Mental Health Revolution Pat Bracken RCPsych Oct 28

Mental Health Revolution Pat Bracken RCPsych Oct 28 th 2008

Mental Health Revolution • Changing ideas about revolution • The nature of the dominant paradigm in mental health • Causes of, and justification for, revolutionary change • Implications for our profession

Che Guevara

Killing Fields of Cambodia

John Gray • “the world in which we find ourselves at the start of the new millennium is littered with the debris of utopian projects”

Copernicus

Kuhn: paradigms ‘when paradigms change, the world itself changes with them’

Technological Approach Medical model Cognitive approaches Technological Approach Language of Management

Main Assumptions of the Technological Paradigm • The problem to be addressed has to due with a • • faulty mechanism or process of some sort The mechanism or process can be modelled in causal terms, ie described in a way that is universal, a way that works regardless of the context Technological interventions are instrumental. They are not to do with opinions, values, relationships or priorities.

Technical idiom • ‘Bipolar disorder is a complex, recurrent mood disorder, and its impact on everyday life can be devastating. Although pharmacological interventions remain the primary tool in its management, medicines cannot control all aspects and consequences of the disorder. Psychosocial interventions target issues untouched by pharmacological treatments, such as medication adherence, awareness and understanding of the disorder, early identification of prodromal symptoms, and coping skills’ (Beynon et al, 2008).

Modernist Psychiatry • Primary discourse is technical: focused on diagnosis and classification, causal explanations, evidence-based interventions (EBM) • Other issues become secondary: ethics, values and priorities, meanings and contexts, relationships and power

Why is Technological Paradigm dominant? • Cultural support • Patient expectations • Underscores professional roles • Pharmaceutical industry

Roy Porter ‘Indeed, the rise of psychological medicine was more the consequence than the cause of the rise of the insane asylum. Psychiatry could flourish once, but not before, large numbers of inmates were crowded into asylums’

Why is Technological Paradigm so dominant? • Cultural support • Patient expectations • Underscores professional roles • Pharmaceutical industry

Role of Service-user Organisations in the Technological Paradigm -consultation -help with fund-raising and recruiting subjects for research -their expertise secondary to that of the technical knowledge of the professional

20 th Century Psychiatry Social position Cultural issues Focus on technology of diagnosis and treatment relationships Ethics and values

Direction of Revolutionary Change Training priorities Use of drugs and therapy Appropriate Discourse research centred on: -values/ethics Service -meanings/contexts models -relationships/power

Challenges to technological paradigm • Postmodern culture • Changing understanding of technology itself • Moves away from the embrace of Pharma

Why Revolution is Justified • Empirical evidence • Conceptual analysis • Political reasons • Ethical imperative

CBT ‘little evidence that specific cognitive interventions significantly increase the effectiveness of therapy’ (Longmore and Worrell, 2007)

Why Revolution is Justified • Empirical evidence • Conceptual analysis • Political reasons • Ethical imperative

Psychiatry and Philosophy

Why Revolution is Justified • Empirical evidence • Conceptual analysis • Political reasons • Ethical imperative

Ethical if we say that we are working to develop user-centred services, training and research programmes then it is simply unethical to carry on as if the user movement did not exist.

Mad Pride in Cork

Icarus Project • ‘we shared a vision of being “bipolar” that differs radically from the narrow model put forth by the medical establishment, and wanted to create a space for people like us to articulate the way we understand ourselves, our “disorder”, and our place in the world’.

Implications for Psychiatry • Rethinking psychopathology • A different understanding of expertise • Training • Research • Service developments

Insights from Recovery Literature 1. Recovery often made through paths that 2. 3. are alternatives to drugs and psychotherapy Importance of loss of social position that comes with being a service user Community development approach

Relationship with service user movement From Consultation to collaboration