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|BMJ 2006;333:1026 (11 November),
Postpsychiatry: Mental Health in a Postmodern WorldJack Piachaud
You would imagine thinking about thinking to be the province of psychiatry. This, surprisingly, is not the case. There are many differing views and approaches to the mental world, but these largely reside in the discipline of philosophy. Psychiatry has been taken over by a biomedical model, leaving little space for other considerations; this book attempts to open up that space.
The path for psychiatry was largely determined by two major social processes of the 18th and 19th centuries: the development of institutions for the insane and the Enlightenment. As society became increasingly complex, institutions emerged for not only the insane but for poor and unemployed people; over time medical care became concerned with the madness within their walls. Parallel to this, the process in European thinking called the Enlightenment broke free from the spiritual and moved to rationalism, science, and the hope of self determination.
Crucial to psychiatry was the work of Karl Jaspers, linking the philosophical study of phenomenology with mental disorder and inventing a new science of psychopathology. Derived from Descartes' notion of dualism—that the mind is separate from the body and therefore open to inquiry as an independent thing—psychiatry and all its allied disciplines are based on a rational scientific inquiry into the mind, on diagnosis of fault and treatment of disorder.
There are alternative models—the authors deriving theirs from the philosophers Foucault, Heidegger and Wittgenstein—that do not separate mind from body or from the social discourse and that do not validate a snapshot of mental activity. What matters most in mental phenomena is meaning. To regard a person's utterances simply as symptoms of a disease rather than to engage in exploration of meaning may deny that person opportunity to make sense of their unusual experiences.
Placing the person at the centre, empowering and enabling, has become the dominant social process in the field of disability, but those with mental disorder are far from that goal. Campaigns against stigma may only serve to reinforce notions of otherness. The linkages between mental illness and public risk have become too close and psychiatry, with its roots in the coercive institutions of the past, still plays a role of social policing.
The enmeshed relationship between psychiatry and the pharmaceutical industry promotes the illness model. The power of the industry has become great, guiding research and teaching, even influencing policy. Is it the wealth of Big Pharma or is it the success of the biomedical model that drives the current system? The evidence may be questioned and our models of thinking falsely reduced.
The book is a worthwhile though not an easy read; it is postmodern in its complexity. The authors do not dismiss science or medication. They are not calling for medicine to abandon mental health. They wish to recapture models of thought lost in the intensity of the scientific gaze and apply these in practice.
Patrick Bracken, Philip Thomas
Oxford University Press, £29.95, pp 312
ISBN-10: 0 19 852609 1
ISBN-13: 978 0 19 852609 4
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