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Healthcare NHS Trust for allowing us to PRATT.P. (1993) Pharmacokinetics and interactions of the publish the results. SSRIs. In A Review of the Selective Serotonin Reuptake Inhibitors (eds A. Mackay. P. Pratt & B. Leonard). Clwyd: References Unicorn Health Communications Services. DRUGANDTHERAPEUTICSBULLETIN(1993o) Selective Serotonin Reuptake Inhibitors for Depression? Drug and Thera peutics Bulletin, 31, 57-8. "John Lawton, Ciinicai Services Pharmacist. —¿ (1993b) Prescribing costs. Drug and Therapeutics Nottingham Healthcare NHS Trust. The Wells Bulletin. 31. 87. ECCLESTON,D. (1993) The economic evaluation of antide- Road Centre, Wells Road, Nottingham NG3 pressant drug therapy. British Journal of Psychiatry, 3AA: and Prakash Naik, Consuiianf Psychia 163. 5-6. trist, Lyndon Clinic. Hobs Meadow. Solihull. MACKAY,A. V. P.I1993) Foreword. In A Review of the West Midlands B92 8PW Selective Serotonin Reuptake Inhibitors 1993 (eds A. Mackay. P. Pratt & B. Leonard). Clwyd: Unicorn Health Communications Services. 'Correspondence

The rise and fall of anti-psychiatry

Mervat Nasser

A review is made of the anti-psychiatric movement beginnings can be traced back to the writings through its major protagonists, Lacan, Laing, Cooper of Jacques Lacan who was probably the first to and Szasz. The ideology was set to challenge the glorify madness and regard it as the road to concept of mental illness and question the authority of freedom. In a statement extracted from Propos the psychiatrist and the need for mental health institu sur ¡aCausalitépsychique (Paris. 1947) Lacan tions. The anti-psychiatric movement received a lot of says, "madness is not an insult to liberty but attention in the 1970s but is now considered to be of the follows liberty like its shadow". Lacan was also past and of likely interest to the psychiatric historian. the first to launch an attack on established However, the impact of the movement on current psychiatric thought and demand that psycho psychiatric practice requires further re-examination analysis re-examine its concepts, with parti and appraisal. cular reference to explaining paranoia. He thought that the psychotic experience could The anti-psychiatric movement grew in the be psychoanalytically understood in the same realm of politics, particularly the politics of way as psychoanalysis offers an explanation the left, which was considered at one time the for neurosis. In his rebellion he undermined main source of progressive ideas and possibly genetic disposition and dismissed the possibil the only instrument against capitalist oppres ity of any organic pathology. sion. It gained its initial respect and glamour Lacan attempted to challenge accepted ways from its association with the prevailing exist of understanding the psychotic experience and ential philosophy at that time. The need to introduced to psychiatry what could be called stengthen the relationship between psychiatry a revised Freudian doctrine (Bowie, 1987). and philosophy is an old one and based on However, he is more likely to be remembered Kant's contention that judgements on matters for the importance he gave to language in the of sanity should be the prerogative of the field of psychoanalysis. His system strongly philosophical mind. relates language to the unconscious, where he Despite these connections, the roots of the regards the spoken word as man's peculiar anti-psychiatric movement are undoubtedly to privilege and his tool to displace desire and be found in the psychoanalytic tradition. The attain freedom. In developing his linguistic

Psychiatric Bulletin (1995). 19, 743-746 743 ORIGINAL PAPERS theory he was influenced by poetry, particu is representative of an overall repressive social larly the surrealist movement headed by structure. In Laing & Esterson's Sanity, Mad Eluard, and was also impressed by what he ness and the Family (1971) is written "... if the referred to as the poetic power of his patients nuclear patriarchal family is to be opposed, it (Lacan, 1968). His critics found no convincing is because it frustrates peoples' desires and basis to his argument and disputed the limits their possibilities in addition to its validity of his work, especially his inability to necessity to the survival of capitalism..." make distinction between descriptive account Laing expanded his political views in The and the practical means he used to help his Politics of Experience, where he regards mad patients. ness as the product of a struggle between the repressive society and the individual who is seeking to escape its repression. He formulated The age of the true radicals his views on schizophrenia accordingly, and Lacan may or may not have influenced the rejected the notion that schizophrenia is a anti-psychiatric movement that flourished in failure of human adaption, on the contrary, he the '60s and early '70s, but the names that regarded it as a successful attempt not to came to be associated with the movement adapt to what he called pseudo-social realities. knew of him and acknowledged his contribu Laing asserted that political dissidents fell tion even if they did not wholeheartedly agree into this category and were especially prone to with him. David Cooper (1980) writes in his the fate of madness ".. .when a nation is in Language of Madness "... when psychoanaly confusion and disorder, patriots are recog sis is done by a philosophical guru like nised..." (Laing. 1967). Jacques Lacan it may be treated with affection, fascination and poetic respect... but the age of romanticisation of madness is now over, Cooper and the non-psychiatry politicisation of psychiatry is indispensable". David Cooper extended Laing's political argu Cooper is one of three major figures linked to ment to an extreme. Capitalism is seen as the the movement that included R. D. Laing and source of all evil and has a responsibility Thomas Szasz. He is, in fact, the one who towards reinforcing the nuclear family ideology introduced the term anti-psychiatry in Psy (Laing & Cooper, 1969). Psycho-technological chiatry and Anti-psychiatry (Cooper, 1971). training is nothing but a method that fulfils the Cooper. Laing and Szasz had one thing in purpose of mystification and social policing. common, the belief in the wickedness of the He advocated 'non-psychiatry', arguing that psychiatric orthodoxy and the desire to chal modern psychiatry is a pseudo-science that lenge it. grew hand in hand with capitalism as society's R. D. Laing is considered in Britain the true repressive device. The main purpose of psy father of this movement although he never regarded himself as an anti-psychiatrist! He chiatry is to médicalisedefianceand persecute the non obedient in order to teach its citizens belonged to the psychoanalytic school and his how to conform to society's norms. Demolishing thoughts reveal his admiration for existentialist psychiatry will be the desired goal which can philosophical ideas. He has been described as only be achieved by a political transformation of Sartrean in theory and Freudian in practice. the society (Cooper, 1980). Politics also played a role in shaping his views: Cooper's views find resonance in Breggin's his politics were socialist in content and based criticism of psychiatry who stated that all on Marxist theory. The fundamentals of his psychiatric therapy is inherently political theory revolve around rejecting the illness "... ultimately every therapy implements some model in psychiatry, based on his conviction Utopian political vision against which the of the intelligibility of the psychotic experience. client will measure his own success and failure Madness and sanity in his opinion are socially in the therapy" (Breggin, 1975). relative phenomena and, in his fascination with the assumed link between genius and madness, he was ready to consider statistical normality as not a necessarily desirable state Szasz, myth of mental illness or attack of affairs. on institutions? For him, to understand madness you must Szasz's contribution to the anti-psychiatric study the family. However, the skewed family movement was made in his famous and in his view that is responsible for the madness notorious book The Myth of Mental Illness

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(1972) in which he referred to the "game personal freedom, it is extremely libertarian model" in hysteria; the hysterical symptom compared to other treatment environments." was considered a form of language that is Latterly, Dentali (1993) while identifying meant to mobilise help. The approach adopted weaknesses in the Szaszian premise, pointed is transactional and based on earlier psycho to his contribution in drawing attention to analytic writings by authors like Sullivan and psychiatric prejudice and the role of values in Fairburn. However, Szasz would have not been psychiatric decision making. regarded an anti-psychiatrist if his theories were limited to hysteria. His contention how ever stems from the fact that he considered the Impact of the anti-psychiatric hysterical model applicable to all mental ill nesses. In so doing he rejected the essence of movement on current psychiatric psychiatric morbidity. He described mental practice illness as a metaphorical illness because There is a tendency among psychiatrists to "... the mind (whatever that is) is not an organ regard the anti-psychiatric movement as hav or part of the body. Hence it cannot be ing entered the annals of modern psychiatric diseased in the same sense as the body can". history and to look back on the ideology as an He took the view that any psychiatric diagnosis attempt to flirt with polemics at the expense of is a licence for coercion and the exercise of scientific thought and enquiry. But while the psychiatrist power. "If mental illness is not a anti-psychiatric movement failed to sustain its disease why then treatment or indeed admis claim that it presents a true challenge to sion?" orthodox psychiatry it will be naive to assume Ian Kennedy (1980), in broad agreement that the anti-psychiatric movement had little with Szasz, argued that the psychiatrist acts or no impact on the way psychiatry is conceived as a thought policeman and that psychiatric and practised today. The trend towards politi- diagnosis is a political weapon aimed to cisation of psychiatry can be seen in everyday constrain civil liberties. This attack was par practice, particularly in new terminology tially justified given the use of psychiatric which reflects the growing understanding of therapy as a police measure in the Soviet the political power of the word. Therapy' has Union at that time. Against this background of largely replaced 'treatment' and the 'patient' is psychiatric abuses, Kennedy concluded that commonly referred to as a 'client'. Indeed one the disease approach to mental illness was aspect of Laing's political argument was his untenable. contempt for psychiatric literature which he Szasz, as a consequence of his rejection of referred to as vocabulary of denigration (Laing, the disease model, spared no effort in attack 1967) ing the mental hospital. His views were shared The anti-psychiatric movement, with its by the psychiatric historian and philosopher emphasis on the sociogenesis of mental ill Foucault. In Madness and Civilisation (1971) ness, has contributed towards generating Foucault argued that madness was tolerated demand for grass roots involvement in laying and respected as a different way of being and down the guidelines for the provision of psy knowing until the European renaissance and chiatric services. This has resulted in the the ascent of reason; only then unreason development of advocacy groups concerned acquired the name of madness and the exclu with the legal, social and personal conditions sion ofthe mad became necessary to conform to of people under psychiatric treatment or who the new society's values. Szasz's and Foucault's have experienced treatment before. These ad views echo the thoughts of the sociologist Goff- vocacy groups see themselves as responsible for man (1961) who articulated the impact of upholding the rights of the mentally ill and psychiatric labelling on the mentally ill in his restraining the powers of the psychiatrist. book Asylums which arguably was the one that The World Federation for Mental Health is had the greatest infuence on psychiatric the world's only multidisciplinary, non-gov thought and practice. ernmental mental health coalition whose Szasz concluded that the only help that objectives are to promote the rights and can be given to those patients is through welfare of the mentally ill and their families. psychotherapy which is infinitely superior to In the United Kingdom the association devel any treatment. The same view is also ex oped a strong advocacy role and in 1970 was pressed by Breggin with some reservations renamed MIND. MIND was instrumental in "...the therapy is voluntary and promotes strengthening the patient's legal rights with

The rise andJaR of anti-psychiatry 745 ORIGINAL PAPERS reference to detention and the need for The discrepancy in orientation is bound to patients' representation on Mental Health widen the gap between the psychiatrist and Act tribunals. The philosophy of MIND was other professionals despite constant pressure seen as embracing the anti-psychiatric ideol to achieve the desired objective of team cohe ogy and its sentiment was perceived as hostile sion and harmony. It seems inappropriate to psychiatrists. therefore to ask if an ti-psychiatry is alive or However, the greatest impact of the anti- dead. Anti-psychiatry may have fallen from psychiatric movement is seen in the shift of grace and no longer be led by eminent focus from the large mental institutions to the psychiatrists but the movement lives on. It provision of care in the community. This trend has only been handed over to the team. is the product of various schools of thought and the anti-psychiatric ideology is certainly one of them. It is not a coincidence that graffiti painted on References the walls of San Giovanni's Psychiatrica Demo BENTALL.R.(1993) Thomas Szasz. crazy talk and the myth of cratica reads "prison=asile=usine=ecole" which mental illness (comment). British Journal of Medical Psychology. 66. 69-76. conveys the Foucaultian principle that pris BOWIE. M. (1987) Freud, Proust, and Lacan, Theory as ons, mental hospitals, factories and schools Fiction. Cambridge: Cambridge University Press. are all agencies of capitalist control (Foucault, BREGGIN,P. R. (1975) Psychiatry and psychotherapy as 1975; Jones & Fowles, 1984). The philosophy political processes. American Journal of Psychotherapy, 29. 3. that governed the development of community COOPER,D. (1971) Psychiatry and Anti-psychiatry. London: centres in Britain was largely shaped by the Paladin. Italian experience as well as the American —¿(1980)The Language of Madness. London: Pelican Books. model of community care. These community FOUCAULT.M. (1971) Madness and Civilisation. London: Tavistock. centres have the tendency to distance them —¿(1975) Surveiller et Punir. Paris: Gallimard. English selves from the so-called medical model of edition. Discipline and Punish (trans. A. Sherida). New psychiatric disease and perceive the good York: Pantheon. psychiatrist as the one who refrains as much GOFFMAN.E. (1961) Asylums - essays on the social situa tions of the mental patients and other inmates. London: as possible from prescribing drugs, frowns Penguin Books. upon detention and is more inclined to use JONES, K. & FOWLES,A. J. (1984) Ideas on Institutions. psychotherapy. This model of care derives its London: Routledge & Kegan Paul. support from the non-medical psychiatric KENNEDY.I. (1980) Great Caution Must be Exercised in Visiting the Status of Mentally III on Anyone. The Reith professionals who arguably still celebrate the Lectures: Unmasking Medicine. anti-psychiatric ideology in their education LACAN,J. (1947) Propos sur la CausalitéPsychique. Paris: Seuil. and training and constitute the main source —¿(1968) "The Mirror phase", the functions of language in of care for the psychiatrically ill in the com psychoanalysis. New Left Review. 5. munity. They see themselves as representing LAING.R. D. (1967) The Politics of Experience. New York: the culture of resistance or opposition to the Pantheon Books. psychiatrist's power. This is more evident in —¿(1969) The Dialectics of Liberation ¡withD. Cooper). New York: Collier Books. the case of social workers who acknowledge —¿(1971)Sanity. Madness and the Family (with A. Esterson). that their training and practice orientation New York: Basic Books. come in close conflict with conventional psy SZASZ.T. (1972) The Myth of Mental Illness. Foundations of a chiatric practice. theory of personal construct. London: Granada Publish ing. On the other hand, the medical establish —¿(1972) Bad habits are not diseases. Lancet. Ãœ.128. ment seems to have departed from the social model and is now more interested in biological theorising, believing that the organic model is Mervat Nasser, Senior Lecturer and Consultant likely to be the one that offers better under Psychiatrist, Department of Psychiatry, Univer standing of the nature of mental illness and sity of Leicester, Clinical Sciences Building, serves the needs of the mentally ill. Leicester Royal Infirmary, Leicester LE2 7LX

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