Bracken & Thomas Authors’ response. Invited commentary on . . . Beyond consultation

Psychiatric Bulletin (2009), 33, 245^246. doi:10.1192/pb.bp.109.026773

PAT BRACKEN AND PHIL THOMAS editorial Authors’ response. Invited commentary on . . . Beyond consultation{

Dr Holloway is right when he says that our editorial psychiatric patients out with the bathwater of descriptive contains a significant challenge to professionals working psychopathology by describing the value of narrative in the field of mental health. However, he misses the and other hermeneutic approaches in our work as point entirely that this challenge arises not from our psychiatrists.7, 8 analysis but from the growing service user movement. Moreover, we believe that an increasing number Our editorial is an attempt to articulate a positive of psychiatrists are seeking to work with different response to this challenge. But it is the ideas of groups frameworks and to engage positively with the diversity such as the Hearing Voices Network and the Icarus of the user movement. Our work is an attempt to Project that throw down the gauntlet to the traditional think through some of the theoretical and practical assumptions of psychopathology. Although psychiatrists implications of these developments. We deny that this like Holloway may respond defensively and maintain is anti-psychiatry. We have always argued that medicine that these ideas are ‘dangerous’, the fact is that this has a legitimate and important role to play in the lives movement is growing from strength to strength. Since of those who suffer episodes of ‘madness’, distress our editorial was written, Newsweek magazine has and alienation. But we need to rethink some of our featured an article on the Icarus Project and the fundamental assumptions if this work is not to be phenomenon of Mad Pride (www.newsweek.com/id/ experienced as damaging. This is not anti-psychiatry, 195694). anti-medical or anti-scientific. But psychiatry deals We agree with Holloway that ‘Effective dialogue is with the most complex aspects of our experiences as ...acoreelementofgoodmedicalpractice for all embodied, encultured beings. An authentic science of doctors working in the UK’. However, the evidence human beings needs to face the fact that the meaningful suggests that this is lacking in at least some consultations world of psychological suffering will never be adequately between consultant psychiatrists and their patients who grasped through the same scientific framework we experience chronic psychoses. McCabe et al1 in a currently use to understand bodily tissues such as livers, conversation analytic study found that consultant lungs and neurons. psychiatrists had difficulty engaging with their patients’ We referenced the work of Thomas Kuhn in our belief systems, especially when patients wanted to editorial not, as Holloway maintains, because we discuss the meaning and content of the delusional beliefs believe that he is ‘anti-science’ but because he shows or hallucinations. The consultants in this study appeared us that science does not evolve in a linear fashion. to be embarrassed by their patients’ attempts to raise Holloway’s assertion that paradigm shifts ‘do not these issues, and responded by changing the subject or abolish previous scientific knowledge but absorb it into a giggling nervously. This corroborates service user better fit with the empirical evidence’ involves a serious narratives that a number of consultants are, contrary misunderstanding of what Kuhn’s work was about. His toHolloway’sassertion,not‘...sensitivetothe explanatory frameworks that our patients and their central concern was to show that what counts as carers hold’. This makes it difficult for some psychiatrists empirical evidence in the first place is determined by the at least to work with patients in ways that are helpful for paradigm at work. He points out that it is hard for them.2 scientists who have worked through one paradigm all We agree with Holloway that some excellent work their lives to give it up, as it shapes not only their beliefs has been done by psychiatrists in relation to recovery, about the world but also their perceptions of that world, and are very familiar with the work not only of indeed how they experience that world. Paradigms Davidson3,4 in the USA, but of Glenn Roberts5 and others determine what we understand ‘the facts’ to be. Indeed, in the UK, all of whom we applaud. In citing Davidson’s Kuhn says: ‘when paradigms change, the world itself 9 work, however, Holloway inadvertently validates the changes with them’. point we make in our paper. In their work on recovery, Holloway may be right that the comment by Peter both Davidson and Roberts choose not to use an Tyrer that we quoted was a ‘throw away remark’ and that approach grounded in traditional descriptive psycho- somehow Tyrer really wanted to ‘celebrate’ the steady pathology, but turn instead to narrative theory and evolution of psychiatric knowledge and treatments. methods, seeing this as providing a rigorous empirical However, this does not tally with the Lancet editorial and clinical methodology in helping people suffering from from January this year by the same author in which he chronic psychosis to move to recovery. For this reason we comments: ‘The spurious invention of the atypicals can {See editorial, suspect that Holloway, like others, is highly selective in his now be regarded as invention only, cleverly manipulated pp.241^243, and 6 invited commentary, reading of Postpsychiatry. In our work, we have by the drug industry for marketing purposes and only pp.243^244, been keen not to throw the baby of the distress of now being exposed. But how is it that for nearly two this issue.

245 Bracken & Thomas Authors’ response. Invited commentary on . . . Beyond consultation

decades we have, as some have put it, ‘‘been beguiled’’ and, most important of all, how they should seek genuine into thinking they were superior?’.10 opportunities for meaningful engagement with service editorial This is far from a celebration of the steady advance users and carers. of knowledge. Rather, it represents a serious indictment of our profession. The Critical Psychiatry Network came into being 10 years ago because some practicing psychiatrists were not ‘beguiled’ by the marketing forces References of the drug industry, were sickened by the corruption of 1 McCabe R, Heath C, BurnsT, Priebe aPostmodernWorld.Oxford academic psychiatry, opposed the extension of coercive S. Engagement of patients with University Press, 2005. psychosis in the consultation: 7 Bracken P.Trauma: Culture, practices and sought ways of working more closely with conversation analytic study. BMJ Meaning and Philosophy.Whurr organisations set up by service users. The credibility of 2002; 325:1148^51. Publications, 2002. our profession has been put in question, not by the 2 ReadJ, ReynoldsJ (eds). Speaking 8 Thomas P, Bracken P, activities of those of us in the critical psychiatry Our Minds: An Anthology. Leudar I. Hearing voices: a Macmillan, Open University,1996. movement, but through the corruption of our research phenomenological^hermeneutic and training agendas by the interests of major drug 3 Davidson L. Living Outside Mental approach. In Voices in the Brain: companies in alliance with senior individuals from our Illness. Qualitative Studies of The Cognitive Neuropsychiatry of profession. In the USA, the layers of these alliances are Recovery in Schizophrenia. New AuditoryVerbal Hallucinations (eds York University Press, 2003. S Spence, A David). Psychology now being exposed by the work of Senator Grassley Press, 2004. 4 Roe D, Davidson L. Self and (www.nytimes.com/2008/07/12/washington/ narrative in schizophrenia: time to 9KuhnTS.The Structure of Scientific 12psych.html?____r = 1). These exposures are the real author a new story? Med Humanit Revolutions (2nd edn):111. ‘wake-up call’ for our profession. 2005; 31: 89^94. University of Chicago Press,1962. It is unfortunate that Holloway reduces complex 5 Roberts GA. Narrative and severe 10 Tyrer P, KendallT.The spurious issuestosimplebinaries,‘heroes...[and]...villains’, mentalillness: what place do stories advance of antipsychotic drug or psychiatry and anti-psychiatry. Critical psychiatry have in an evidence-based world? therapy. Lancet 2009; 373:4^5. Advan PsychiatrTreat 2000; 6: 11 Bracken P,Thomas P. From Szasz to is concerned with moving our understanding of the 432^41. contested nature of mental disorder beyond such Foucault. On the role of critical 11 6 Bracken P, Thomas P. Post- psychiatry. Philos Psychiatr Psychol crude distinctions. In presenting his arguments in psychiatry: Mental Health in 2009; in press. this way, Holloway obscures the complexity of the debate and perpetuates historical divisions that have *Pat Bracken Consultant Psychiatrist and Clinical Director,West Cork Mental no part to play in contemporary discussions about the Health Service, Department of Psychiatry, Bantry General Hospital, Bantry, Co. Cork, Ireland, email: [email protected], PhilThomas Professor, role of psychiatrists in the care of people with mental Institute for Philosophy, Diversity and Mental Health, University of Central disorders, their relationships with other professionals, Lancashire

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