Dr Pat Bracken - West Cork Mental Health Service, Ireland
Dr Pat Bracken discussed the value of “critical psychiatry” in moving beyond a “common sense” view of mental health to a recovery-oriented approach.
The Nature Of Critical Thinking
Pat asks: How is that we come to be deferential towards those forces that oppress us? Pat argues that:
- “Common sense” has important limitations and dangers
- The assumptions that we take for granted may lead to ruin for individuals, systems and societies
- Critical thinking provides opportunities for questioning common sense in ways that reduce these risks
- Critical thinking involves “an attempt at objective judgement so as to determine both merits and faults of a particular perspective”
Pat also provided an introduction to Paolo Friere's critical pedagogy, an approach to teaching and learning in which:
- The students are not docile recipients of knowledge, but are instead critical co-investigators through dialogue with the teacher
- The purpose of pedagogy is the nurturing of active citizens through critical and imaginative reflection on the status quo
- The status quo is never fixed, but rather is always based on contextual and cultural assumptions
- Our common sense should therefore always be open to challenge
Expertise and Dialogue
- Critical thinking aims to create conditions in which real dialogue can take place
- The teacher seeks to become the student, while the student becomes the teacher
- The true expert, then, is someone who can negotiate dialogue - real dialogue - which promotes ”active citizenship”
- Rather than a consumer of wisdom, an active citizen is someone who can actively engage with the status quo and the institutions that frame their lives
Our Current “Common Sense” About Mental Health: The Technological Paradigm
Pat argued that the current “common sense” about mental health is a “technological paradigm” in which:
- The problem to be addressed has to do with a faulty biological or cognitive mechanism or process
- The mechanism or process can me modelled in causal terms, i.e. described in a way that is universal, a way that works regardless of context
- Technological interventions are value-free and instrumental in that they are problem-oriented and not to do with opinions, values, relationship or priorities
Why Is The Technological Paradigm Dominant, And What Are Its Effects?
- Cultural support – the technological paradigm is consistent with the continuing dominance of modernism within the medical world
- Patient expectations – at times passing some responsibility over to the expert and adopting the sick role can be useful (in the short term)
- It underscores and reinforces professional roles and authority – allows workers to adopt the position of expert – and this is attractive to workers
- The pharmaceutical industry also supports and reinforce the technological paradigm – extending technological thinking about human distress to new areas of the human experience in the promotion of pharmacological solutions
Recovery approach as a revolutionary challenge
Consumers in the recovery movement have reported that the technological approach used by mental health services has at times undermined their recovery. Pat stressed how critical psychiatry challenges current assumptions of mental illnesses in order to move towards a “recovery approach” that places focus on interpersonal relationships as central to the recovery process. This is a different emphasis to the technological paradigm that promotes expert diagnosis and classification, causal explanations, and evidence-based interventions as pathways to recovery. Pat expressed concerns that because the technological approach frames mental illnesses as a biological or cognitive defect of sufferers that can be identified and fixed, it is not so different from historical notions of mental illness as a moral or spiritual weakness. The recovery approach is revolutionary as “it is not about ‘getting rid’ of problems, it is about seeing people beyond their problems – their abilities, possibilities, interest and dreams – and recovering the social roles and relationships that give life value and meaning”. Furthermore, in spite of widely-held views of medical and psychological expertise having the ability to bring about both understanding and cure for mental illness, evidence from treatment studies suggest that this is not always the case.
Dimensions Of Critical Psychiatry
An ontological challenge: Theories of being – what exists? What is mental “illness”?
The technological view implies the existence of faulty biological, cognitive or emotional processes.
Critical Psychiatry presents a challenge to ontological reductionism – the mind is not just another organ of the body, mental illness involves meanings, meanings always involve contexts, and mental illness is not a series of entities outside of their contexts. Given that the context of mental distress is in constant flux, mental illness is itself a fluid concept.
An epistemological challenge: Theories of knowledge – what kind of knowledge can we have about mental health problems?
The technological view rests on a “positivist” epistemology” – arguing that we should identify universal causal laws underlying social, cultural and psychological phenomena.
Critical psychiatry would suggest that understanding meaning is fundamental to our work and that technological aspects are important but relegated to secondary status behind values, meaning and relationships.
An empirical challenge: What works and how does it work?
In a technological view, research should be directed towards defining and explaining what is 'faulty', and on instrumental interventions targeting dysfunction as defined by experts
From a critical psychiatry perspective, Pat argues that the history of empirical research into both biological and psychological treatments presents a fundamental challenge to the technological approach: much of the variance in outcomes is outside of the technical aspects of the work – including relationships and meaning, extra therapeutic values and the “placebo” effect. Patients get better, but more because of common factors than because of the specific technological aspects of treatment – drugs, cognitive or behavioural treatments.
Pat argues that we need to focus on non-technological aspects of care as our central focus, with a secondary (but still important) focus on technological aspects of care
An ethical critique: Critical psychiatry presents a critique of the corruption of academia and clinical practice by pharmaceutical lobbying.
A political critique: We need to emphasise the social positions of clients and the role of all partners (consumers, carers and clinicians) in the development of real dialogue that promotes active citizenship.
Pat concludes by reiterating that both the recovery approach and critical psychiatry are first and foremost ways of thinking and being, rather than a set of strategies or even a new technology of change. Furthermore, critical reflection and real dialogue between service users and professionals is necessary for the recovery approach to gain ground.