more valid with the developments that have been built on it the past decade. The other useful point within that paper is the way that you trace the psychiatric treatment of depression in parallel with the psychiatric treatment of schizophrenia. The argument is far more powerful as you track the rise of the Defeat Depression Campaign and the use of the concept of depression to generalise treatment to the community at large. It moves the discussion away from a psychiatric notion of mental illness towards that of an emerging market…
JM: … and it makes a political message about what it is to be normal in modern society, which is very much tied to consumerism and neo-liberal ideals: encouraging people to aspire to be something different, to work harder, do more, buy more, and to always look for a quick consumable fix for every problem that they have.

RL: It certainly provides a quick and convenient short cut to the current situation in the psychological field with its growing emphasis on increasing access to psychological therapies [IAPT]…

JM: ... Yes, CBT ...

RL: ... and treatments of depression which are then heavily anchored in the Evidence Based Movement which obscures the social construction of what is at stake. By reminding everyone that they are not happy we see a self-perpetuating loop of promise and disappointment that creates demand and the proliferation of an industry.

JM: I meant to read up more on the sociology of consumerism. It’s important. It has become ‘a bad thing’ these days to put up with something. The idea that you might tolerate conditions that aren’t perfect would classify you as a bit stupid and certainly not a dynamic modern go-ahead person ...

RL: … especially if there are surgical fixes out there …

JM: … yes, the rise of cosmetic surgery is probably the best example of this, but I think that psychiatry with anti depressants and CBT is a similar phenomena…

RL: … depression is seen as a life style issue that can be solved by consumerism – if only you were more weal thy you’d be more happy. And the other side to this is the internalisation of a psychological deficiency: you are only depressed because you haven’t achieved self-fulfilment. Again, it’s a life style issue, but this time it’s because your attitude is wrong.

JM: To get back to the Critical Psychiatry Network - we met up with the group in Bradford and produced a document that we put into the review of the Mental Health Act. And then we started having regular meetings and were joined by other people from around the country,

RL: How many were you? JM: fifteen at most.

RL: I think it’s important to contextualise what is required to get something like that off the ground - not a cast of thousands.

JM: Yes there were between 10 and 15 people at that initial meeting. We organised conferences, the first one was around the review of legislation. Those have been well attended (the best was about 300 people). The audience has always been mixed, but included a number of other sympathetic psychiatrists. We have about 70 people on the email list, about 15 who turn up regularly at meetings. In the early days we tried to come up with a list of objectives, a sort of manifesto, which proved a difficult task. It was clear that we had things in common, but it was difficult to write something that everyone would sign up to. I did bat out some points that we could agree on: scepticism towards the evidence base, the biological basis to psychiatry, the=2 0efficacy of biological treatments, and an objection to the emphasis on coercion and medicalisation and the issues of social control.

RL: The diversity of voices within your group is probably your strength.

JM: We didn’t really need a manifesto actually. Duncan Double, a psychiatrist from Norwich, made us a great website and that’s a much better way of illustrating what we are about. You can put lots of different perspectives on there without everyone having to subscribe to everything.

RL: Yes, your website is important. Your involvement with the initial problem of the reform of the Mental Health Act produced valuable documents that are still available as a trace of the=2 0work you were doing. Part of the difficulty we all have is of keeping up with the political discourse ­– we are always one step behind. There are always full time bureaucrats generating proposals for this an d that! We can’t fight every single proposal, but it’s very important to have a trail that shows what we said at the time. What gets set out in opposition is more valid than any small modification made to the government’s proposals.

JM: One of my personal objectives for the Critical Psychiatry Network and for my own work is simply to create a record that there are voices opposing the mainstream view. I would say that in psychiatry quite a lot are not fully signed up to the mainstream view. I go round and do a lot of talks at education meetings and I rarely get a completely hostile response - almost always there is quite a large proportion of the audience that are sympathetic.

RL: I was speaking to Michael Po wer recently, discussing the rise of audit culture and the impact it has had on various professional domains, and he mentioned that there is a counter discourse out there but that there is nowhere for it to be inscribed. There are20questions and dissenting voices, most of all amongst those who are responsible for implementing the programmes. The auditors themselves are not that convinced, let alone anyone else!

JM: On the issue of audit, we are a registered stakeholder for the NICE process. I was dubious about whether we should be at first, as I have lots of doubts about the NICE process…

RL: …but those doubts don’t make it go away...

JM: No they don’t. We haven’t influenced the process, but by putting in objections and demonstrating the flaws in their arguments we have been able to highlight the vested interests at stake. We have been able to demonstrate that t hey are not just evidence based, that there are lots of different vested interests.

RL: This reflects our own problems in the field of the talking therapies. There’s an endless series of consultations, and our responses go in but that’s the last you hear before the next document comes out for consultation. There’s a growing cynicism about the process, which is clearly just one of justification for decisions already made. There’s the danger of co-option, of giving legitimacy, but if we don’t find ways of speaking out and registering somewhere the alternative is worse.

JM: Yes, it’s been a very interesting process. We may not have influenced NICE guidelines, but by making objections to their drafts, and demonstrating the flaws in their arguments we have been able to highlight the vested interest at stake, the fact that these are not simply evidence based, that it is not an objective process, and that they reflect all sorts of vested in terests. For example, with the depression guidelines, Duncan Double, Irving Kirsch, and I made the point that all their primary analysis was actually negative. They said themselves that the result was too small to be clinically significant, but then they went onto do secondary analysis on the same data! They wrote a detailed response to all our other points, but didn’t mention this ‘minor detail’! Irving and I wrote a paper for the BMJ which pointed this out - to their great embarrassment. I’m not sure it changed the NICE guidelines, but it has been publicly recorded that they actually ignored advice which pointed out the fundamental flaw in their analysis.

RL: The other side of that is the recent question about the pharmaceutical industry’s role in directing the research and suppressing or selecting the evidence base which is made available.

JM: And there are deeper conceptual issues. Is it right to have NICE guidelines on depression? Is depression a useful concept? We submitted some evidence in which Sami Timimi, a psychiatrist from Lincoln, makes a cogent attack on the concept of ADHD (also published in the BMJ). The NICE guideline committee have so far taken no notice whatsoever of his advice. Yet again it may not have made an impact on the guidelines, but it is recorded that there’s another point of view, and that the guidelines committee have taken no notice whatsoever even though we are a registered stakeholder.

RL: It becomes important to establish an alternative view just to say that this is not the only version of best practice. It becomes i ncreasingly necessary to say something about established best practice. It becomes ever more important to establish an alternative view, not just conceptually, but practically. To say that although this may be the dominant, or orthodox approach, it is not the only version. In order to say that although we don8 0t practice in that way, we are not unscientific, unethical or un-proven.

JM: The areas link up. The main problem with the NICE guidelines is that it is impossible to be completely objective in the area of the mind. There is not just one simple factual answer about how to deal with people who are distressed or disturbed. It is not like a liver disease or chest infection. In our discussions about the MHA review we had a meeting with Barry Turner (an academic layer and a very useful person to know). We were talking about what would happen when the new Mental Health Act conditions for compulsory treatment came into force. Some of us would like not to have to implement them, and we needed to know how we could defend our practice in those cases. We had a meeting with about 12 people, and we all agreed that there were good reasons for not coercing people in the community and we wrote that up and put it on th e website. It exists as a document for people who choose not to use those new measures (that have been added to the 1983 Act).

RL: This was a shift in the boundary between the forensic and the civil, and is an important shift in the boundary in the realm of psychiatry itself.

JM: My impression is that the criminal law is already overwhelmed: the police are overwhelmed, and that is one of the reasons why a lot of criminal proceedings are actually being shifted into the mental health field. For example, I have a number of patients who have committed very serious crimes, but I cannot get the police to prosecute them. I think that is another reason why these boundaries are being blurred, and psychiatry is increasingly being used to mop up the capacity that the criminal justice system cannot deal with.

RL: That provides a nice loop back to the construction of psychiatry as a profession in the first place.

JM: Coming back to the issue of professional practice, we’ve been having a debate recently about the use of forcible intramuscular injections of a drug called haloperidol as a method of rapid tranquilisation, in other words “restraint”. Some doctors have been criticised by their Trusts for trying to restrict its use, but we looked at various guidelines on the use of emergency sedation and it became clear that there was little evidence about the full implications of its use and no evidence that it was superior to other drugs. It is also well established that patients find haloperidol particularly frightening and unpleasant. So we hope that by having a discussion and preparing a position statement on it which we will publish on the website, we can support doctors who are criticised for trying to avoid this practice. It comes down to establishing that there is a body of professionals who can say what a variant of acceptable practice is.

RL: That’s relevant to a body such as ourselves: Lacanian psychoanalysis has had a very marginal representation within the field of the psychological therapies=2 0in general but also amongst psychoanalysts in the UK. The danger is that with the move to regulation we find ourselves on the margin of what is considered ‘best practice’.

JM: I was reading an interesting article by Terry Johnson - a chapter in a book on Foucault - he is suggesting that there was a contract between the state and professions to manage different forms of deviance, to manage areas of social life. The contract was that the professions would have autonomy (and this is Friedson’s theory of profession) in return for managing this difficult area of social life. Now, this contract is being reneged on by the government

RL: … renegotiated …

JM: Absolutely. The government are taking back... they are denying the professions their autonomy. They want to increasingly regulate the professions centrally themselves.

RL: And that opens up a complex and central field about the status of the experts in contemporary society, because government doesn’t actually want that responsibility at its door. The expert then gets caught in between.

JM: I wonder if that means that the basis of psychiatry is going to start to break down. It will become more obvious that this is just social control, and20the position of psychiatrist will become less tenable. This latest rise of psychological therapies is linked: less well-paid people are being asked to take on these difficult problems. This will change the nature of the problems, the nature of the treatment, and the nature of the contract - everything.

RL: That=2 0contract being rapidly rewritten, without any clear articulation of the possible consequences for any of us: practitioners and patients. Maybe you will write about this, although perhaps not as part of the RAE …

1. www.critpsynet.freeuk.com
2. Ben Goldacre is the Guardian’s ‘Bad Science’ columnist.
Summer 2008Transcript & Edit: Janet Low

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