Saturday, August 18, 2018

Comments by Philip Thomas, MD

Showing 49 of 49 comments.

  • Thanks, Frank. Will Hall’s recent blog and the one I posted yesterday make pretty much the same point, but come at the problem from slightly different trajectories. It seems to me ironic that people on the right and the left see neoliberalism as a threat to democracy, which is exactly what it is. Chomsky makes this point with incisive clarity in Profit over People. What is becoming clear to me is that neoliberalism is a form of totalitarianism, and in that regard is no different from Fascism or Stalinism. I’m no student of political philosophy, but I think my political position is very close Chomsky’s view of libertarian socialism – see https://en.wikipedia.org/wiki/Libertarian_socialism I think the way we shaft our current dystopia is to build alliances with a wide range of anti-austerity groups to challenge the neolib hegemony. It’s vital that communities of interest – like the greens, disabled, feminists, mad groups unite with anti-austerity groups. If we can do that it’s an immensely powerful way of challenging the marginalisation of madness by opposing,with those other groups a shared oppressive system. I think the signs are that this is beginning to happen in UK.

  • Thanks Norman. I agree with you. Some psychotherapists in UK are implacably opposed to the government plans referred to in my blog. See the excellent letter from the Alliance for Counselling and Psychotherapy to the Guardian at http://www.theguardian.com/society/2015/apr/17/austerity-and-a-malign-benefits-regime-are-profoundly-damaging-mental-health There are psychologists too who are taking action. One of the positive things about this is it feels that new alliances are beginning to form as different interest groups, whether survivors or service users, carers, or different professional groups over here are beginning to see the bigger picture. If this means we can all put turf wars to one side to fight a common enemy with other anti-austerity groups, then so much the better.

  • Will, thanks for this brilliant piece, probably one of the most significant and important blogs ever to appear on MiA. Although the names and institutions differ in UK and Europe, where the emphasis is perhaps more on the problems that arise from the ideology of neoliberalism, and the impact of austerity on benefits, the fundamental issue – those of the democratic accountability of government and corporations to the public, remain the same. This issue concerns the unfettered and unethical use of power to shape our lives. Thanks again.

  • The problem is not so much the report’s content, which for the most part is excellent, but the key issue that we have drawn attention to in our letter to the report’s coordinating editor (http://www.sumanfernando.com/Letter%20to%20Anne%20Cooke.pdf) is that the institutional and organisational processes resulted in very few if any people from BME communities – survivors, service users, mental health professionals – being involved with the DCP in the report from the outset. For this reason it’s difficult to accept your assertion that ‘…if these central points are taken on board, and embedded into services, service users from all cultural backgrounds will benefit.’ It’s clear from what I’ve heard already that many BME survivors and professionals are saddened and offended that the DCP failed to engage them from the outset. That said, it’s also clear that the DCP recognises that it has made an error, and is keen to rectify this.

  • Thanks Steve. I agree with you, and especially with your point about integrating cultural, sexual / gender and historical trauma identities. There is a great deal that is good about the report, and the last thing that those of us who have expressed concern (see our letter to Anne Cook at http://www.sumanfernando.com/Letter%20to%20Anne%20Cooke.pdf ) want to see happen is for the benefits to be obscured by controversy. Nevertheless our criticisms are valid and need addressing. That said, I am hopeful that the DCP will respond positively.

  • Thanks John. The difficulty with this is that members of Britain’s BME communities are in any case disproportionately represented in working class / economically disadvantaged sectors of our communities. They have all the attendant struggles that that brings, but in addition they also have to cope with racism from white people, rich and poor., working class and middle class, whatever these terms mean these days (and I suspect their meaning are quite different from a generation or two ago).

  • Stokeley Carmichael’s term institutional racism come to mind, Darby, something that permeates British society despite the best efforts of equalities legislation and the Equalities and Human Rights Commission. The difficulty is we have no way of knowing what discussions took place in the BPS, and to what ends. This is why they should hold a fully transparent inquiry into what went on.

  • I completely agree with you, Ron, about the value of the report in terms of paradigm shifts. However, the fact that there was no black survivor / mental health professional black people input means that yet again, black people’s voices are marginalised and excluded, and invalidating the report as far as 14% of the population of UK is concerned. The only way round this is for the BPS to withdraw this report, and start again with black input from the outset.

  • Thanks Chrys. The ‘stickiness’ of psychiatric diagnoses is a really serious issue. The assumption in society is that because they are ‘diagnoses’ made by doctors, they must be like any other medical diagnosis. This is nonsense. All the evidence indicates that having a biomedical psychiatric diagnosis is a prime cause of stigma. The reasons for this are many and complex, but we must continue to argue the case this is a seriously flawed, harmful position. All people who have been given these diagnoses should, if they wish, have a right of appeal to an independent body empowered to strike the diagnosis off someone’s records.

  • Lovely point well made, Duane, many thanks. I fully agree with you. I love science. I’m deeply fascinated by the work at CERN, the insights of cosmology and so on. Medical science has revealed deep insights into physical illness, and new treatments based in this, but psychiatry? No. Consciousness is beyond the grasp of neuroscience. Read more about this in chapter 6 of my forthcoming book, Psychiatry in Context.

  • Many thanks for drawing this to my attention. I wasn’t aware of this. Indeed, the way pharma is pushing psychiatric drugs in LAMI countries is reminiscent of the way the tobacco industry has targeted these same countries as the ‘rich’ countries have restricted advertising for tobacco products, introduced public smoking bans, and made sales to young people illegal. It stinks.

  • Sandy

    many thanks indeed for yet another excellent piece. It is so important to mobilise the discussion about does reduction strategies, both for people on neuroleptics, their families and psychiatrists. It may be the case that it is difficult for your data to capture the positive benefits of tapering, but the other side of this, given the evidence elsewhere, is that it strengthens the arguments for avoiding the use of these drugs, and certainly their long-term use.

    You make a really interesting point about your colleague’s ‘more conservative approach’, related to the the fact she had not been involved her patients’ care that long. This points to something that evidence based medicine completely overlooks, and that we (Pat Bracken, Sami Timimi and twenty six others) drew attention to in our special article in the British Journal of Psychiatry a year ago. This is the importance of the quality of the therapeutic relationship – the issue of trust and understanding between patient and doctor – in how medications are used. It takes time and hard work on both sides of the office to establish this, something that your colleague clearly recognised.

    Your post really reminded me of what I spent most of my time at when I was a clinician – doing my best to encourage people to consider dose reductions. It is deeply rewarding work; I just wish I had been as well organised as you and your colleagues in documenting it!

    Keep up the great work.

    best wishes

    phil

    Bracken, P., Thomas, P., Timimi, S. et al (2012) Psychiatry beyond the current paradigm. British Journal of Psychiatry, 201:430-434.

  • Dear Anonymous

    Thanks for your comments, which strictly speaking are off topic, but they are so important they merit a response.

    In broad terms, CPN is opposed to any form of forced treatment in psychiatric care. This would certainly apply to ECT and psychosurgery (for anyone, regardless of age), and drug treatment too. As far as the latter is concerned the lack of evidence for the effectiveness of neuroleptic drugs, and the accumulating evidence that shows that the long-term use of these drugs may contribute to chronicity, as well as having major adverse consequences for physical health and reducing life expectancy, means that it is ethically indefensible to force people to take them long-term, either in hospital or in the community. It follows that this evidence seriously undermines the argument for a ‘mental health’ act.

    It is also important to say that circumstances may and do arise where people’s behaviour and distress is so severe for short periods of time that it may be necessary to detain them in hospital, and to use medication for short periods of time (i.e. no more than a couple of weeks). However, the need for hospital detention (and medication) would be minimised if people were offered greater choice in where they received help, which is why I support Soteria Network UK (as a trustee) in its aim of supporting and developing alternative systems of care for people experiencing severe distress.

    I should make it clear that CPN has not formally discussed this, so it’s my personal view. That said, I think that many in CPN would agree with this position.
    We haven’t specifically discussed the insanity defence, but personally I am opposed to it, and I think that many colleagues in CPN are too.

    I don’t know who you are or where you’re based, but your spelling of the word ‘defense’ suggest you are in the US, so you may not be familiar with the position, and activities undertaken by CPN since 1999. Here are some links to some of the policy statements we’ve made on coercion and the exposure of trainees to ECT – we recently tried to get the RCPsych to ditch the requirement for trainees to opt out of ECT training. Of course they refused. I think CPN would be keen to work in alliance with UK-based survivor groups opposed to the use of ECT so if there are any out there please do get in touch with me.

    Finally I am not aware of the Scottish legislation for forced psychosurgery, and I am horrified to hear of it. Could you please post relevant details and I’ll look into it.

    Here is a selection of links that provide further background to your queries.
    CPN letters on ECT and training – http://www.criticalpsychiatry.co.uk/index.php?option=com_content&view=article&id=278:ect-and-training&catid=35:documents&Itemid=56
    CPN evidence to MHA scoping committee – http://www.criticalpsychiatry.co.uk/index.php?option=com_content&view=article&id=199:evidence-submitted-to-the-scoping-study-committee-for-review-of-mental-health-act&catid=35:documents&Itemid=56
    CPN response to MHA scoping committee outline proposals – http://www.criticalpsychiatry.co.uk/index.php?option=com_content&view=article&id=136:response-to-the-draft-outline-proposals-of-the-scoping-study-committee&catid=35:documents&Itemid=56
    CPN response to consultation on draft mental health bill http://www.criticalpsychiatry.co.uk/index.php?option=com_content&view=article&id=130:response-to-consultation-on-draft-mental-health-bill&catid=35:documents&Itemid=56
    CPN statement on government proposals for managing people with ‘Dangerous and severe personality disorders’ http://www.criticalpsychiatry.co.uk/index.php?option=com_content&view=article&id=133:managing-dangerous-people-with-severe-personality-disorder&catid=35:documents&Itemid=56
    Letter of resignation of CPN from MH Alliance (Because the Alliance finally supported compulsory treatment in the community) http://www.criticalpsychiatry.co.uk/index.php?option=com_content&view=article&id=121:letter-of-resignation-from-the-mental-health-alliance&catid=35:documents&Itemid=56

    Thanks

    Philip Thomas

  • Thanks for reminding us of Loren’s wonderful letter, Marian, and for reminding us about the importance of the existential basis of our human relationships in helping people who have experienced trauma. If I amy be permitted a brief plug for my chapter on Soteria in Madness Contested (Thomas, P. (2013) Soteria: Contexts, practice and philosophy. Chapter 9 in (eds. S. Coles, S. Keenan & B. Diamond) Madness Contested: Power and Practice. Ross-on-Wye, PCCS Books. (pp 141-157) see http://www.amazon.co.uk/Madness-Contested-Practice-Steven-Coles/dp/1906254435/ref=sr_1_1?s=books&ie=UTF8&qid=1370090223&sr=1-1&keywords=pccs+books+madness+contested

  • The Royal College of Psychiatrists would almost certainly say this is a matter for the Institute of Psychiatry. Critical Psychiatry Network is writing to the Institute requesting that they withdraw Nemeroff’s invitation. I’ll post a copy of the letter and a link when this has been sent.

    In the meantime can I encourage people to contact the IoP to protest at Nemeroff’s invitation, by emailing the Executive Assistant to the Dean, Jas Rana at [email protected]. The more people protest about this, the stronger the message. Academic psychiatry must be told that it has to be guided by the same ethical considerations as the rest of the profession.

    Please protest!

    Thanks

  • Absolutely, Steve. Look at this article just published by Acta Psychiatrica Scandinavica – The neurobiological correlates of childhood adversity and implications for treatment Acta Psychiatr Scand 2013: 1–14. It’s clear that some in the neuromanic brigade are in the process of ditching ‘schizophrenia’ in favour of establishing a biological basis for childhood adversity and trauma. And we all know who eagerly follow in their footsteps…

  • Thanks Duane. This is exactly why we wrote the piece. We were sick and tired of this argument being portrayed as psychologists vs psychiatrists. Colleagues in critical psychiatry UK have questioned the role of diagnosis and scientific models of madness for twenty years or more. Likewise there are some (ok a few) clinical psychologists who are happy to run with diagnoses. I’d be really interested to hear where mental health nurses stand in this debate. Arguably they have the greatest potential impact (for good and bad) on the experiences of people who have to use mental health services. What do nurses think?

  • Love the poem, and yes, John, absolutely right, replace object relations theory with neuroscience works well. All that I would say in fairness, is that later variants of O/R theory under the influence of Anthony Ryle stress the importance of human relatedness in the interpersonal world.

  • Many thanks for this, Morias. Frying pans and fires is exactly how I see it, and I share your concern about the ultimate direction in which a neurogenetic form of psychiatry will end up. Again, I didn’t have time or space to go into this, but it is a coming together of neuroscience and genetics. Tallis deals with this in his excellent book. It’s important too that I’m clear about where I stand in relation to neuroscience and neuroimaging. As far as neurological disorders are concerned, conditions like MS, Parkinson’s disease, Alzheimers, neurodegenerative disorders like HC, brain tumours and so on, neuroscience and neuro imaging is of inestimable benefit. But the line is drawn, as far as I am concerned, at the functional psychoses (schz etc) sadness, so-called ‘personality disorders’ etc, all the diverse forms of madness and distress dealt with by clinical psychiatry. The plane of cleavage that I’ve just set out is more or less that set out by the late Thomas Szasz in The Myth of Mental Illness. However, I part company with TSz where he claims that medical science alone is all that we need to respond to diseases. He claims, for example that a diphtheritic membrane is the same in the US as it was in Tsarist Russia. In effect what he does here is to deny that the concept of illness has any legitimacy. People suffer illness, bodies are the site of disease. Psychiatrists don;t deal with diseases of the brain, but the essence of my work as a psychiatrist was dealing with suffering human beings. Suffering and Illness are, as Arthur Frank points out in Wounded Storyteller, moral and existential aspects of our lives as human beings.

  • Many thanks indeed for your deeply thoughtful comments, Faith. I am grateful to you for drawing attention to the importance of embodiment, neurodiversity, and neural plasticity, all of which are important themes that I didn’t have time to touch on in the blog. I also really like the point you make about dance. Have you come across Lou Pembroke’s work, especially her dance, Dedication to the Seven, about her voices? Also your point about free will is well made. This for me is one of the deepest mysteries about being human. The problem is wider than neuroscience, because it is of course possible to construct deterministic accounts of being human through narrative – that what we are and what we have become is given to us through our life stories. In broad terms, however, I think that narrative ways of engaging with other human beings avoid this. The Russian literary critic, Mikhail Bakhtin, talking about that characters in Dostoevsky’s novels, famously said that they weren’t characters, they were like human beings, infinite, full of possibilities for becoming. I believe that is an inspirational view for us all, but especially if we are engaged in trying to help people who experience madness and distress. It seems to me that morally, the most important thing to avoid is regarding all people as the same, or fixed, as you indicate. I fully agree with you that people shift in and out of different modes of being at different points in their lives. There are frequently times in my own life where I’ve thought what point is there because I just go on thinking in the same self-defeating way. Then, for no clear reason, or sometimes for clear reasons, like the people I’m fortunate enough to have in my life who love me, I snap into a different mode of being and just get on with it, trying my best to be creative. Thanks again for your comments.

  • The analogy with economics is a good one, because like psychiatry, it fundamentally concerns human beings, their desires, fears, needs and so on. All this is a matter of interpretation which scientific methods can’t really cope with. I think the same holds too for DSM, because again, what a ‘patient’ says to two psychiatrists is ultimately a matter of interpretation, and as the DSM-5 filed trials indicate it remains extremely difficult to get two or more psychiatrists to agree about the interpretation of what patients say about their experiences. It’s so different from other fields of medicine that have physical tests (e.g. blood tests) that are more objective and robust. Even then, clinicians will disagree about the interpretation of diagnostic tests.

  • Many thanks for your comments Phil, which resonate with Jonah’s comments below. We are fortunate in GB in having (a small number of) journalists who see through the way science is reported, but no one at the moment who could fulfil the role of Bob Whitaker and MIA. Maybe one way of understanding why MIA has become such an important forum of debate is because of the utterly dire state of science journalism in the US. It’s bad enough here, but reading Jonah’s comments below, it’s nowhere near as bad as the US. We all have the power of ideas, and one of the really important functions of the internet is the democratisation of knowledge. We can share ideas, exchange understandings and, together, resist the oppressive uses of neurotrash in psychiatry.

  • OMG!!! Jonah, thanks for putting our complaints here (GB) in perspective. I fully agree with you that this is a terrifying prospect. What worries me is that GB is heading in the same direction. What I regard as real science, by that I mean cosmology and particle physics (the very large and the very small) deal with the fundamental nature of the universe, far detached from human interests. As soon as scientists step into the domain of the human world, science becomes mired in human interests. But it still pretends to be impartial and objective in the way that cosmology and particle physics are. Then again, I have to add a caveat, because as Thomas Kuhn points out in the Structure of Scientific Revolutions, paradigm shifts occur in part because of the accumulation of ‘anomalies’ (scientific evidence form experiments that do not fit within the current paradigm) and extra-scientific factors (things like scientists’ academic reputations, careers and so forth) also influence which theories gain ground. Social scientists would extend the range of extra-scientific factors to include wider social and cultural pressures – just the sort of horrors you describe in your comments.

    Elsewhere, Pat Bracken, Sami Timimi, and I published a paper in the current edition of Philosophy, Psychiatry and Psychology arguing that the lack of evidence for the effectiveness of psychiatric ‘treatment’ from within evidence based medicine, can be seen as Kuhnian anomalies that show that the technological paradigm in psychiatry is a failed paradigm.

    The arguments and comments of contributors on this website (MIA) are absolutely vital. If we can share openly our concerns about the misuse of science, distorted and intellectually dishonest reporting of it, especially as far as the interface between madness and science is concerned, we can open up a plane of resistance to the nonsense that masquerades as ‘science’ in the media. Bob Whitaker and his colleagues at MIA are to be applauded for their integrity and determination to provide this forum.

    thanks

  • Many thanks for these comments, Donna. I haven’t seen the article you are referring to, but I completely agree with the points made by Dr. Josephs in his excellent work on the failure of replicability in genetic research. This is more generally true across the whole field of biological and neuroscience research into psychiatric ‘diagnoses’. That this is a major weakness of these categories is well recognised by may psychiatric researchers themselves, as can be seen in articles by prominent psychiatrists – see the references below. The essence of scientific investigation established in the early seventeenth century is the replication of experiments set up to test hypotheses. In private, many psychiatric researchers are starting to acknowledge that madness has been a barren field for scientific inquiry, but they are reluctant to admit this in public because their livelihoods are at stake, or (in the case of pharma) profit and dividends.

    What worries me is the timing of the launch of DSM-5 next month, hot on the heels of Decade of the Brain 2. It’s too late to change DSM-5, but we have to work all out to staunch the worst excesses of neurodrivel on TV, radio and the internet. This fires up public belief that we can somehow ‘explain’ madness and the moral tragedies (shootings) that you refer to. I hope you enjoy Demedicalising Misery – it’s a great book (but I would say that wouldn’t I!)

    best wishes

    Anckarsäter, H. (2010) Beyond categorical diagnostics in psychiatry: Scientific and medicolegal implications. International Journal of Law and Psychiatry, 33, 59–65.

    Andreasen, N. (1995) The Validation of Psychiatric Diagnosis: New Models and Approaches. American Journal of Psychiatry, 152, 161 – 162.

    Kendell, R. & Jablensky, A. (2003) Distinguishing Between the Validity and Utility of Psychiatric Diagnoses. American Journal of Psychiatry; 160:4–12

    Kendler, K. (1980) The Nosological Validity of Paranoia (Simple Delusional Disorder) Archives of General Psychiatry, 37, 699 – 706.

    Robins, E. & Guze, S. (1970) Establishment of Diagnostic Validity in Psychiatric Illness: Its Application to Schizophrenia. American Journal of Psychiatry, 126, 983 – 987

  • I agree completely that Claudia Hammond’s coverage of psychology and mental health is fair and balanced. The problem is how these issues are covered for the general audience as part of news and current affairs, which is emphasised in out letter. Claudia’s work is aimed at audiences interested in the field.

  • From Professor Marius Romme:

    Thanks for your fine article. It made me again conscious of the great
    responsabilty psychiatrists have in what they tell their patients. You
    are quite right when you write that for people who are troubled the
    sort of stories that are presented to them, and whose strands may be
    picked up and weaved into their lives, open up or close down the future. In
    our study with 50 recovered voice hearers from their stress with their
    voices, most of them were put on a closed future road just by what
    the system told them, while by finding others who opened that road
    again they became able to recover. In itself it is so easy to start
    at the road of personal troubles as with your example with Jill. When
    that is not open one always can use the other road; another sequence is
    not very effective. It is not only the diagnosis but what is told
    about it is the most harmful; taking away hope. It is good that many
    find another way but helas even more do not and it is not strange that
    we see a hgh percentage of suicides when put on the closed road.

  • Thanks, John, for your points, which are all well-made. The Occupy movement draws on ordinary people’s experiences and moves the debate about the sort of world we live in away from unhelpful political polarisations (left / right etc). Most people are sick and tired of established political discourses, which is why right and left cynically dismiss what is a movement for democracy. As you say, it is vital that survivors, service users and their allies make sure that the issue of madness in placed firmly at the centre of the debate about democracy.

    thanks and best wishes

    phil

  • Many thanks, Louise. Yes, I agree with you about the role of corporate capitalism. The difficulty with such analyses, however, is that it tends to polarize debate. The problems described by Wilkinson and Pickett in their book have much more complex origins. Each and every one of us is involved by virtue of our existence in structures and organisations of inequality. It really is worth reading chapter 16 of their book, where they suggested ways forward, e.g. employee ownership schemes, that reduce inequality and give everyone a stake..

    best wishes

    phil

  • Dear Altostrata

    This is a powerful analysis, and I agree with you. A number of people have made similar observations in the past, most notably the historian Kathleen Jones (Jones, K. (1988) Experience in Mental Health. London, Sage – see page 83).

    This is one reason why I believe the humanities are really important in the education of psychiatrists. We (even psychiatrists) engage with poetry,literature, dance and music in quite different ways. Survivor poetry, dance (e.g. Louise Pembroke’s Dedication to the Seven) is a really powerful way of getting all professionals to drop the objective gaze that dehumanises suffering.

    Many thanks indeed for raising this issue.

    bestw ishes

    phil

  • Thanks, Phooey, whoever you are. Of course you can use scientific arguments to defend any political position. The genetic theories of the psychiatrist Ernst Rudin and the Nazis are a case in point. But you miss the point. My argument is an appeal to a moral argument about how we position ourselves as individuals in the face of individual experiences of suffering.

    philip thomas

  • Many thanks, Chrys, for your comments. I’m really grateful for any responses that people can give to the idea of moral imagination, and I will be writing much more about this in the weeks to come. Your point about fairy tales is really important. I was reading from Grimm to our four-year-old grand-daughter last week, and it afterwards it really brought home to me the importance (developmentally) of culture and narrative in forming our moral imaginations. Thanks for helping me to establish the link,

    best wishes

    phil

  • Dear Arija

    many thanks indeed for your comments. Nowhere do we see more clearly the effects of injustice. oppression and social dislocation that war refugees experience. I really am grateful to you for reminding us all about this. This blog was really an attempt to start thinking through the implications of social justice, oppression and abuse for mental health work, and I will be writing much more about it in future. I will certainly be thinking about the role of war in this.

    best wishes

    phil

  • Hi Chrys

    the tension you refer to between psychiatry and survivors / service voices is at the heart of the struggle for a more democratic psychiatry, if such a thing is possible, and I know well that Thomas Szasz would regard such a term as a paradox. The social reality is that In Britain, and vast swathes of the US, most people have no choice. They have to use mental health services. For this reason the onus is on psychiatrists to engage with those voices, even if they find it difficult to face up to what they have to say. Only then will tokenism end.

    Thanks for your comments

    phil