Coping and causing change as a critical psychiatrist
Critical psychiatry is a relatively new approach to psychiatry and its popularity is growing steadily. The Critical Psychiatry Network (CPN), formed in 1999, is an informal group of psychiatrists who follow this approach.
Critical psychiatry is sceptical of reductionist approaches to mental health which try to explain emotional distress in terms of biochemical imbalances and neurological deficits. Instead, critical psychiatry prefers to understand emotional distress (such as depression or psychosis) in terms of the patient’s social context and life experiences.
Following on from this, critical psychiatry sees drug treatment as only a minor part of treatment. For example rather than seeing neuroleptics as the central essential treatment for people with psychosis, critical psychiatrists would focus on psychological and social support and use drugs as an adjunct, for instance on a short-term basis to help a patient cope with overwhelming experiences.
In contrast to mainstream psychiatry, critical psychiatry is keen to value and work with patients’ own explanations for their experiences. For example, if a patient considered the voices they were hearing to originate from spirits and saw their experiences as being a spiritual crisis, this explanation would be respected.
Additionally critical psychiatry has a strong ethical focus and working alongside survivor organisations is a voice for human rights in the mental health system. For example, the CPN was active in campaigning against Community Treatment Orders.
As with any approach which challenges the status quo, those who follow the critical psychiatry approach often face resistance and harassment from the proponents of the mainstream. Members of the CPN have experienced false accusations, bullying and persecution because of their critical psychiatry beliefs and practices.
In order to help those currently working in critical psychiatry and to encourage more trainees to use this approach a number of strategies for ‘coping and causing change as a critical psychiatrist’ have been developed. A list of questions was distributed to the CPN email group and the following suggestions developed from the answers received.
Strategies for dealing with bullying and threats from colleagues
If you become aware of hostility from colleagues the first step could be to talk to someone you trust about the situation while trying to avoid a knee-jerk reaction. See if those being hostile towards you are open to talking and try and understand each others’ perspective. If colleagues make inappropriate accusations be prepared to defend yourself robustly.
Pursuing bullying and harassment through the complaints procedure is a possibility although it is accepted that in a bullying culture this will make things worse. Some CPN members have found it helpful to remind colleagues that it is a requirement of Good Medical Practice to respect colleagues and not allow personal opinions to adversely affect professional relationships.
Build a local power base and strong relationships with other staff such as nurses and social workers (who may potentially be more likely to share CPN’s concerns about mainstream psychiatry) and local service user organisations who can support you and back you up should you start to be harassed by medical colleagues or management:
‘When I had problems at work many years ago, at the final hour it was the nurses and social workers in the team who supported me. None of my medical colleagues did. This is maybe the answer – to build a local power base’ – Rhodri Huws
‘Build strong relationships with a variety of staff but avoid ‘pairing up’ with one member of staff who gets on with you who also feels unhappy about what’s going on, but have good relationships with a variety of staff’ – Sami Timimi
For some people however, it may become necessary to move to a different area where colleagues are more supportive:
‘… in my first consultant post it was very clear that my early attempts to work closely with service users (the earliest days of the Hearing Voices Network in England) and communities (especially my work with African-Caribbean communities) was seen as ‘odd’ and way outside the mainstream … I was convinced that what I was trying to do was the right thing so decided that the only course of action was to work somewhere where colleagues would be more supportive. Thus I went to work in Wales, where I found a group of supportive consultant colleagues, and in other disciplines especially nursing.’ – Philip Thomas
For trainees facing harassment it can be helpful to bear in mind that once you are a consultant you will be able to have a much greater influence on healthcare - both on individual patients and on policy. On some occasions it may be worth just putting up with hostility from colleagues and keeping quiet or ‘going along with’ things you don’t agree with in order to get through training.
Support from likeminded colleagues is extremely important in coping. These colleagues can be found through alternative mental health organisations, the survivor movement and perhaps most importantly, the Critical Psychiatry Network:
‘The most important single factor in coping with being a critical psychiatrist has been the comradeship and support of like-minded colleagues, whether service users, carers or other professionals, but especially like-minded consultant colleagues in the Critical Psychiatry Network’ – Philip Thomas
‘The existence of the CPN and involvement in writing about and reviewing the evidence to support my practice has been key in helping me believe it’s worthwhile staying in practice as a psychiatrist’ – Sami Timimi
Even when taking note of all the above it can still be difficult to cope with harassment and lack of support from work colleagues. In these situations, finding and talking things though with a psychotherapist may be helpful.
How to protect yourself if you choose not to follow NICE guidelines
It is important to remember that NICE guidelines are only guidelines and even NICE accepts that they cannot completely override clinical judgement. Unfortunately however some Trusts take the position ‘if you follow NICE guidelines and things go wrong, we will support you, but if you don’t then you’re on your own’.
There were two main viewpoints regarding the problems with NICE guidelines. Some members feel the problem with NICE guidelines is that they focus on Evidence-Based Medicine (EBM). These members feel the CPN has a key role in challenging the idea that EBM is the Gold Standard that everyone must follow. Indeed, they note an important aspect of the academic writings of critical psychiatrists has been to question and challenge two aspects of EBM. Firstly, its reliance on a very selected and limited notion of effectiveness, and secondly the influence on the pharmaceutical industry on what passes for scientific knowledge in psychiatry. They feel these challenges are very important to provide a clear line of dissent against blind and thoughtless adherence to NICE and other clinical practice guidelines.
Other members feel that the problems with NICE guidelines are due to the guidelines being consensus driven not evidence-based. These members feel EBM should be embraced as mainstream psychiatry would be severely challenged if it followed the evidence. For example, they note if the NICE guidelines for depression and ADHD had kept to the evidence both the diagnosis and the recommendation for medication would have been severely challenged.
How open can critical psychiatry orientated trainees be about their beliefs
Trainees are advised to be very careful about expressing their critical psychiatry opinions:
‘My advice to any trainee in psychiatry would be to be very careful and judicious in talking with your consultant about your opinions. You should be able to gauge your consultants attitudes by his or her response to articles about critical psychiatry’ – Philip Thomas
Demonstrate that you have a good knowledge of mainstream positions (even if you disagree) for example show that you can do a detailed standard mental state examination and a mainstream assessment of differential diagnosis. Then as time goes on and you have been demonstrating your competencies, gradually introduce less mainstream ideas:
‘As a trainee for most of the time I was getting very positive feedback because I made sure I could do things by the book (even through from a very early stage in my career I was sceptical about the basis of diagnosis, ECT, medication etc, however I also accepted that I needed to learn from more experienced colleagues). As time went on I would introduce the, to me more interesting critical ideas I was discovering through journal clubs and training events, where I often put myself forward to present something in the spirit of trying to get a ‘can we talk about his’ type exchange. On the whole this was received positively.’ – Sami Timimi
How trainees can resist pressure to act in ways they morally object to
Argue your case using evidence and principles such as the importance of informed consent and patient choice. Use papers to back up your argument where possible. This will mean keeping up to date with the critical literature. Try not to get into a hostile verbal exchange however much you feel provoked. Instead get advice from others you can trust or if necessary a representative from the BMA. If the advice after all this is to do the thing you disagree with, then do it anyway as many more will loose out from having the benefits of your insights and skills if you end up unable to progress in your career while a trainee.
Unfortunately the current situation is that the College requires trainees to know how to use ECT in order to complete their training. One perspective on this is that perhaps you can only fully understand ECT if you are trained in it and so by participating enables you to speak from a more considered perspective. Since ECT is currently mandatory most members advise that trainees participate in order that they are able to complete their training and so be in a better position to change things. Several members suggested that the CPN should discuss the issue of ECT and work with the college to make this training optional. In addition, Phil Thomas states that he would personally support any trainee who did not wish to participate in ECT training.
How trainees can learn alternative ways of working with patients
Training in psychotherapy and working in the voluntary sector are two ways to learn alternatives. Regarding working in the voluntary sector:
‘I would advise either voluntary work or a short term contract with a non-statuary organisation. There are national organisations but maybe more valuable would be local organisations that only survive because they are locally relevant.’ – Rhodri Huws
‘I would strongly advise any trainee in psychiatry to spend time doing voluntary work with a non-statuary organisation working in mental health. There are many such organisations for example local Mind Associations and third sector organisations working with Black and Minority Ethnic Communities. Working in the community in close contact with service users and carers has been one of the most valuable experiences in changing my professional practice.’ – Philip Thomas
In respect to psychotherapy training the importance of gaining a variety of perspectives and in particular not just cognitive therapy was emphasised:
‘Most training courses are somewhat weak on gaining a psychodynamic perspective in training, but I do think it is essential to have this appreciation – after all it was not so long ago that American psychiatry was dominated by a psychoanalytical viewpoint and this does need to be understood.’ – Duncan Double
‘During your training I would also get some formal psychotherapy training in an analytically orientated field – i.e. not cognitive therapy. CPN members have differing views on the former. I know that some view psychotherapy as pernicious as the influence of the pharmaceutical companies though I don’t agree. You have to have a philosophical basis for practice and to me it makes more sense that psychological distress be treated within a psychological framework’ – Rhodri Huws
‘I would definitely advise doing some form, preferably a variety of, psychotherapy trainings. I am happy to talk to anyone who wants to about which ones might suit them if that’s at all helpful’ – Sami Timimi
Additionally, learning from the therapeutic community movement and gaining experience from working in such an environment is another method trainees can use to learn alternative ways of working with patients.
Finally, by being open to the ideas the patients you work with have about the nature of their problems, and by working closely with colleagues from a variety of perspectives, you can discover different ways of working.
How to change colleague’s opinions regarding issues such as ECT or biological explanations – are there any particularly good arguments to use?
In order to enter the debate it is necessary to have a good knowledge of the evidence against whatever it is that you oppose – for example biological reductionism, compulsion or ECT. There are also ethical arguments surrounding these issues. The CPN website contains articles and links to books covering a variety of arguments and positions against mainstream psychiatry. An article particularly recommended for trainees is Thomas P & Bracken P (2004) Critical psychiatry in practice Advances in Psychiatric Treatment 10: 361-70. Each person is likely to favour a different style in opposing mainstream psychiatry – some focus on, for example, the conceptual issue about not needing to say that the brain is disordered in mental illness, others on opposing the ‘chemical imbalance’ idea.
It was also pointed out that the study of epistemology (i.e. knowledge about the world) shows that it is not good or valid arguments that make people believe what they believe but rather it is cultural. An example would be the dopamine theory. This theory explains ‘schizophrenia’ because it explains the way early antipsychotics work. The theory is still held onto even though newer antipsychotics don’t work in this way i.e. you can’t scientifically disprove the dopamine theory.
Finally, it was suggested that perhaps we shouldn’t try and change people’s opinions as people will always interpret the evidence to suit their own perspective. In this case the approach would be to state critical psychiatry beliefs and arguments and hope to convince people (general public and in the profession) who previously didn’t have an opinion on the subject.
How to create services which are true alternatives to the ‘medical model’
In the past consultants could develop their own service with a great deal of freedom. Unfortunately, this is not possible now. It appears that there are two options, either seek to change the national agenda (which the CPN is doing) so that there can be large scale change within the NHS, or seek to develop alternative services outside NHS. As the NHS becomes more business-like with competition introduced there is the opportunity to establish services outside the NHS, contracting directly with commissioners.
For people wanting to create ‘alternative’ services in the NHS in their own area it is essential to have a vision, allies and support from colleagues and managers:
‘Build relations with senior management, which of course depends on personalities, but we are often the ones who will bring more interesting service development ideas, so that even though the NHS is a terribly constraining organisation, you may find that you can get the ear of more senior management’ – Sami Timimi
‘This can only happen where you have supportive senior colleagues and managers. In Wales in 1993 I was involved with my friend and nursing colleague, the late Ian Murray, in setting up Dryll-y-Car, a crisis house that did not use diagnosis, and used minimum amounts of medication (Williams, B. Thomas, P. et al (1999). Exploring ‘person-centeredness’: user perspectives on a model of social psychiatry. Health and social care in the Community, 7, 6, 475-482. See CPN website). This would not have been possible without the support of senior management and consultant colleagues.’- Philip Thomas