Wednesday, February 6, 2013

Personal Health: Effective Addiction Treatment

Personal Health: Effective Addiction Treatment: Many addiction treatment programs are rooted in outdated methods rather than new evidence-based approaches, dooming many addicts to failure.
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Treatment, Not Jail, for the Mentally Ill

Treatment, Not Jail, for the Mentally Ill: In an ideal system, the mentally ill who commit minor offenses and pose no real danger to the public would never see the inside of a jail.
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Boycott the DSM-5!

via Mad In America » Blogs by Jack Carney, DSW on 2/5/13
 

Boycott the DSM-5!

 
 
Believe it or not, there’s some confusion about what “boycott” means. Bluntly, it means “Don’t purchase or use the object being boycotted.” Remember the United Farm Workers and table grapes and iceberg lettuce? I remember walking a picket line daily for weeks in front of my neighborhood supermarket carrying a sign urging customers entering the store not to buy grapes and lettuce. It must have worked – this was back in the 1970’s – because the grape and lettuce growers in California’s Salinas Valley were obliged to sign contracts with the UFW and its members.
The Committee to Boycott the DSM-5 is comprised of regular, not-so-famous mental health professionals, users of psychiatric services and their family members and those who’ve managed to survive many years as patients in the mental health system. In short, folks like many others, who’ve grown to mistrust and/or been adversely affected by the psychiatric establishment and its series of “bibles” or DSMs, and who anticipate even worse experiences with the new DSM-5. Our objectives are to trigger the memories and sensibilities of those – professionals, patients, family members and survivors – who’ve had similar unhappy experiences; convince the professionals neither to buy nor use the new DSM; encourage current patients to urge their psychotherapists and psychiatrists to neither buy nor use the DSM-5; and ask the survivors to do what they do best, viz., reach out to those they know still caught up in the system and support their efforts to press those who treat them to neither buy nor use the DSM-5.
I think you get the message.
The Boycott statement below contains a series of brief rationales for our opposition to the DSM-5: that it’s unscientific, unsound and ultimately unsafe; that it continues the DSM tradition of pathologizing ordinary behaviors – the new DSM will contain over 300 diagnostic categories, up from DSM-IV TR’s 250; that it narrows “treatment of choice” to the prescription of psychoactive medications despite their known toxicity and suspect effectiveness; that the APA has undermined its own credibility by disregarding the many criticisms of the DSM’s nosology.
If you’re so inclined, additional and more detailed critiques can be obtained on this very website in the several articles about DSM-5 written by me and others over the last 12 and more months. My last post was on December 10, 2012 and entitled “Boycott The DSM-5: Anachronistic Before Its Time.”
If we succeed in getting a sizable number of the millions of prospective DSM buyers to sign on to our Boycott statement, a copy of which you’ll find at the end of this post, we’ll put a sizable dent in the sales needed by the American Psychiatric Association to recoup its investment in the development of the new DSM.
Allen Frances, the most well-known critic of the DSM-5, has estimated that the new DSM cost the APA $25 million to bring to press, which explains the hefty price for each volume — $199 per – the APA is charging. Which translates to a break-even figure of 12.5 million buyers world-wide. The APA is already soliciting pre-orders of on its website, nearly four months before the new DSM’s scheduled mid-May publication.
One final point. We realize that all professionals employed in the public mental health system, indeed any professional or agency seeking third party reimbursement for services rendered, must use diagnostic codes. Accordingly, we are recommending that, if you must use diagnostic codes, use those contained in the ICD-9. Please be advised that you do not need to rely on the DSM’s codes – they are entirely superfluous to billing procedures, which, by U.S. law and international treaty, must employ ICD codes. Our recommendation should not be construed as an endorsement of the ICD – we consider all diagnoses reductive and demeaning to the persons so diagnosed. Rather, our recommendation to use the ICD codes is meant as a bureaucratic expedient for those obliged to use them. In short, anything but the DSM-5.
The Boycott statement itself can be found and signed by those who agree with its contents and intent at Boycott the DSM-5 (http://www.ipetitions.com/petition/boycott5/) on petitions.com. I realize that our Boycott statement is far from perfect – frankly, it’s impossible to address or anticipate all the concerns of prospective supporters in a brief document. But, as I like to say, any rock that’s handy, I’ll toss it at the behemoth.
And that’s also why we have a companion information website — Boycott DSM-5— (http://boycott5committee.com) where additional information will be posted by the Committee and where those who wish to can post comments. Should any reader wish to join the Committee and do some work on its behalf or should you belong to an organization that might be interested in co-sponsoring the Boycott, please contact me via MIA e-mail, via our support website or directly to me at jacarneysr@aol.com.
I trust that most readers will find themselves able to support the Boycott and sign the Boycott statement. Feel free to cut and paste it, send it on to friends and colleagues, post it on your Facebook pages or websites. Thanks.
Remember, “Don’t mourn, organize! We are all prisoners of hope.”
For the Committee, Jack Carney
References:
Carney, J., “Boycott The DSM-5: Anachronistic Before Its Time,” December 10, 2012, www.madinamerica.com/jcarney/author/
Frances, A., Price Gouging: Why Will DSM-5 Cost $199 a Copy? http://www.psychologytoday.com/blog/dsm5-in-distress/
* * * * * *
Boycott the DSM-5!
We, the undersigned, will not purchase nor will we use the new DSM-5 when it is published by the American Psychiatric Association. Further, those of us associated with professionals who use the DSM – as persons receiving services from them or as family members, friends or advocates – will urge service providers not to use the DSM-5:
• DSM-5 is unsafe and scientifically unsound.
Its categories or diagnoses, including newly introduced diagnoses, are not supported by scientific evidence. These diagnoses will pathologize rather than bring relief to persons in distress.
• DSM-5 will drastically expand psychiatric diagnosis, mislabel millions of people as mentally ill, and cause unnecessary treatment with medication.
All references to psychosocial, environmental and spiritual factors have been removed from DSM-5. This sends a clear message to clinicians that treatment for persons judged to have psychiatric disorders can be reduced to the prescription of psychoactive medications, despite growing concerns of their dangers and skepticism about their effectiveness.
• The APA has been unresponsive to widespread opposition.
The APA has been unresponsive to criticism received from professional, advocacy and lay public stakeholders during the three public reviews of its proposals. The concerns expressed by over 14,000 signatories to the “Open Letter to the DSM-5” and the request for independent, scientific review of proposed changes to the DSM have been ignored.
• The APA has undermined it own credibility, choosing to protect its intellectual property and publishing profits, not the public trust.
Accordingly, we agree to boycott the DSM-5 and to urge service providers and others not to use it. If we find ourselves obliged to employ diagnostic codes, we agree to disregard the new DSM and utilize the codes listed in the ICD-9 and the next edition of ICD, when the latter is implemented in October, 2014.
SPONSORED BY THE COMMITTEE TO BOYCOTT THE DSM-5
http://www.ipetitions.com/petition/boycott5
http://boycott5petition.com
 


DSM5 in Distress



 
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Monday, February 4, 2013

DUOS: jung & freud


Mike Nova shared Сергей Словалкер's photo.
22 hours ago
DUOS: jung & freud
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eddie ray routh - GS

eddie ray routh - GS


Eddie Ray Routh - News Review


Last Update: 2.10.13



"A puzzle inside of an enigma wrapped in a mystery"


Eddie Ray Routh, Accused of Killing Chris Kyle, ‘American Sniper,’ Had Troubled Past
www.nytimes.com
Eddie Ray Routh, accused of killing Chris Kyle, the author of “American Sniper,” had been released from a hospital over his parents’ objections just days before the shooting, his lawyers said.


Chris Kyle’s Alleged Killer – Who Is Eddie Ray Routh?

Posted on Feb 3, 2013 @ 16:34PM | By Radar Staff
 
Landov
Landov
 
He’s been charged with murdering Chris Kyle, the deadliest sniper in U.S military history but who is Eddie Ray Routh and what made him allegedly turn his gun on one of the countries’ most decorated Iraq war heroes?
Routh is accused of killing both Kyle, a retired Navy Seal and author of the best-selling American Sniper, and his neighbor, Chad Littlefield, at the posh Rouge Creek Lodge gun range near Glen Rose, Texas.
Now RadarOnline.com is looking at new details about the man behind bars.
PHOTOS: James Holmes’ Yearbook Photos

 
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Saturday, February 2, 2013

NYT: Veterans Make Up Shrinking Percentage of Suicides

Veterans Make Up Shrinking Percentage of Suicides »
The convergence reflects the fact that suicide numbers are rising slightly among both veterans and everyone else, but has increased more in the general population.
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If psychiatry is not successful, APA will not be successful

(title unknown):
PsychiatryOnline | Psychiatric News | News Article
psychnews.psychiatryonline.org
James H. Scully Jr., M.D., will retire as APA medical director and chief executive officer at the end of this year after a decade of remarkable change and progress.

Scully will leave behind an APA stronger than he found it when he became medical director 11 years ago, and one that is poised to face the future. “We are the voice of psychiatry,” he said. “No other group does what we do. If APA is not successful, psychiatry will not be successful.”
 
Comment: 
 
I would phrase it a little differently, Dr. Scully:
 
If psychiatry is not successful, APA will not be successful.
 
Sometimes it is important to position chickens and eggs properly. And, maybe it is exactly this "mispositioning": prioritising psychiatry as a profession and as a professional organisation over psychiatry as a unique medical and social science and discipline, that is a part of the problem.
 
Michael Novakhov.
 
 
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(title unknown)

(title unknown):
The Complicated World of Higher Education for Troops and Veterans
www.nytimes.com
With more than $10 billion being spent this year educating troops and veterans, the order has been given: help them graduate. But how?
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Thursday, January 24, 2013

News Review: What is Critical Psychiatry? | Critical Psychiatry and Psychology News

 

via BEHAVIOR AND LAW - General, Forensic, Military and Prison Psychiatry News by Mike Nova on 1/24/13
What is Critical Psychiatry? | Mad In America: Over the last twenty years there has emerged a body of work that questions the assumptions that lie beneath psychiatric knowledge and practice. This work, appearing as academic papers, magazine articles, books, and ...

via Mad In America » Blogs by Philip Thomas, M.D. on 1/21/13
Over the last twenty years there has emerged a body of work that questions the assumptions that lie beneath psychiatric knowledge and practice. This work, appearing as academic papers, magazine articles, books, and chapters in books, hasn’t been written by academics, sociologists or cultural theorists. It has emerged from the pens and practice of a group of British psychiatrists.
This is not antipsychiatry. There are important differences between the antipsychiatry of the 1960s and present-day critical psychiatry; there are also important points of convergence, but the two nonetheless are quite different. Some of these similarities and differences will become clear as this series of blogs, written to complement the narrative blogs I’ll occasionally be posting, evolve over time.
In this series of postings, to appear under the ‘Critical Psychiatry’ tag, I want to present an overview of some of this work. This is because interest in critical psychiatry is growing, especially in the USA. There will be presentations by British critical psychiatrists at the APA annual meeting in San Francisco, and the Institute on Psychiatric Services in Philadelphia, both this year. This series of blogs about critical psychiatry is also by way of a sneak preview of a book I’m writing about British critical psychiatry, to be published by PCCS Books – http://www.pccs-books.co.uk – in the near future; watch this space!
So what exactly is critical psychiatry? The bulk of this work has been written by a small group of psychiatrists, all of whom are, or were, practicing psychiatrists in the NHS in England. All are associated with the Critical Psychiatry Network – http://www.criticalpsychiatry.co.uk – which first met in Bradford, England in 1999. The most active members of this group have between them written ten single or dual author books, ten edited books with forty-two chapters, and one hundred and thirty seven papers mostly in peer-reviewed journals. A survey of this work reveals that it covers five themes:
  1. The problems of diagnosis in psychiatry
  2. The problems of evidence based medicine in psychiatry, and related to this, the relationship between the pharmaceutical industry and psychiatry.
  3. The central role of contexts and meanings in the theory and practice of psychiatry, and the role of the contexts in which psychiatrists work.
  4. The problems of coercion in psychiatry.
  5. The historical and philosophical basis of psychiatric knowledge and the practice of psychiatry.
These themes are not mutually exclusive, for example, there is a close relationship between some aspects of the problems of diagnosis, particularly the problem of validity, and the problems of evidence-based medicine. In addition, the problems of diagnosis in psychiatry may also be seen in terms of another set of issues, that of the application of the methods of scientific inquiry to human subjects. This in turn relates to a third, that of the neglect of contexts and meanings in contemporary psychiatric practice. And, at a conceptual level, these problems can be understood in terms of three key philosophical issues, the nature of knowledge and different ways of knowing about the world (epistemology), the nature of the body-mind relationship, and the relationship between mind and the world, especially the social world.
These three issues are of fundamental importance in understanding the limitations of scientific psychiatry. Most important of all, however, is a focus on the moral and ethical implications of the use of scientific knowledge (whether biological, psychological, sociological) in relation to madness and distress. Ultimately, critical philosophical thought has a great deal to offer when it comes to understanding how these different problems of psychiatric knowledge and practice are related. In this blog I will focus on the first of these themes. Subsequent blogs in the coming months will deal with the others.
The problems of diagnosis in psychiatry
The writings of critical psychiatrists see the problems of diagnosis in psychiatry in two areas: problems with the scientific basis of psychiatric diagnoses, and the moral problems that can arise from the use of psychiatric diagnosis.
The scientific basis of diagnosis in psychiatry
Joanna Moncrieff (1997) points out that despite extensive scientific research, there is no convincing evidence that specific biological causes account for either depression or schizophrenia. Research councils and other funding bodies have invested huge sums of money over the years in the quest for the biological basis of the condition called schizophrenia, but without success. Researchers in molecular genetics, neuroimaging and other neuroscientific fields persistently overstate the significance of their findings. Duncan Double (2000) also questions the evidence to support a biological basis for psychiatric diagnoses. He points out that a low level of agreement over the diagnosis of schizophrenia between psychiatrists in different countries has hampered psychiatric research.
Until the 1970s, American psychiatrists had a much broader conception of schizophrenia than their British colleagues, who used the diagnosis much less frequently. He also points out that the monoamine theory of depression and the dopamine theory of schizophrenia developed after the introduction of drugs that were claimed to ‘cure’ these conditions. Prior to this there was little interest in neurotransmitters like dopamine and the monoamines. This emerged when laboratory research drew attention to the effects of these drugs on neurotransmitters. Only then did these theories emerge. In contrast, the discovery of drugs to treat neurological conditions like Parkinson’s disease resulted from extensive laboratory research into the role of dopamine as a neurotransmitter.
The biological basis of schizophrenia remains elusive and unsubstantiated (Thomas, 2011). One reason for this as Duncan Double (2002) points out that is the poor level of agreement between psychiatrists over the diagnosis. This was one of the factors responsible for the move towards a more scientific psychiatry heralded by DSM-III. The first edition of the DSM published in 1952 gave definitions and criteria for 106 categories of psychiatric disorders, but the publication of the fourth edition in 1994 saw this number swell to 354. The third edition ‘…encouraged the reification of psychological conditions. Social phobia, post-traumatic stress disorder, for example, were first included in international classifications in DSM-III.’ (Double, 2002:902). The third edition, he suggests, coincided with the growing influence of scientific psychiatry, and a return to the values expounded by the German psychiatrist Emil Kraepelin a hundred years earlier.
Sami Timimi (2004) argues that the diagnosis of attention deficit hyperactivity disorder (ADHD) is a cultural construct. He points out that there are no specific biological or psychological markers for the condition, and as a result of disagreements and uncertainties over the definition there are wide variations in the prevalence of the condition. One thing that is clear from epidemiological studies is the condition has become much more common over time. In order to understand this we have to adopt a cultural perspective, and in particular recent changes in Western culture.
The expansion of diagnosis has also been a feature of child psychiatry. Until relatively recently the emphasis here was on child development, the family, and psychodynamic and social understandings of childhood. Sami Timimi (2004a) points out that before the introduction of DSM-III, depression was an uncommon diagnosis in childhood. It was also considered to be different from depression in adults, and not to respond to antidepressant drugs. This changed when an influential group of academic child psychiatrists claimed that childhood depression was more common than most people thought, and that it responded to physical treatments. Sami Timimi argues that current psychiatric diagnostic criteria in depression are so broad as to be useless. Most children can be identified as suffering from some form of psychiatric disorder. In addition there are low levels of agreement between the diagnosis of depression and the psychosocial problems that are usually associated with it. This raises serious doubts about the value of constructs like childhood depression.

The moral problems of diagnosis
In Britain this is seen most tragically in the problematic encounter between psychiatry and people from Black and Minority Ethnic (BME) communities. Suman Fernando (1991) argues that belief in the neutrality of psychiatric knowledge and practice has helped to conceal the racist assumptions in which the two are based. This problem operates nationally and globally. In Britain there a huge body of evidence has accumulated over the last fifty years that the incidence of schizophrenia is much higher in people from African-Caribbean communities, especially young men. This fact, allied with what is a widely held but racist perception that young Black men are dangerous, is linked to the higher rates of compulsion and coercion they experience in mental health services. Young black men are also more likely to receive physical treatments and higher doses of drugs in hospital than other groups.
But the problem doesn’t end there. Psychiatric theories resort to racist explanations for the raised incidence of schizophrenia in black people, based either in supposed biological or genetic differences between black people and the white majority, or in the family structures and life styles (especially cannabis use) that are said to characterise the African-Caribbean cultures. Psychiatry consistently locates the origins of the problem of schizophrenia in the biology or culture of these young men, and not in the experiences of racism and discrimination that feature prominently in their lives. This is a serious moral failure.
Racism is a difficult issue for health professionals to have to face up to. Kwame McKenzie (2003) argues that the experiences of racism have adverse effects upon the health of those affected. This can be seen in the raised incidence of high blood pressure, respiratory illnesses, anxiety, depression and psychosis in black people. Writing in the context of the Macpherson Report into the failure of the Metropolitan Police to bring about a prosecution in the racist murder of black teenager Stephen Lawrence, he (McKenzie, 1999) points out that like the police, doctors take offence to accusations of racism. This is where the idea of institutional racism is helpful, because it considers how the values and structures of mental health services inadvertently discriminate against minority groups.
More generally, as Duncan Double (2002) argues, the use of diagnosis based in biological explanations of experience eliminates the possible significance of the meaning of distress, and obscures its social and psychological origins. This encourages people to see themselves as powerless to do anything about their problems. This has important implications for recovery.
The use of diagnosis has become an important tool in the pharmaceutical industry’s attempts to extend its global commercial interests, and Suman Fernando (1991) points out that this has harmful consequences on local understandings of distress and madness and the systems of support that are based in this, especially in non-Western countries. Western scientific understandings of distress originate in historical and philosophical assumptions about the self that are a feature of Western civilization. International agencies like the World Health Organisation (WHO) place additional pressures on non-Western countries to adopt Western ‘solutions’ to the problem of madness, indirectly endorsing the pharmaceutical industry’s agenda and further weakening local support systems. Support for this view comes from a paper that Pat Bracken & I wrote (Bracken & Thomas, 2001), which argues that scientific accounts of distress exemplified by the DSM are rooted in the view that human suffering would ultimately yield to scientific progress.
The notion of progress through rational scientific thought originated in the European Enlightenment. One of the important outcomes of this period of thought and history was the replacement of religious belief and superstition by science and rationality in our attempts to understand our lives and our relationship to the world. The scientific approach, which reached its apogee in the Decade of the Brain, replaced a wide variety of non-scientific ways of understanding madness and distress, first in Europe, but increasingly through the second half of the twentieth century, across the globe.
If it is the case that psychiatric diagnoses have no firm scientific basis, and that they are little more than consensus statements produced by committees of experts, then it should come as no surprise to discover that political factors play an important part in their creation and abolition. Forty years ago the British and American psychiatric establishments rightly attacked the former Soviet Union for its use of the diagnosis sluggish schizophrenia as a means of silencing dissidents. At the same time gay activists in the USA campaigned politically to have homosexuality removed as a diagnosis from the DSM, and in 1973 it was replaced by the category sexual orientation disturbance. Derek Summerfield draws attention to the political nature of psychiatric diagnosis, and the moral problems that arise from this. He argues that the origin of the diagnosis of post-traumatic stress disorder (PTSD) was a political, not scientific, achievement.
Following the Vietnam War the U.S. anti-war movement persuaded military psychiatry to provide help and support for veterans. As a result the diagnosis of PTSD replaced earlier conceptions of battle fatigue and war neurosis, and drew attention to the traumatogenic nature of war. In doing so the diagnosis also transformed Vietnam veterans from perpetrators of war atrocities to victims of trauma; the category ‘…legitimized the “victimhood”, gave moral exculpation…’ (Summerfield, 2001:95). The diagnosis of PTSD has less to do with science and natural categories than it has to do with internal political struggles to salve a nation’s conscience after a terrible conflict.
Western concepts of trauma and the psychiatric diagnosis of PTSD attempt to redefine the moral consequences of conflict. In another paper Derek Summerfield points out that surveys of the residents of war zones tend to interpret feelings of revenge as an indicator of poor mental health (Summerfield, 2002) For example in Croatia, a foreign-led project told Croatian children affected by the war that not hating Serbs would help them to recover from trauma. In South Africa, studies of the victims of apartheid found that PTSD was significantly more common in those who were unforgiving (as measured by their score on a ‘forgiveness’ scale).
These, and similar, studies give weight to the view that forgiveness is necessary for recovery. Thus the emotional responses of those affected by war, ‘traumatisation’ or ‘brutalisation’, are held to be harmful and in need of modification. This belief, he argues, provides the basis for large scale counselling interventions by Western aid agencies. He challenges this view, by asking is anger and the need for revenge necessarily a bad thing. They draw attention to the moral aspects of injustice that lead to suffering in the first place, and the importance of social cohesiveness and solidarity as a social and cultural response to the injustices of war.

References
Bracken, P. & Thomas. P. (2001) Postpsychiatry: a new direction for mental health. British Medical Journal, 322, 724 – 727.
Double, D. (2000) Critical Psychiatry. CPD Bulletin Psychiatry, 2, 33 – 36.
Double, D. (2002) The Limits of Psychiatry. British Medical Journal, 324, 900-904.
Fernando, S. (1991) Mental Health, Race and Culture. Macmillan / Mind Publications, London. (1st edition).
McKenzie, K. (1999) Something borrowed from the blues? British Medical Journal, 318, 616 – 617.
McKenzie, K. (2003) Racism and Health. British Medical Journal, 326, 66.
Moncrieff, J. (1997) The medicalisation of modern living. Soundings, 6, 63 – 72.
Summerfield, D. (2001) The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. British Medical Journal 322, 95 – 98.
Summerfield, D. (2002) Effects of war: Moral knowledge, revenge, reconciliation, and medicalised concepts of recovery. British Medical Journal, 325, 1105-1107.
Thomas, P. (2011) Biological explanations for and responses to madness. Chapter Fourteen in (eds. D. Pilgrim, A. Rogers and B. Pescosolido) The SAGE Handbook of Mental Helath and Illness. London, Sage. (pp 291 – 312).
Timimi, S. (2004) In Debate: ADHD is best understood as a cultural construct – For. British Journal of Psychiatry (In Debate) 184, 8-9.
Timimi, S. (2004a) Rethinking childhood depression. British Medical Journal, 329, 1394-1397.





Reprinted from CPD Bulletin Psychiatry (2000) 2 33-36


Critical Psychiatry

    • Modern-day psychiatry relies too much on the "medical model" and emphasises diagnostic decisions. If psychiatrists adopted a more social or therapeutic community approach treatments would be more effective.

    • The categorisation of psychiatric illness is not as clear as most psychiatrists believe. Assessment of aetiology too often fails to take personal and social factors into account.

    • There is too much emphasis on the scientific possibilities of randomised controlled trials. The evidence of these trials is biased.

    Introduction
    Psychiatry is open to criticism because of its power of compulsory detention and treatment. This issue could be avoided by psychiatrists restricting themselves to voluntary treatment, and psychotherapists indeed routinely do practise on this basis. However, the social responsibility of caring for the mentally ill is an essential function of psychiatry and should not be neglected. The question is how well psychiatry fulfills its role.

    Critical psychiatry suggests that psychiatric practice is often inadequate for a number of reasons. This article will review this critique of psychiatry by examining its main constituents. Over recent years mainstream psychiatry has marginalised its critics by dismissing them as "antipsychiatrists". However, those identified as part of the antipsychiatry movement, such as David Cooper, Thomas Szasz and RD Laing do not represent a single view (Tantam 1991). Cooper was politically Marxist and the only one that accepted the designation "antipsychiatrist"; Szasz (1972) regards mental illness as a myth; Laing recognised the turmoil of mental suffering, whilst acknowledging that the term mental illness is used metaphorically. Arguably, the "antipsychiatrists" are only linked by their willingness to criticise psychiatric practice.

    Biological bias in psychiatry
    Detaining the mentally ill creates the potential for abuse. From the 1950s, attempts were made to make psychiatric hospitals more therapeutic by unlocking the doors (WHO 1953). The maltreatment of patients in hospital was exposed in several scandals that gave an impetus to the dehospitalisation of patients (Martin 1984). Conversely, inquiries over recent years, particularly following homicides by psychiatric patients, have expressed concern about neglect of patients in the community (Peay 1996). Psychiatric services have to find a precarious balance beside abuse and neglect.

    Accordingly it can be difficult to sustain interpersonal relationships. One temptation is to retreat into objectification of those identified as mentally ill, insisting on the somatic nature of their illness. An advantage of this strategy is that it protects those trying to provide care from the pain experienced by those needing support. Notwithstanding some intuitive understanding of mental illness as a disorder of the mind, it is simpler to concentrate on its bodily substrate. Such a biological bias is not new in psychiatry, although psychopharmacological developments following the discovery of antipsychotics and antidepressants have reinforced this emphasis. As expressed by John Haslam (1798) over two centuries ago: "[T]he various and discordant opinions, which have prevailed in this department of knowledge, have led me to disentangle myself as quickly as possible from the perplexity of metaphysical mazes."

    Both the dopamine theory of schizophrenia (dopamine overactivity in schizophrenic brains) and the amine hypothesis of depression (amines depleted in depressed brains) arose following the introduction of psychotropic drugs, at a time when only few neurotransmitters had been discovered. Despite the subsequent discovery of a vastly more complex neurotransmitter network, psychiatrists still use such simplistic notions in their everyday management of patients when they explain that mental illness is due to "chemical imbalance".

    The evidence for the organic basis of functional psychiatric conditions such as schizophrenia is not as considerable as certain claims suggest. Functional imaging of receptors has produced equivocal results. Structural and functional cerebral abnormalities in schizophrenia are at best subtle rather than gross (Chua & McKenna 1995). In contrast, the identification and cloning of genes and the elucidation of chromosomal abnormalities has led to major progress in the molecular biology of genetic neuropsychiatric disorders, such as Huntington's disease, in which the abnormality of triplet repeat on chromosome four has now been demonstrated.

    Taken to its extreme, the danger is that people with mental health problems will be reduced to purely physical terms wherein their brain chemistry needs correction. Moreover, the biological hypothesis is used to give justification to medical control in the treatment of mental illness. In relations of power, it suits psychiatrists to keep other mental health professionals thinking that they may be missing vital knowledge about bodily processes. The authority of the challenge to the biological hypothesis is thereby undermined.

    Diagnosis
    Single-word diagnoses fail to give an adequate understanding of a person's mental health problems. The modern explicit and intentional concern with diagnosis and classification disguises uncertainty about psychiatric disease entities.

    In particular, over recent years, psychiatric diagnosis has become increasingly codified following the original paper by Feighner et al (1972), and the introduction of the Research Diagnostic Criteria (Spitzer et al 1975), through editions of DSM-III, DSM-IIIR and DSM-IV (APA 1994) and ICD-10 (WHO 1992). Robert Spitzer, who chaired the DSM-III Task Force, was particularly concerned about a study by Rosenhan (1973), which raised the fear that unreliable diagnoses may invalidate the whole process of psychiatric practice (Spitzer & Fleiss 1974). Rosenhan demonstrated that normal people could gain admission to hospital and acquire a diagnosis of schizophrenia by merely feigning a mundane, simple hallucination, saying they were hearing a voice say "thud", "empty" or "hollow". He concluded that professionals were unable to distinguish the sane from the insane. Operationalisation of psychiatric criteria arose as a response to the perceived need for objectification in diagnosis.

    The US-UK Diagnostic Comparison Study demonstrated that American psychiatrists were using the term schizophrenia more inclusively than their British counterparts (Kendell et al 1971). This finding also contributed to a tightening of diagnostic criteria, particularly a restriction of the use of the term schizophrenia. Concern about stigmatisation has made psychiatrists much less ready over recent years to use a diagnosis of schizophrenia which tends to imply poor prognosis.

    The movement to create explicit diagnostic criteria has been called neo-Kraepelinian, as it promotes many of the ideas associated with the views of Emil Kraepelin, often seen as the founder of modern psychiatry (Klerman 1978). Adolf Meyer was regarded as extremely influential in American psychiatry in the first half of this century, and his influence came to Britain via Aubrey Lewis and David Henderson (Gelder 1991). Meyer (1951/2) is remembered for his opposition to the preoccupation of the Kraepelinians with diagnosis. Although he accepted that there may be a place for classification, he argued that if diagnosis was meaningful, it was secondary to the assessment of the patient as a person (Double 1990). He may be held responsible for helping to create a trend which depreciated the role of diagnosis, which the neo-Kraepelinian movement deliberately countered. Psychoanalysis was strong in academic psychiatry in the post-war period in America and also appears to have played a role in de-emphasising the importance of diagnosis and classification..

    It is illegitimate to postulate an underlying disease entity just because mental disorders may seem unintelligible. Assessment should concentrate on the "facts of the case", as Meyer was fond of saying, and diagnosis usually does justice to only part of "the facts". Even if "the facts" do not constitute a diagnosis, clinical management has to act on them. Meyer favoured a psychogenic explanation of mental illness and regarded it as not completely foreign to normal experience. In particular, he explained schizophrenia (dementia praecox) as a maladaptation that could be understood in terms of the patient's life experiences. Psychiatric assessment too often fails to appreciate personal and social precursors of schizophrenia by avoiding or not taking account of such considerations.

    Social therapy
    Several experimental attempts have been made to provide a more therapeutic milieu than the traditional hospital environment. For example, Harry Stack Sullivan established a small ward for schizophrenic men that was staffed with hand-picked attendants, set apart from the rest of the Sheppard Pratt Hospital in the 1920s (Barton Evans III 1996). He gave his staff autonomy to operate on their own with patients. As Sullivan (1962) stated:

    [W]e found intimacy between the patient and the employee blossomed unexpectedly, that things I cannot distinguish from genuine human friendship sprang up between patient and employee, that any signs of the alleged apathy of the schizophrenic faded, to put it mildly, and that the institutional recovery rate became high.
    Sullivan's experimental ward could be seen as a precursor of the therapeutic community movement, whose influence came to be integrated with mainstream psychiatry (Jones 1952, van Putten 1973). This emphasis on the social aspects of treatment, though, is much less obvious in the current climate of risk assessment and psychotropic drug management (Clark 1974).

    The "antipsychiatrists" also experimented with institutional alternatives. For example, David Cooper set up Villa 21 in Shenley Hospital, although Cooper's positioning as an antipsychiatrist makes it difficult to appreciate the similarity with ventures like that of Sullivan. Cooper's (1967) "experiment in antipsychiatry" failed to change the ward staff's role-bound behaviour. Laing's Kingsley Hall was outside the hospital system and was perhaps more like a commune. Criticism of its laissez-faire ethos should take account of Laing's own concession - that he had failed to find "a tactical, workable, pragmatic . . . . sort of thing that could work for other people" (Mullan 1995).

    Scepticism about therapeutic efficacy
    Historically doctors have prescribed medications which are now regarded as useless and often dangerous. Non-specific placebo effects can be powerful (Shapiro & Shapiro 1997). Uncontrolled evaluation of the efficacy of treatment was eventually replaced by clinical trials and the acceptance and use of the double-blind method. However, randomised controlled trials are commonly flawed in practice and the most rigorous trials are associated with less treatment benefit than poor quality trials (Moher et al 1998). The recent emphasis on evidence-based medicine with initiatives such as the Cochrane Collaboration has also focused on methodological issues.

    The double-blind method is not infallible because frequently the double blind can be broken (Fisher & Greenberg 1997). Patients and doctors may be cued in to whether patients are taking active or placebo medication by a variety of means. For example, they may notice that placebo tablets they have been taking taste differently from medication to which they have previously become accustomed. Active medication may produce side effects which distinguishes it from inert medication. There is evidence even of deliberate deceit in clinical trials so that randomised allocation is not concealed (Schultz 1996).

    Studies where an attempt to measure unblinding has been made confirm that it does occur and significant correlations with efficacy ratings have been found (Shapiro & Shapiro 1997). These problems of unblinding may be minimised by trialists because there seems to be nothing that can be done to prevent it completely. Nonetheless, there should then be no pretence that unbiased evaluation of treatment is being carried out. Although the apparent specific effect of treatment may not be as great as the placebo effect itself, it may merely be the wishfulfilling amplification of nonspecific effects. Using active drugs without apparent specific treatment effects as controls generally reduces the effect size of the active treatment, maybe because patients are less likely to be unblinded in the trial because of the detection of active effects in the control drug (Thomson 1982).

    The placebo effect may be relevant to problems in discontinuation. People may form attachments to their medication more because of what it means to them than what it does. Any change threatens an equilibrium related to a complex set of meanings that their medication has acquired. These issues of reliance on medication should not be minimised, yet commonly compliance with treatment is reinforced by emphasising that antidepressants, for example, are not addictive (Double 1997). Psychotropic medication is often prescribed in life crises reinforcing defensive mechanisms against overwhelming anxiety, and the power of the placebo effect should be recognised. Counteracting such placebo effects may not be easy when discontinuing medication.

    Conclusion and future developments
    Psychiatric practice can be criticised for its failure to regard the patient as a person. Mainstream psychiatry acts on the somatic hypothesis of mental illness to the detriment of understanding people's problems. Laing's (1982) primary motivation was his appreciation that schizophrenia, in particular, was more understandable than mainstream psychiatry recognized. This stance is consistent with Adolf Meyer's (1951/2) philosophy. The neo-Kraepelinian has eclipsed the Meyerian approach over recent years and encouraged excessive enthusiasm about diagnosis and treatment which requires critical analysis (Double 1991).

    Antipsychiatry has been marginalised because it accuses psychiatry of social control (Farrell 1979). Renewed criticism of modern psychiatry is required and the Critical Psychiatry Network gives expression to a "post-psychiatry" (Critical Psychiatry Network website). Psychiatry need not feel negative about this process. Patients and society will continue to demand its services and appreciate realistic expectations.
     

    References

    American Psychiatric Association (1994)
    Diagnostic and Statistical Manual of Mental Disorders (4th edition). Wahington: APA.

    Barton Evans III, F. (1996)
    Harry Stack Sullivan. Interpersonal theory and psychotherapy. London: Routledge.

    Chua, S.E. & McKenna, P.J. (1995)
    Schizophrenia - a brain disease? A critical review of structural and functional cerebral abnormality in the disorder. British Journal of Psychiatry, 166, 563-582.

    Clark, D.H. (1974)
    Social therapy in psychiatry. Harmondsworth: Penguin.

    Cooper, D. (1967)
    Psychiatry and anti-psychiatry. London: Tavistock Publications.

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    Double, D.B. (1997)
    Prescribing antidepressants in general practice. People may become psychologically dependent on antidepressants. [Letter] BMJ, 314, 829.

    Double, D.B. (1991)
    What would Adolf Meyer have thought of the neo-Kraepelinian approach? Psychiatric Bulletin, 14, 472-4.

    Farrell, B.A. (1979)
    Mental illness: a conceptual analysis. Psychological Medicine, 9, 21-35.

    Feighner, J.P., Robins, E., Guze, S.B., et al (1972)
    Diagnostic criteria for use in psychiatric research. Archives of General Psychiatry, 26, 57-63.

    Fisher, S. & Greenberg, R.P., (eds) (1997)
    From placebo to panacea. Putting psychiatric drugs to the test. Chichester: John Wiley.

    Gelder, M. (1991)
    Adolf Meyer and his influence on British psychiatry. In Berrios, G.E. & Freeman, H., (eds) 150 years of British psychiatry. London: Gaskell.

    Haslam, J. (1798)
    Observations on Insanity. London: Rivington.

    Jones, M. (1952)
    Social psychiatry: A study of therapeutic communities. London: Tavistock.

    Kendell, R.E., Cooper, J.E., Gourlay, A.J., et al (1971)
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    Klerman, G.L. (1978)
    The evolution of a scientific nosology. In Shershow, J.C. (ed) Schizophrenia: Science and Practice. Cambridge, Mass: Harvard University Press.

    Laing, R.D. (1985)
    Wisdom, madness and folly. The making of a psychiatrist. London: Macmillan.

    Martin, J.P. (1984)
    Hospitals in trouble. Oxford: Blackwell.

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    Collected Papers (Four Volumes). Baltimore: John Hopkins.

    Moher, D., Pham, B., Jones, A., et al (1998) Does quality of reports of randomised trials affect estimates of intervention efficacy reported in meta-analyses? Lancet, 352, 609-613.

    Mullan, B. (1995)
    Mad to be normal. Converations with RD Laing. London: Free Association.

    Peay, J. (ed) (1996)
    Inquiries after homicide. London: Duckworth.

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    On being sane in insane places. Science, 179, 250-258.

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    Spitzer, R.L. & Fleiss, J.L. (1974)
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    ____________________________

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