Pat Bracken is a psychiatrist who questions many of the fundamental assumptions of his field. He has worked as a psychiatrist in rural Ireland, inner-city and multi-ethnic parts of the UK, and in Uganda, East Africa.
Bracken, who holds doctoral degrees in both medicine and philosophy, calls for a movement toward critical psychiatry. He was one of the people involved in starting the Critical Psychiatry Network, an organization of psychiatrists, researchers, and mental health professionals that question the assumptions that lie beneath psychiatric knowledge and practice.
Through his clinical practice and his academic work in philosophy and ethics, he has seen the limits and dangers of standard approaches to mental health in the West. As a result, he has become an advocate for listening to different understandings of madness from those who are routinely ignored and dismissed — namely, service-users and people who themselves experience madness, and those from indigenous and non-Western cultures.
The transcript below has been edited for length and clarity. Listen to the audio of the interview here.
Justin Karter: You grew up in a Catholic country. How has that influenced your thinking and your belief systems?
Pat Bracken: I grew up in Ireland in the sixties and seventies, and it was a very different place then. I see my kids growing up now, and the Ireland that they are experiencing and call home is a much more open society, and I think overall probably a better place to grow up and to find yourself. In the sixties and seventies, Ireland was quite an oppressive society. We were very much dominated by the Roman Catholic church.
I’m not anti-Catholic. I grew up in that tradition, and I see a lot of very positive things that religion can bring to people in their lives. I saw it with my own parents, for example, when they experienced difficulties and crises. The church and their strong Catholic faith offered them something substantial in terms of navigating those issues.
But there was a very dark side to the domination of Catholicism in Ireland. We know now just how dark that was in terms of child sexual abuse. But it was wider than that. It was a very harsh atmosphere for anyone who showed any deviance from the mainstream mores of the time. So, if you were gay, it was a very difficult place to be. I think if you came into conflict with the church in any way, it was a difficult place to be.
It was also the 1970s when we were in the middle of, what we now euphemistically call “the troubles,” which was a war on this island. That had major implications for all of us. Even though I lived in and studied down in the south of Ireland, the conflict in the north of Ireland was never far from us and dominated the political scene of the 70s and well into the 80s. Economically, it was hard times as well. There were not a lot of luxuries around.
I say all of that to say that it was not it an easy time, nor was it in many other places. I think in some ways that also helped to shape a critical response to society. In a society where you see lots of oppression in all its forms, you have to take a position on that. I think it helped me as a young person to know that there were deep problems with the status quo, and I learned that one had to struggle against it.
Karter: How did you decide on a career in psychiatry? Why did you want to become a psychiatrist?
Bracken: Very early on, actually. Quite unusually, I think I wanted to be a psychiatrist before I started training in medicine. From a very early age, I became interested in madness. I was very interested in art and extreme states as a youngster in the 1970s. I was fascinated by things like surrealism. What I got from that was a positive perspective on difference and deviance from norms and “craziness.”
Perhaps naively I thought that practicing in the world of psychiatry–to make a living and to make my life in that area–would be a straight-forward kind of process. Like many people in the 1970s, I read R.D. Laing’s book, The Divided Self, and was fascinated by it. Not that I agreed with it all or understood it at the time 100%, but the way Laing wrote was compelling . . . there’s no denying just how passionate the man was and the imagination he brought to the territory of “mental illness.”
At that time, people with any kind of serious mental health problem were locked up in great big asylums that were uninteresting, that were places you didn’t want to go. They were, you know, called snake pits. What Laing did was say, “These people are fascinating. These people are interesting. Their take on reality is something that needs honoring and needs exploring and needs a whole different kind of way of thinking about.”
I think I got some of that passion from reading him and other people at that time. I wanted to be part of that work. I just wanted to get straight into the world of madness.
Then when I graduated in the early eighties, of course, I found myself in the reality of the psychiatric system in Ireland. After a couple of years, I thought I can’t continue with this; the contradictions between caring for people and trying to understand them, and at the same time the power and the control that went with psychiatry.
I started really practicing psychiatry in 1983. At that stage, the DSM and the full impact of biological psychiatry hadn’t happened. This is the very early eighties. Psychoanalysis, for example, still had a role in our training, and other approaches weren’t dismissed. At that time, training in the early 1980s, from a theoretical point of view, psychiatry wasn’t as dogmatic as it has become
Once I left medical school and got my exams out of the way, I started studying philosophy. When you’re into the world of studying psychiatry, you’re reading about the mind and the body, and the relationship between the mind and the body and society, and all those kinds of ideas. My immediate sense when I came to psychiatry was the thinness of our understanding of some fundamental concepts. That we were building an empirical science on very, very dodgy conceptual foundations.
After a number of years studying the philosophy of science, ethics, and other things, I became fascinated with the work of Michel Foucault, who of course spent a lot of his time exploring the history, assumptions, and practices of psychiatry and where they came from. That was a really important experience for me to experience the work of Foucault while I was studying and learning psychiatry. Philosophy is about questioning. Never being happy that you’ve reached the point where you have all the answers. There are always more questions.
The point I’m making is that I learned psychiatry from the outside. I never understood the world or saw the world from within a psychiatric way of thinking. I could see the concepts, where they were coming from, how contingent they were, how local they were, how partial they were; so I never believed them. I never believed that there was a thing called schizophrenia that somehow that was just there as a disease process. I understood the history of that concept, the assumptions in it, the problems with it. I’ve never had a relationship with psychiatry where I see the world through a psychiatric set of glasses.
Karter: Through the work of Foucault, you could see that there was a set of philosophical assumptions built into the science of psychiatry. I’m wondering what those assumptions are. What assumptions about being a human being were being baked in, without a lot of reflection, to the practice of psychiatry at that time?
Bracken: Well, the great irony is that if you go back in the history of psychiatry, to the 1920s and thirties, psychiatry had a much richer discourse about conceptual issues.
For example, the tradition of phenomenology. If you train in psychiatry, you train in what they call phenomenology, but that has become, over the second part of the 20th century, little more than a list of psychiatric symptoms and a description of them. For most psychiatrists, they think of phenomenology as simply this kind of listing of symptoms and asking the patient whether you hear voices or what kind of voices they hear.
Whereas in philosophy, phenomenology is a huge, rich way of encountering our position in the world and how the world opens up for us as human beings. There are huge insights if you go to philosophy and use that to understand various experiences of one sort or another. Phenomenology has huge things to offer, but the concept of phenomenology in psychiatry became restricted, distorted.
What’s been handed down now to psychiatrists in their training, philosophers wouldn’t recognize what psychiatry has called phenomenology. I think that’s been a huge disadvantage for us. I would encourage us as a discipline is to go back to our history in psychiatry and to reengage with some of those debates psychiatrists were having in the early twenties.
Karter: You mentioned earlier that the rise of the Diagnostic and Statistical Manual (DSM) and medicalized diagnosis transformed the practice of psychiatry in Ireland. How has the DSM changed the thinking of psychiatrists in practice?
Bracken: When the DSM III came out in 1980, it represented the coming to power, within American psychiatry, of a group of people who rejected the psychoanalytic way of thinking. Who said, this is getting us nowhere, if we want to be proper doctors, we’ve got to have a proper diagnostic system, that’s our first step. We’ve got to be able to get that right, and we’ve got to be able to do studies where the same patient will be seen by different psychiatrists and be given the same diagnosis.
That move to operationalized diagnosis meant that psychiatry was saying that mental problems can be addressed in just the same way that we address problems of the liver or the lungs. So the move to DSM III was, in fact, a deeply philosophical move. It was a move towards what I would call reductionism.
What happened then through the 1980s, and the late 1980s, in particular, was that Pharma started funding a lot of psychiatric research and psychiatric practice. Then you also have, in the United States, the emergence of managed care. All of those factors came to produce a psychiatry in the late 80s, 90s, and into our own time, which has become conceptually very impoverished.
Psychiatry now is modeled on making quick diagnoses with a list of symptoms and applying a drug to the problem. That kind of psychiatry is an anathema to me. I find that it does a lot of violence to the reality, the messy reality, the complex reality, the encultured reality, the embodied reality, of people’s problems. That very simplistic, narrow approach can do a lot of violence and leads to a lot of suffering. It has led to the sort of problems that you at Mad in America are addressing today, and have done for the last number of years.
Karter: The latest version of the DSM, the DSM V, has faced critique from mental health professionals and service-users, and some alternatives have been offered. Some are on the sociopolitical end, like the Power Threat Meaning Framework (PTMF) in the UK. Others seem to be doubling down on finding answers in the brain, like the RDoc initiative from the National Institute of Mental Health (NIMH) in the United States. I know you’ve written on RDoc – what are your ideas about the alternatives that have been offered?
Bracken: Quite incredibly, the response to DSM V from psychiatry has been a redoubling of reductionism. The RDoc is a disaster as far as I can see. It has consumed billions of dollars and has delivered nothing. It is incredible.
If this were in any other branch of medicine, it just would be scandalous. If the whole United States research budget on cancer for a period of 10 years had failed to deliver anything of use to patients, people just wouldn’t stand for it. Somehow, these people have been allowed to get away with this scandalous waste of resources.
But it’s not just RDoc. The Lancet Psychiatry World Psychiatric Association Commission report, which came out in the last few years, drew on psychiatrists from around the world and asked them to imagine what the challenges are and what the future would be, and obviously, a lot of thought was put into it, but it is really sad. The imagination is not there. Again, it comes back to seeing the future from a very medical point of view; that the job is more biological research, neuroscience, genetics. It’s a highly technicalized understanding of the field of mental health and where progress will come from, and it is missing the exciting things that are happening in the world of mental health.
In my career, the most exciting thing, the most important thing, has been the rise of the service-user movement or the consumer movement. People come at that from different points of view, but it’s an amazing phenomenon that’s happened in the past twenty or thirty years. People who experience mental health issues, crises, difficulties have started to articulate that, and they’ve come together in groups of different sorts and started to campaign and challenge the status quo.
The challenge for us professionals is to find ways that we can open up spaces for dialogue. To do that we have to change the way we think about knowledge and expertise and we have to move substantially away from the idea that we’ve got to be doing more research and we have to be doing more of our investigations and that the future is about our science and our way of training ourselves.
That way of thinking, as though somehow there is some kind of singular truth about mental health and mental illness and that psychiatry and our allied professionals have access to, goes in the opposite direction from what is needed. As professionals, we have to substantially move away from the idea that we’ve got some privileged source of knowledge and science about mental illness. We have to go right back to basics and say what kind of space, what kind of thinking, do we have to nurture within ourselves and our profession that will allow us to actually engage in genuine dialogue with people who come to services for help.
Karter: How have you been influenced in your understanding of mental distress as historically situated and culturally constructed by your international work?
Bracken: I already mentioned that, in my early days, I became very disillusioned with psychiatry and my first years of training, and I actually decided to quit. I decided I couldn’t continue. I had decided to pursue a career in philosophy instead.
But then I saw an advertisement in the British Medical Journal — it was an ad by an organization that had just set up in London in the late 1980s called the Medical Foundation for the Care of Victims of Torture. They were being asked by Amnesty International to set up a project in Uganda for victims of torture.
I applied for the job, and I went. I found myself in what was still at the time a very insecure place with a lot of problems. I went out there, I met my partner Joan Giller there, and we’ve worked together on a lot of these issues over the years.
Joan is a gynecologist by training and subsequently trained in anthropology and psychotherapy. The two of us were recruited for this project, and we ended up wondering what the hell are we going to do? We realized very quickly that as two white people, white doctors from Europe, in a country that was reeling from a devastating civil war and massive human rights abuses, that we could do a lot of harm by thinking that we have some solution. Or by thinking that the solutions to the problems in Uganda are going to come from Europe, that they’re going to come from western psychiatry or counselors from the Western world who are trained in a particular way of working.
If you come with that kind of way of thinking, then you start to undermine local ways of dealing with suffering, local ways of creating society, collectivity, and solidarity. Because you start to say, actually there is an expertise that we have, that we’re trained in, that you don’t have available to you, and the only way you’re going to move on from your suffering at the moment is by having access to our expertise. Not through your own resources, your own culture, your own religions, your own way of doing things, and finding solidarity.
We became aware very quickly that we have to tread very carefully in that world. At the same time, we also respected the idea that Ugandans of all ages, all groups, all tribal backgrounds, desperately wanted some recognition from the rest of the world as to what they had been through. Some people were very happy to have people there who were interested in that suffering.
You asked about what that experience did, and it was very transformative for me because I became absolutely aware of the importance of social context in shaping how we experience mental suffering, how we respond to it, and how we can help. We can’t do any of those things without understanding the context in which people are struggling.
Karter: Looking at the Lancet Commission on Global Mental Health and the movement for global mental health more broadly, there seems to be an assumption made that there is a paucity of mental healthcare in low and middle-income countries. You have made the point that different cultures have ways of dealing with stress and the results of social issues that we might not see clearly as “mental healthcare” through the lens of Western psychiatry. What have you seen in your work internationally as far as alternative therapeutic or cultural strategies that allow people to recover from or deal with immense amounts of distress?
Bracken: What we have to do is to respect the diversity of responses to distress that human beings have come up with; not try to understand the global issues around mental health with this kind of arrogant imperialistic sense that the only answers are from us in the West.
For depression, for example, some of the papers I have read are just mind-boggling. They’re incredible — the only ‘evidence-based’ treatments for depression, on a world scale, are antidepressants, ECT, and CBT, or some modified form of CBT. I think this is just ridiculous. People have all sorts of ways of coping, of supporting one another, of making sense out of things, and we need to respect that. We also need a critical consciousness around harms that can be done by our by, so-called, ‘evidenced-based’ treatments and by our concepts.
Science can be very helpful to us. There’s no doubt about that. But, in many ways, science is like the bright light of the sun. It shines, and it illuminates things in a particular way, and that allows us to see certain things. But when we think about it, it’s only when the sun goes down in the evening, when the sun is gone, that we can then start to see the stars. For me, the stars are all the different cultural ways of thinking and coping and dealing with distress and the state of madness.
Karter: You were recently a co-author on a paper published in Transcultural Psychiatry, which we covered here at Mad in America (Research report; Interview), about developing culturally responsive and culturally informed therapeutic practices with the Maori indigenous community in New Zealand. How did you come to be involved in that study, and what did you learn?
Bracken: My own involvement was far from central in any way. I got involved there in New Zealand after I retired from my post in the health service here in Ireland in 2016. Basically, I wanted some time in my life that I could not be working in the health service as a clinical manager, clinical lead. I wanted to be able to travel and do a few other things.
New Zealand has a tradition of respecting culture, particularly the indigenous Maori culture. They have set up a lot of different services that work as cultural services alongside traditional psychiatric practices within New Zealand. I read about this, and I was very interested because I’ve worked in services, particularly in the UK, that are struggling to cope and offer something positive to immigrant communities. So I looked around after I retired from my job in Ireland and made inquiries and I was lucky enough to connect with the service on the North Island out on the east coast in the city of Gisborne.
I ended up doing a locum position out there and got to know Diana Kopua, who is a Maori psychiatrist, and her husband Mark, who is a Maori artist, and their work developing a practice called Mahi a Atua, which roughly translates as the ‘Work of the Gods.’
What Diana had been doing for a long time was developing a practice of intervention with individuals and families that drew not on Western psychiatry and its diagnosis and its theories and its assumptions, but instead went back to Maori creation stories. She uses the characters and family events within those creation stories as a way of locating the problems that people were encountering in their lives.
Problems of all sorts, from family conflict to drug abuse, to madness, to states of melancholy and depression and withdrawal. All of those states were dealt with within the rich tradition of Maori creation story and narrative. What Diana was doing was developing a practice that didn’t start by trying to make a diagnosis and rush in with a drug or a treatment.
You started by talking about those creation stories and finding one that perhaps had echoes or resonances with what was going on. Because Maori culture is very family-centered, when we talk about family, we’re talking about the wider family. It is not just the nuclear family; it is much wider. So when you’re talking about family meetings, you can have a whole room full of intergenerational cousins and aunts and all sorts in there. Their approach was about getting all of the people talking and engaging in a dialogue and a discourse using, not western psychology and its assumptions, but Maori psychology and its histories.
What struck me was that to make that come alive, there needed to be a critique of western psychology. When I looked around in New Zealand, while there was great respect for these practices and Maori cultural practices in particular, actually the mental health system still worked according to a logic based in western psychiatry and psychology. So the whole mental health law in that country is set up around a western psychiatric way of thinking. The way in which psychiatrists are trained, the way in which decisions are made in practice, while there was respect for cultural workers and their inputs, in the end, the western psychiatry was dominant.
With critical psychiatry in combination with indigenous psychology, you can start to crank down the power, the authority, the deference, paid to western ways of thinking and its assumptions and practices. When you start to point systematically to the downside of interventions that come from, for example, placing someone with a diagnosis of schizophrenia on long-term neuroleptic medication that really restricts that person’s life, you can critique that and try to find ways of not doing that.
Karter: Many critiques of the movement for global mental health have been published, and now we are seeing that alternatives, like the one you’re discussing, are also being published in well-respected journals. How will this be absorbed? What do you think are the likely responses from the powerful center of psychiatry and psychology in the West?
Bracken: It depends what kind of day you get me on and how I answer that! If I’m feeling pessimistic, I’d say there’ll be no listening at all. On a more positive day, I think yes, there is hope.
I can be hopeful. Our own critical psychiatry network, for example, has grown and has more people involved now than it did 20 years ago when it started. I think there is beginning to be signs of respect for critical thinking. I also think that there may be increasing respect for the gifts of indigenous cultures, what they can bring to us, not just in the area of psychiatry, but we can and have to start to learn from indigenous cultures about saving our planet.
In indigenous cultures, like in Maori culture, for example, the natural world has personhood. The world that we live in, the forest that we live in, the land underneath our feet, the mountains that surround us, they regard them not just as resources for us to do what we like with. In Maori culture, those natural parts of the world have a status close to us, human beings, and demand respect from us.
I think that way of thinking about the world we live in is the only thing that will save us from destroying the planet that we’re on, destroying ourselves. We have to rethink our relationship with Indigenous cultures and start to think about how it can be given a greater deal of respect. Part of that is about us learning to listen to them. Again, that is about nurturing in ourselves, a critical self-reflexivity that understands the destructive aspects of our own history. In the Maori context, that is about understanding the history of colonialism.
Karter: I can imagine a therapist, psychiatrist, or mental health professional, listening to this or reading this and thinking about this humility being important when working cross-culturally. It may be a little bit less obvious how this approach could be implemented in individual practice within the West. You are talking about being open to both the critique of psychiatry from service-users, anti-psychiatry groups, and psychiatric survivors, but also about having a respect for the alternative ways of understanding mental distress that people might bring in to the therapeutic encounter. Can you say more about that?
Bracken: I think that is very well put. I’m trying to argue for a way of thinking about psychiatry that has a future. I do believe that medicine has a legitimate and positive role to play in the lives of people who are struggling with states of distress, madness, and dislocation but only if we can radically rethink the starting point for that involvement. Psychiatry cannot get there on its own. It has to start that process from a place of dialogue.
We won’t get to that place of genuine dialogue until we fully understand the harm that we’ve done and how we’ve damaged people and come to terms with that somehow. I’ve already talked about postcolonial studies, Queer Studies, feminist scholarship, that are all about trying to undo some of the dominant ways we’ve understood the world and move to a place where we’re not harming each other through the concepts we use. We’ll only get there by really working on this. That’s the role of critical psychiatry. That, to me, is what critical psychiatry is about.