Mental Health RevolutionMental Health Revolution

Pat BrackenPat Bracken

RCPsych Oct 28RCPsych Oct 28thth 2008 2008

Mental Health RevolutionMental Health Revolution

• Changing ideas about revolutionChanging ideas about revolution

• The nature of the dominant paradigm The nature of the dominant paradigm in mental healthin mental health

• Causes of, and justification for, Causes of, and justification for, revolutionary changerevolutionary change

• Implications for our professionImplications for our profession

Che GuevaraChe Guevara

Killing Fields of CambodiaKilling Fields of Cambodia

John GrayJohn Gray

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

CopernicusCopernicus

Kuhn: paradigmsKuhn: paradigms

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

Technological ApproachTechnological Approach

Technological Approach

Medicalmodel

Cognitive approaches Language of

Management

Main Assumptions of the Main Assumptions of the Technological ParadigmTechnological Paradigm

• The problem to be addressed has to due The problem to be addressed has to due with a faulty with a faulty mechanism or process mechanism or process of some of some sortsort

• The mechanism or process can be The mechanism or process can be modelled modelled in causal terms,in causal terms, ie described in a way that is ie described in a way that is universal, a way that works regardless of the universal, a way that works regardless of the contextcontext

• Technological interventions are Technological interventions are instrumental. instrumental. They are not to do with They are not to do with opinions, values, relationships or priorities. opinions, values, relationships or priorities.

Technical idiomTechnical idiom

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

Modernist PsychiatryModernist Psychiatry

• PrimaryPrimary discourse is technical: focused on discourse is technical: focused on diagnosis and classification, causal diagnosis and classification, causal explanations, evidence-based interventions explanations, evidence-based interventions (EBM) (EBM)

• Other issues become Other issues become secondary:secondary: ethics, values and priorities, ethics, values and priorities, meanings and contexts, meanings and contexts, relationships and powerrelationships and power

Why is Technological Paradigm Why is Technological Paradigm dominant? dominant?

• Cultural supportCultural support

• Patient expectationsPatient expectations

• Underscores professional rolesUnderscores professional roles

• Pharmaceutical industryPharmaceutical industry

Roy PorterRoy Porter

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

Why is Technological Paradigm Why is Technological Paradigm so dominant? so dominant?

• Cultural supportCultural support

• Patient expectationsPatient expectations

• Underscores professional rolesUnderscores professional roles

• Pharmaceutical industryPharmaceutical industry

Role of Service-user Role of Service-user Organisations in the Organisations in the Technological ParadigmTechnological Paradigm

-consultation-consultation

-help with fund-raising and recruiting -help with fund-raising and recruiting subjects for research subjects for research

-their expertise -their expertise secondarysecondary to that of to that of the technical knowledge of the the technical knowledge of the professionalprofessional

20th Century Psychiatry20th Century Psychiatry

Focus on technology of diagnosis and

treatment

relationships

Ethics and values

Social position

Cultural issues

Direction of Direction of Revolutionary ChangeRevolutionary Change

Discoursecentred on:

-values/ethics-meanings/contexts-relationships/power

Appropriate research

Service models

Training priorities

Use of drugs and therapy

Challenges to technological Challenges to technological paradigmparadigm

• Postmodern culturePostmodern culture

• Changing understanding of Changing understanding of technology itselftechnology itself

• Moves away from the embrace of Moves away from the embrace of PharmaPharma

Why Revolution is JustifiedWhy Revolution is Justified

• Empirical evidenceEmpirical evidence

• Conceptual analysisConceptual analysis

• Political reasonsPolitical reasons

• Ethical imperativeEthical imperative

CBTCBT

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

Why Revolution is JustifiedWhy Revolution is Justified

• Empirical evidenceEmpirical evidence

• Conceptual analysisConceptual analysis

• Political reasonsPolitical reasons

• Ethical imperativeEthical imperative

Psychiatry and PhilosophyPsychiatry and Philosophy

Why Revolution is JustifiedWhy Revolution is Justified

• Empirical evidenceEmpirical evidence

• Conceptual analysisConceptual analysis

• Political reasonsPolitical reasons

• Ethical imperativeEthical imperative

EthicalEthical

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

Mad Pride in CorkMad Pride in Cork

Icarus ProjectIcarus Project

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

Implications for PsychiatryImplications for Psychiatry

• Rethinking psychopathologyRethinking psychopathology

• A different understanding of A different understanding of expertiseexpertise

• TrainingTraining

• ResearchResearch

• Service developmentsService developments

Insights from Recovery Insights from Recovery LiteratureLiterature

1.1. Recovery often made through paths Recovery often made through paths that are alternatives to drugs and that are alternatives to drugs and psychotherapypsychotherapy

2.2. Importance of loss of social position Importance of loss of social position that comes with being a service that comes with being a service useruser

3.3. Community development approach Community development approach

Relationship with service user Relationship with service user movementmovement

From Consultation to From Consultation to collaborationcollaboration