This shorter-than-usual contribution signifies a departure from my earlier blogs. It is the first in an occasional series that uses semi-fictional clinical narratives to examine some of the difficulties that face people who use psychiatric services in England, and the psychiatrists and other mental health professionals who work in them. I use the expression semi-fictional to refer to a way of writing about clinical psychiatry which whilst based in real experience (the patients’ and the clinicians’) adapts this creatively in order to draw attention to moral, ethical and philosophical aspects of clinical work, and also to anonymise the true identities of the actors in each story.
Over the coming months I will use these stories to examine the different ways of working that follow on from being a ‘critical’ psychiatrist. The great advantage with thinking about psychiatric practice in terms of narrative, as Brad Lewis (2011) points out in his excellent book, Narrative Psychiatry (see http://www.madinamerica.com/2012/09/narrative-psychiatry-a-review/) is that it refuses to privilege a particular view of the world, and thus places different narratives on the same footing. This does not, however, result in a free-for-all relativistic morass, because it opens up to scrutiny the contrasting ethical and moral positions of different actors, the person identified as ‘patient’, the psychiatrist, other mental health workers, the community and indeed the culture in which these stories are embedded. It’s not a case of anything goes, but a way of foregrounding what Pat Bracken and I have referred to as ‘ethics before evidence’ in Postpsychiatry (Bracken & Thomas, 2001)
This cultural aspect is important. The experiences of the great majority of people identified as suffering from ‘madness’ in Britain are embedded within the complex socio-political matrix of the National Health Service. This has a powerful influence in shaping expectations (for ill and for good) on the part of people who use services, and the possibilities for action (for ill and good) on the part of those who work in it. Participants’ actions – psychiatric patients and professionals – are further constrained by the Mental Health Act. In addition to this, the wider cultural phenomenon of the fear of risk and the untoward has an enormously powerful influence on professional behaviour. Finally, professional interventions are largely determined by guidelines written by the National Institute of Health and Clinical Excellence.
Under these circumstances, to practice as a critical psychiatrist involves a degree of flexibility, inventiveness and a preparedness to stretch the boundaries of what is possible. It also requires the most precious commodity of all time. The NHS is effectively being dismantled as a free market ideology is imposed upon it. Cost-reduction is the priority, and this means a focus on throughput and efficiency. Time, of course, is money. This is why quick-fix ‘therapies’ and drug interventions dominate. They are time-limited and it is easy to measure their throughput. Such approaches are inimical to the way of working I will be exploring.
Some of the areas I want to explore using these semi-fictional stories include working without diagnosis, working towards meaning, working without, or with minimum, medication, as well as minimising the harm of medication, and ways of working around the problematic issue of coercion. I will also be looking at working with diverse communities, and working in alliance with survivor/service-user/experts by experience groups. These two (communities and survivors) are a vitally important component of any attempt to practice a critical psychiatry.
From time to time I will continue to post more general blogs, but the first of these narrative psychiatry blogs will appear very shortly under the tags critical psychiatry and narrative psychiatry.
Bracken, P. & Thomas, P. (2001) Postpsychiatry: A new direction for mental health. British Medical Journal, 322:724-727.
Lewis, Bradley (2011) Narrative Psychiatry: how stories can shape clinical practice. The Johns Hopkins University press, Baltimore.
People tell the stories they need to tell.
If the “patient” is a “consumer” or “subscriber” of psychiatric services but they are outside of state / government mandates and controls, how much of their experiences will vary from those of us who have been “wards” of the state and turned into life-time “career” psychiatric patients (psychiatric institutionalization)?
What is the difference between these sets of people? I think it does matter.