All who are not lunatics are agreed about certain things.  That it is better to be alive than dead, better to be adequately fed than starved, better to be free than a slave.  Many people desire these things only for themselves and their friends; they are quite content that their enemies should suffer.  These people can be refuted by science.  Humankind has become so much one family that we cannot insure our own prosperity except by ensuring that of everyone else.  If you wish to be happy yourself, you must resign yourself to seeing others also happy.

Bertrand Russell (1)

I am traveling back from a three day conference that was held in one of my favourite cities in the world and that addressed two of my favourite topics in life.  The city is Liverpool and the topics are mental health promotion and social justice.

The conference was organised by the International Network Towards Alternatives and Recovery (INTAR) who believe that…

“the prevailing biological over-reliance on diagnosis, hospitals, and medications has failed to respect the dignity and autonomy of the person in crisis, and that full recovery must be at the centre of ethical care” 

and…

“works to gather prominent survivors [patients who have made it through the psychiatric system alive], professionals, family members, and advocates from around the world to work together for new clinical and social practices in response to emotional distress and what is often labelled as psychosis”. (2)

The position, described above by INTAR, typically falls under the banner of “critical psychiatry” which, as you may have already gathered, is a response to mainstream psychiatry.

Recently a group of prominent critical psychiatrists collectively wrote a paper calling for a shift away from the dominance of the “technological paradigm” of “brain sciences and psychopharmacology” and towards a psychiatry that involves “collaboration with the service user movement” who are “generally united by a rejection of the technological framework and the way it defines their problems through an expert vocabulary and logic”.  The authors then go on to highlight the Hearing Voices Network as a “good example” of this. (3)

The Hearing Voices Network (HNV) recently put out a statement which argues that “psychiatric diagnoses are scientifically unsound” because, amongst other things, “psychiatric diagnoses are not provided on the basis of objective tests or measures”, but are “voted into existence by committee, representing opinion rather than scientific fact” and are “shaped by drug company funded research and interests”.

HVN also argue that, amongst other things, “psychiatric diagnoses have damaging consequences” because “mental distress is an understandable reaction to adversity, including: bereavement, loss, poverty, discrimination, trauma, abuse and victimisation” and by “focusing on ‘what’s wrong with you’, diagnoses can stop professionals asking ‘what’s happened to you’” which in turn can “stop people addressing the links between social and economic policy and mental distress.” (4)

I first became familiar with these issues during my training as a mental health nurse.  During this three year period I had an opportunity to explore the theory and practice of mainstream psychiatry.  It was quite early on in my training that I started to feel that there is something seriously wrong with mainstream psychiatry which compelled me to take an even closer look into critical psychiatry.  It was this interest that ultimately lead me to attend the UNTAR conference.

One of the first speakers at the conference was Prof Isaac Prilleltensky (University of Miami) who’s interests are in psychosocial problems and the promotion of wellbeing.  His research shows that there is a link between specific aspects of social organisation (fairness) and mental health (wellness) and, importantly, that there are many opportunities for preventative measures to be put into place at the societal level in order to promote mental health. (5)

Another key speaker was  Prof Kate Pickett (University of York), who’s interests are in the social determinants of health.  As she pointed out, inequality as always been thought of as socially corrosive but the evidence now shows that even small differences in material wealth can make a difference to life expectancy, levels of violence, teenage birth rates, drug abuse, child wellbeing, obesity rates, levels of trust, educational performance, and of course mental health.  As Prof Pickett, and her coauthor Richard Wilkinson, have pointed out; “…it is now clear that income distribution provides policy makers with a way of improving the psychosocial wellbeing of whole populations .  Politicians have an opportunity to do genuine good.” (6) (7)

Along similar lines Prof John Read (Liverpool Psychosis Research Group) summarised his research which showed that poverty and relative poverty – as opposed to genes and neurotransmitters – are reliable predictors of who ends up with a diagnosis of, for example, “schizophrenia”.   Elsewhere, Prof Read and coauthor Pete Sanders, point out that this research supports the general publics position on the causes of mental health problems whilst undermining that of the professional mainstream psychiatrist.  (8)

This general theme – that social injustice is the main cause of mental health problems – ran through most of the presentations and workshops during the three days.  And to my mind this all fitted perfectly well with what I had been reading on social justice and mental health issues.

For example, as Law Prof Joel Bakan has pointed out:

“As a psychopathic creature, the corporation can neither recognise nor act upon moral reason to refrain from harming others.  Nothing in its legal makeup limits what it can do to others in pursuit of its selfish ends, and it is compelled to cause harm when the benefits of doing so outweigh the costs.  Only pragmatic concern for its own interests and the law of the land constrain the corporation’s predatory instincts, and often that is not enough to stop it from destroying lives, damaging communities, and endangering the planet as a whole.”  (9)

And as the late George Albee pointed out:

“Primary prevention research inevitably will make clear the relationship between social pathology and psychopathology and then will work to change social and political structures in the interest of social justice.”  (10)

The obvious logic of such insights is that those who are serious about mental health promotion should work to replace the current pathological economic system with a sane economic system.  However, when I discussed the impact pathological social systems – like capitalist economics – can have on people’s minds with other conference participants I began to detect a resistance to the use of the word pathological.  It seemed that it was okay to describe social systems as pathological but not mental systems.

This issue of embracing socio-pathology whilst rejecting psychopathology came up again during a workshop and a plenary speech that I attended that was given by one of the main speakers at the INTAR conference.  The speaker was Jacqui Dillon who is the chair of the Hearing Voices Network (England) that was discussed earlier.  (11)

During her workshop Jacqui talked about surviving childhood abuse, her own experiences of hearing voices and subsequent use of psychiatric services.  At one point she also described society as “sick” but then went on to talk quite positively about her voices.   In her closing plenary speech Jacqui went on to highlight the need for collective action in order to address the social injustices that can lead to the kinds of personal problems that she has experienced.  One conference participant even joked that it sounded like Jacqui was calling for revolution.

Anyone who is familiar with my work in social justice organising will know that I have no problem with the call for collective action, or even revolution.  Quite the opposite in fact, as this is exactly the kind of work that I engage in myself.  So it was very satisfying for me to hear Jacqui talk so openly about the need for such radical social change if we are ever to address these kinds of issues.  (12)

Despite these important overlaps, however, I cannot understand how it makes sense for critical psychiatry to highlight socio-pathology (be it pathological behaviour in the kinship sphere or the economic sphere – as discussed above) as a cause of mental health problem but then to reject the notion of psychopathology.

One obvious, and understandable, explanation for this rejection is that psychopathology has many negative connotations.  Put simply, people diagnosed as having a psychopathology are stigmatised and are often excluded by society at large which, in its self, is a known contributing factor to mental health problems.  But I think that there is more to this rejection than this.  (13)

In addition to the legitimate concerns regarding stigmatisation and social exclusion (which should be, and are being, address by popular education programmes) I suspect that many people associate psychopathology with both   diagnostic labels from mainstream psychiatry such as “schizophrenia” and the necessity of medical interventions to treat such “illnesses”.

Again, I think that this is understandable – especially for survivors of mainstream psychiatry!  However, I have to say that whilst I find this position to be understandable I also think it is mistaken.  Furthermore, I not only think that it mistaken, I also believe that to reject the notion of psychopathology is counterproductive to critical psychiatry.  Let me try to explain why I think these things.

First of all, it is important to identify the suggested direction of causality of the psychopathology from the research.   As we have seen, critical psychiatry is founded on an evidence base that suggest that the direction of causality is from social injustice to mental health problems.  So, from a critical psychiatry perspective an appropriate intervention for mental health promotion is social reform.  Clearly, from this perspective, there is no need to assume that psychopathology implies either diagnostic labels from mainstream psychiatry or medical interventions.

Second, to deny that psychopathology can result from socio-pathology surely undermines critical psychiatry’s reasonable basis of calling for progressive social change.  After all, if pathological social systems – such as capitalist economics – only result in “emotional distress” or “psychological disturbances” (to use critical psychiatry’s preferred terminology) and that this distress / disturbances can, in the end, have positive outcomes and even become a point of celebration, then the validity of our call for reform towards a more sane society is surely subverted.  Clearly, rejecting psychopathology is counter-productive to critical psychiatry.

Notes and Links

(1)  This quote is taken from Russell’s essay The Science to Save Us From Science

(2)  For more on INTAR go to: http://intar.org/

(3)  The title of the paper is Psychiatry Beyond the Current Paradigm available here: http://bjp.rcpsych.org/content/201/6/430.abstract

(4)  You can read the full HVN statement here: http://www.hearing-voices.org/about-us/position-statement-on-dsm-5/

(5)  You can follow Prilleltensky’s blog here: http://prilleltensky.blogspot.co.uk/

(6)  This quote is taken from the book The Spirit Level: Why Equality is Better for Everyone. 

(7)  For more info on inequality and to get involved in campaign to address it visit: http://www.equalitytrust.org.uk/

(8)  See A Straight Talking Introduction to The Causes of Mental Health Problems.

(9)  This quote is taken from the book The Corporate: The Pathological Pursuit of Profit and Power, which has also been made into an excellent film with the same title.

(10)  This quote is taken from Toward a just society. Lessons from observations on the primary prevention of psychopathology.

(11)  You can read more about the life and inspirational work of Jacqui Dillon here: http://www.jacquidillon.org/

(12) I am an ICC member of the International Organisation for a Particiaptory Society (IOPS) – http://www.iopsociety.org/ – and co-author of the Fanfare for the Future series –http://www.amazon.co.uk/Fanfare-Future-Volume-Occupy-Vision-ebook/dp/B0094A2VKY/ref=sr_1_sc_2?ie=UTF8&qid=1405360418&sr=8-2-spell&keywords=Fanfarefor+the+future

(13)  The Government strategy on mental health promotion – No Health Without Mental Health – acknowledges the importance of tackling stigma and social exclusion, which is ironic given their economic policy.  You can download the policy here: https://www.gov.uk/government/publications/no-health-without-mental-health-a-cross-government-outcomes-strategy