What is Psychiatry?
I was led to this colloquium by a tweet from Medical Humanities – a tremendously active and inspiring bunch of people at Durham University – and thought I would enquire within. It was the third part of a travelling symposium marking the centenary of Karl Jaspers’ foundation of psychopathology as a science in its own right. (Jaspers, 1913)
In the few weeks preceding it, there had been a week-long summer school in Oxford entitled Philosophy of Psychiatry: Mind, Value and Mental Health. This was followed by the 15th Institute for Neuro-Physiological Psychology (INPP) conference/travelling three-center UK Symposium, the first one-day seminar of which was held in Durham and titled Current and Future Applications of Phenomenology in Psychiatry. This included presentations such as ‘Rethinking the First Person in Phenomenological Psychopathology’ and ‘Incomprehensibility: A New Ethics for Psychiatry’. The second seminar, at King’s College London, was entitled Conceptual Issues and the DSM. Sessions there included ‘The Definition of Disorder in the DSM: Evolving but Dysfunctional’ and ‘Lost in Translation: Dysfunction and Domains’. I was to attend the third part of the Symposium in St Catherine’s College, Oxford. The dominant theme linking all three events was (and still is) ‘Making Change Happen’, and how philosophy and psychiatry can work together to achieve this.
Back in January I was asked to provide a 100-word autobiography/declaration of interest and passed the first (and only) test! Then hefty reading material started to appear in my inbox – some surely only decipherable by the initiated. Highly intrigued and appetite whetted I set off at a punishing 4.30 am for Oxford one bleary July morning and was for the next two days buried in a fabulous mix of ideas, thoughts, secret languages, buzzy presentations and edgy controversy – all adding up to a really mind-changing experience.
Not being a philosopher or a psychiatrist I guess I, as A.N.Other, would have positioned myself with the service user/survivor cohort – if pressed. I began to boldly declare myself as an ex-psychotic (for that I am) as I found the environment a safe and trusting one. Swiftly I realized that my lack of knowledge of academic philosophy was something of a hindrance, as some of the presentations were so arcanely worded that only the inner cabal could decode them. But nevertheless nobody made me feel at all deficient and the atmosphere was one of huge support and good will; I even summoned courage from somewhere to be able to feed back to the hall after the group sessions.
Standout moments for me included the patience and kindness of academics within the groups, highlighting the moral courage of the survivors in sharing their stories – and how possibly the psychiatric community could follow suit. Off–piste and outside the formal sessions, I attended an amazingly delicious conference dinner at which I talked to Anke Maatz, a young trainee psychiatrist from Zurich, breakfasted among European philosophy teachers from Lublin and Prague, lunched with a PhD student from Hearing the Voice and a researcher for SANE and bonded with Alicia Monroe, Dean of Tampa medical school in Florida. I was enlightened by conversations with Sanneke de Haan on working with OCD patients who receive deep brain stimulation, and explored the ethics and outcomes of this intervention. Staying with me too are Nev Jones (inter alia a US philosopher from DePaul University, USA) and her fierce but principled calls for alternatives to hetero-normative language, highlighting the dominance of men as main speakers at upcoming conferences.
The power of the poster presentations included a graphic representation of a state of breakdown by Gay Cusack from Australia, calling out for the work of post-psychiatrists Bracken and Thomas. I was haunted by an eerie film presented by a Social Sculpture DPhil student and local psychiatrist Dr. Helena Fox which took us through an asylum-like setting to an intricate study of folds of bedclothes and gradual revealing of hands within. Topics flew around – value-based models, narrative and the nature and form of narratives, de-academicising the language, critiques of CBT, the case for psychodynamic psychotherapy, true freedom of thought, meaning in delusions and hallucinations, recovery and all its meanings, service-user engaged philosophical research, co-production and Thomas Fuchs’ lifeworld.
The colloquium opened with Victor Adebowale, cross-bench peer and Chair of Turning Point, and his hugely inspiring words about change and how to effect it. The mindset has to change, as in his experience there is a tendency of ‘letting the excellent get in the way of the good enough’. Renewal is crucial as well as a shift in power, but who holds the power is key – power needs to be shared.
The two days were split into four parts with overarching themes to each part, kicking off with ‘Making Change Happen in Philosophy’ – how policy, research and practice in mental health that includes first-hand narratives can support research. The morning whirled by with a very arcane presentation on ‘Monothematic Delusions’ (heavily grounded in academic philosophy) from Matthew Parrott. It was pointed out that ‘delusion literature’ is disengaged and does not correlate with the real world.
Other presentations included Tim Thornton (University of Central Lancashire) on ‘Is Recovery a Model?’ He spoke in relation to his writing on the topic – barriers to recovery, meanings of recovery and the varying expectations. He linked narrative understanding to recovery – the telling of the story, changing of it, coming to terms with it and not being besieged by it. He flagged up two issues: how change may happen within the philosophy of psychiatry, and within philosophy and psychiatry, with special reference to service-user engagement in philosophical research. Recovery needs conceptualizing and articulating.
In groups we thrashed out topics such as the exclusive nature of the language of philosophy, the imbalance of power, ways to bust out of traditional methods of academic discourse (for example, reliance on peer-reviewed journals) and the bravery of and the burden upon the service-user that should be matched by equal frankness on the part of professionals. We tried to think of non-traditional ways of breaking out of academic bonds – for example Twitter, new communities of practice and similar. We were all part of the ‘indaba’ (a term originating in Southern Africa) – a getting together where everyone has a voice, in an attempt to find the common voice.
A presentation by Dr Jayasree Kalathil (Trustee of Social Perspectives Network), with discussant Nev Jones, joined by David Crepaz-Keay (Head of Empowerment and Social Inclusion, Mental Health Foundation) around first-person narratives, stressed that the act of telling a story can be an act of taking control, and oneself can be asserted through language. She noted that culturally in some backgrounds there is a ‘tonguetiedness’. There is also an ethical issue around theorizing and the academic retelling and packaging of stories. The discussion raised the question of whether there are other ways to tell stories – not just in words, and that as service-users are from many disciplines, is an experiential take necessarily the most accurate way of making sense of one’s life? Is this the truth, and how can one change biography?
‘Making change happen in practice’ was the theme for the first afternoon – how philosophy can influence politics and research in mental health. Kim Woodbridge-Dodd (Head of Mental Health for Cambridgeshire) asserted the importance of value-based practice – sensitivity to issues of language, power and cultural diversity – summarizing her study of the application of a values-based model to race equality training among staff in an acute inpatient ward in Milton Keynes. (Woodbridge-Dodd et al, 2011). She had become aware of tacit and prescriptive values that are encoded in the ordinary language of mental health. Thus Values-Based Practice (VBP) tested preconceived ideas and assumptions and revealed a range of client, carer and colleague beliefs and needs. She found that combining VBP and race equality training was helpful.
Speeding on from that came Joanna Hicks, who presented ‘The Three Keys to a Shared Approach in Mental Health Assessment’. The First Key is the active participation of the service-user and carer, the Second Key is a multidisciplinary approach, and the Third Key is the individual’s strengths, resiliencies and aspirations, which are essential to recovery and developing self–management skills. We played a cool game – just turning to our neighbour and asking ‘who are you’ – and not including our job. It turned up a lot of searching and revealing suggestions.
Clara Humpston (Department of Psychosis Studies, Institute of Psychiatry, King’s College, London) spoke of ‘Perplexity and Meaning: Personal Narratives and the Phenomenological Core of Psychotic Experience’. She was lucid and fascinating on psychotic experiences – what the individual with psychosis experiences is his/her reality. She also coined ‘delusional double book-keeping’ where multiple realities can coexist in a single mind. There should be a search for meaning in psychosis – open minds to reality and differences in reality. Her writing about hallucinations is clear and thought provoking – “It is mine” – when she refers to delusions and hallucinations, suggesting that perhaps one day reality and unreality could coexist when we finally accept the both of them. The goal should not always be the total elimination of symptoms. I found this very refreshing.
Toby Williamson (Mental Health Foundation) summed up by noting the damage done by psychiatry, and its unhelpfulness, echoing the call for values-based practice.
Confession, confession: I missed the Key Note Plenary due to a pressing engagement with the outside world and to clear my head. So I never heard Daniel Robinson (Distinguished Professor Emeritus, Georgetown University) on “The Courts and the Clinics – where Nosology really Matters’! I must also ‘fess up to not really knowing what nosology means. But by all accounts it was a good listen.
The theme here was ‘Making Change Happen in the Sciences’. Rather as in physics, progress in the sciences underpinning psychiatry depends (in part) on conceptual as well as on observational/empirical research. This third session explored the role of philosophy both in traditional areas of psychiatric science such as psychoanalysis and in the newer cognitive and neurosciences and was ably chaired by David Crepaz-Keay whose cheerful and charismatic style highlights his determination to tip the power balance creakingly towards the user/survivor.
So – Thomas Fuchs (Department of Psychiatry, University of Heidelberg) put forward his future paradigm for psychiatry, ie embodiment. He spoke of the mind/brain and body as a psychobiological unit, and with his paradigm the brain loses its mythological powers. The brain is formed by our interactions with the world; it is an organ of phenomenological and ecological interrelations. He explored his thoughts about patients ‘disturbed’ way of interacting with the world. There are ecological disturbances (‘his world is ill’), somatic disturbances are localized and brain plasticity is influenced. The patient’s embodiment must be described and circular interactions investigated – of mind, organism and environment. Psychosis was described as disembodiment.
Richard Gipps (Psychologist, Oxford) ‘appraised’ CBT – not a laying-into, but an articulation of assumptions. He illuminated his chapter ‘CBT – A Philosophical Appraisal’ – from the OUP handbook (Fulford et al, 2013). He considered the theory rather than the therapy, and the significance of cognition as belief and thought, and cognition as meaning and how this works with CBT as a model. He did stress too the caring relationship between therapist and client as being hugely important – change will happen through love, care, thoughtfulness and respect.
Heythrop College’s Michael Lacewing argued for ‘A Theory of Therapeutic Action Deriving from Psychodynamic Psychotherapy’. As a philosopher he is interested in models of mind and alerted ‘psychiatry’ to the place and importance of psychodynamic conceptualisations in its theories and practice.
Group work touched on many themes: the insularity of the hospital setting, the importance of rehab, the participatory research with the user/survivor movement, the sometimes simplistic notions that psychiatrists have of philosophy, how philosophy needs to engage with qualitative research and the fact that terminology can scare people off. The essence again was the relationship between clinician and patient.
Edward Harcourt (Fellow in Philosophy, Oxford University) summed up with ‘What’s Mental Illness?’ The cures must favour a talking cure – an integrative one, but not sheer off the cognitive. Dance, movement and body-based therapy and narrative resources that include the physical can all be used.
From Anaesthetic to Aesthetic – Helena Fox’s film – provoked differing reactions, from boredom to unease. Social sculpture is ‘a contemporary and expanded form of art’ coined by Beuys (1921-1986) in the ‘70s; he said “everyman is an artist”. The film was a kind of meditation gradually revealing small hints and clues and markers as it progressed. Fox’s aim is rehumanizing healthcare delivery.
Session Four was ‘Making Change Happen Internationally’. Sridhar Venkatakapuram (Department of Social Science, King’s College London) kicked off with the iniquity of health inequalities. There needs to be a philosophy of theory of justice with health embedded in the theory. We need to look beyond the rhetoric and make mental health part of the agenda.
Matthew Ruble (doctoral student from Tennessee) examined the epistemic significance of interdisciplinary peer disagreement as a driver for curriculum change. Werdie van Staden from University of Pretoria Medical School spoke eloquently of the ‘ways-of-doing’ – the international unfolding of the African concepts ‘batho plete’ (people first), ‘ubuntu’ (existence with and through others) and ‘indaba’ (an important conference or meeting held by Zulu men to sort things out). Our Oxford indaba was definitely all-inclusive, a living example of the notion that ‘I am because you are and you are because we are.’ An audience member from New Zealand suggested mind comes into being when there is communication, saying “It’s a jointly created story”.
Finally, Drossi Stoyanov from University of Plovdiv Bulgaria placed us in the center of a case history and raised questions about ethical and cultural differences as well as personal and professional paradigms. After a heated discussion in our group about conference etiquette and possible cultural differences, Alicia Monroe, closed the conference with calm and wise words exploring decision-making and the value of integrity. She looked at whether there is a global set of values and how barriers can become opportunities for creative thought.
We all parted with great goodbyes and huge goodwill for change. Future plans are being laid and hopefully the conversation that has been started will continue to gather momentum. Academia being naturally conservative and tending towards silos of expertise, the fact that the colloquium happened was a huge boost, and the power imbalances can start to be addressed.
As a complete layperson and fairly philosophically naïve, I had come to the conference with the thought that it was about the philosophy OF psychiatry, rather than philosophy and psychiatry. This set me thinking. There is such a need to interrogate psychiatry for what it is. What is it? Does it need to be? Is it a cult or a construct? What could replace it? Could psychiatrists all become neuroscientists in this brave and sinister new world of diagnosis by brain scan? Where will that lead us? Is there a philosophy of psychiatry? What is it? How can the human rights abuses within the field be ethical? What is psychiatric ‘care’? How ethical is psychiatry’s dependence on the major pharmaceutical companies and the use of dangerous, life-threatening drugs on young children, the elderly and others? The fact that recovery is higher in developing countries than in industrialised ones needs to be examined. People are still subjected to ECT and lobotomy – is this ethical?
There’s so much to explore, and I hope that this wonderful and awe-inspiring conference is just the start.
Polly Mortimer, who writes on mental health with particular attention to the effects of psychiatric ‘treatment’, is librarian at the Minster Centre.
Gipps, R.(2013) CBT:A Philosophical Appraisal in The Oxford Handbook of Philosophy and Psychiatry Fulford, KWM, Davies M., Graham, G., Gipps, R., Sadler, J., Stanghellini, G., Thornton, T (Eds) Oxford: Oxford University Press
Jaspers, K. (1997) General Psychopathology – Volumes 1 & 2. translated by J. Hoenig and Marian W. Hamilton. Baltimore and London: Johns Hopkins University Press.
Woodbridge-Dodd, K. Hunkins-Hutchison, E. Fulford, W. (2011) Race equality training and values-based practice in Mental Health Practice 15,2 pp28-32
Image: Bizarre by Angela Radulescu