Reprinted with permission from Openmind 99 (September/October 1999) ©1999 Mind (National Association for Mental Health)

POST-PSYCHIATRY

Pat Bracken and Phil Thomas

Since the caustic critiques of Szasz and Laing in the 1960’s, the concept of schizophrenia has been attacked from a variety of quarters. The psychiatric establishment has defended the diagnosis vigorously, and schizophrenia continues as the dominant paradigm for psychosis. It continues to attract huge sums of research money as biomedical scientists direct a broadside of cognitive and molecular biological techniques in the hope of cracking the problem. Yet the scientific basis of schizophrenia remains shakier than ever. Psychologists like Bentall and Boyle have questioned the scientific validity of the diagnosis, as has the evidence in support of the effectiveness of its treatment with drugs. Thornley and Adams examined in detail 2,000 drug trials in schizophrenia over the last 50 years, and concluded that that the majority of these studies were of poor quality, and that this was likely to have resulted in ‘an overoptimistic estimations of the effects of (drug) treatment’. After a hundred years of study and investigation, schizophrenia still refuses to yield its secrets to science, so why does psychiatry still attach such great importance to the concept?

Psychiatry and schizophrenia were spawned in the same environment, the huge asylums which sprung up across Europe in the mid nineteenth century. In these institutions the medical model had some notable early successes in discovering the pathological basis of some types of insanity. For example, it found that one form of paranoia was caused by syphilitic infections of the brain, and that vitamin B deficiency could cause a wide variety of psychological disturbances, including acute confusion and dementia. This fuelled the conviction that all forms of insanity would turn out to have physical causes. Throughout the twentieth century the quest to unlock the secret of schizophrenia became psychiatry’s raison d’être, a search that left no aspect of human experience untouched by biomedical research. But there is an ever widening gulf between the unreal world of neuroscience research, and the lives that are lived under the shadow of the label of schizophrenia, lives dulled by drugs and blighted by stigma. For psychiatry, schizophrenia remains a sacred relic. It has to attach a great deal of importance to the concept, because it has invested so much time, effort and prestige in a fruitless quest for its causes. Psychiatry claims to be scientific, but scientific approaches to knowledge should be characterised by doubt and scepticism. For psychiatry, schizophrenia is a dogma, an unquestionable article of faith, and to question schizophrenia is to question psychiatry. The failure of biomedical science to reveal the cause of schizophrenia is the ultimate condemnation of the medical model in psychiatry.

It is essential that there is absolutely no ambiguity about our position in attacking the concept of schizophrenia. Unlike the antipsychiatrists, we do not deny the existence of psychosis, nor do we seek to romanticise it as a journey of self-discovery. For most people psychosis is a terrifying, perplexing experience. But the medical model has failed in its task to account for psychosis, and in doing so it has wrenched the ownership of the experience from the sufferers, denying them their own attempts to make sense out of the experience. This is why we believe that there is a desperate need for a different relationship between madness and medicine. How should we go about redefining this relationship? First, medicine must abandon psychopathology, the language whereby the experience of psychosis is turned into symptoms of mental illness. Instead it must work with those who experience psychosis, and their carers and supporters, to define a more human way of talking about and describing the experience. There have already been significant developments in this area, such as the work of the Dutch psychiatrist Marius Romme who has turned verbal auditory hallucinations back into hearing voices. The Psychosis Seminars developed by Thomas Bock in Germany, described in this edition of Open Mind, is another excellent example of this approach. Second, medicine must accept that psychosis can be meaningful for many people, although these meanings may be painful and difficult to face. Third, it must accept that many people who experience psychosis want to make sense of it, and we have a responsibility to help those who want to achieve this. Finally, making sense out of psychosis means that we must be prepared to work with the person’s explanatory framework. This does not mean that we personally have to accept this framework, but working with it is a prerequisite for helping someone to make sense out of his or her own experiences.

As we have said before in these columns, this has implications for the way psychiatrists are trained, and by whom. We do not need special skills to work in this way, no rocket science or tricky therapies, just a willingness to listen to and respect the other person’s experiences. Neither does this mean that we have to stop using medication – many people find neuroleptic medication helpful in the acute stages of psychosis – but medication has become an end in itself, not a means to an end. This new relationship requires a fundamental shift in the power relationship between doctor and patient. Psychiatry has to hand over responsibility for psychosis to those who experience psychosis. Those who experience psychosis must be prepared to accept that responsibility.