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The struggle for mental health reform (I): How are innovative ideas neutralised?

Courtesy of David Castillo Dominici at FreeDigitalPhotos.net 2

I felt a creeping despondency when I learnt that the documentary, My Baby Psychosis and Me, had recently won a MIND charity media award. It seemed incredible that an organisation like MIND – once a leading progressive voice and advocate for survivors of the mental health system – could bestow this prize on a programme, so partisan in its promotion of bio-medical approaches to human suffering, one might be forgiven for thinking it comprised part of a Royal College of Psychiatry publicity campaign. How can MIND, a once-radical mouthpiece for the service-user movement, be transformed into a puppet for biological psychiatry?

 

A history of neutralisation
On reflection, I shouldn’t feel surprise at witnessing a once-pioneering force within the mental health world morphing into a mouthpiece for traditional psychiatry; it is, sadly, an all too common phenomenon. For half a century radical voices and innovative concepts, all intended to promote more humane responses to human suffering, have been neutralised or corrupted so as to become less of a threat to the status quo.

Over 40 years ago Loren Mosher, a dissident American psychiatrist, demonstrated how his ‘Soteria’ approach (comprising small houses staffed by non-professionals) achieved outcomes that were at least as effective as traditional inpatient psychiatric hospitals, with only minimal use of medication (1). Despite publishing 37 papers in research journals offering evidence of the superiority of his non-medical response to people overwhelmed by psychotic experiences, (people who traditional psychiatry would typically label as ‘schizophrenic’), the Soteria project was starved of funding and closed in 1977 (2).

Around the same time, a similar marginalisation befell Thomas Szasz, another high-profile critic of biological psychiatry. Opposition from his more traditional colleagues led to his exclusion from involvement in the teaching of psychiatric trainees (3).

A number of so-called anti-stigma campaigns, often funded by the drug companies, regurgitate the ‘illness like any other’ mantra and thereby increase (rather than reduce) the likelihood that sufferers are marginalised and discriminated against (4).

More recently, two innovative and potentially transformative ideas have suffered some degree of nullification. The recovery approach to mental health originally strove to instil much-needed optimism into core psychiatric services by promoting the idea that each person, irrespective of the severity of problems, can individually define and achieve a meaningful and satisfying life (5). Regrettably, government ‘back to work’ initiatives have sometimes hijacked the recovery concept and used it to justify the abrupt removal of state benefits.

Secondly, the recognition that people with direct experience of mental health problems can often be a potent source of help for current sufferers led to a proliferation in the number of ‘peer support workers’ within the psychiatric system. Unfortunately, there is evidence that this potentially innovative way of challenging the prevalent bio-medical ethos is being neutralised by co-option into the group of core psychiatric professionals and the subsequent adoption of the host’s existing culture and values (6).

 

The tactics used by the neutralisers
So what strategies are deployed to dilute and corrupt innovative ideas? The two major tactics can usefully be described as invalidation and assimilation (7).

Invalidation typically takes the form of ridicule and personal attacks. The innovator is undermined by accusations of ignorance and/or harbouring ulterior motives, usually around self-promotion. Anyone who has argued for alternative approaches, either within a multi-disciplinary psychiatric service or via social media, will probably be familiar with these sorts of reactions from those with vested interests in maintaining the status quo. (I’ve been accused of engaging in ‘turf wars’, being a ‘trouble maker’ and promoting scientology – to name just a few). One high-profile example of invalidation occurred in 2015 when Jeffrey Lieberman, the former president of the American Psychiatric Association, accused the investigative journalist, Robert Whitaker of being ‘a menace to society’ for daring to question the long-term efficacy of antipsychotic drugs.

Another common tactic intended to invalidate is to label the innovator as uncaring. The argument here is that, if you don’t buy into the idea that a brain abnormality is a primary cause of mental health problems, you must be blaming the sufferers for their emotional difficulties – the ‘brain-or-blame’ notion. (A paradoxical fallacy in light of the evidence suggesting that traditional bio-medical frameworks for understanding human suffering encourage punitive responses towards those identified as mentally ill).

A second important strategy used by those seeking to neutralise new ideas – and one that is arguably more difficult to counter – is the process of assimilation. This widespread practice involves the removal of the more radical aspects of a new idea so that what remains appears little different from the accepted orthodoxy (7). Supporters of the medical model can then claim to be already practising in a way that is broadly consistent with the ‘new’ proposal.

Innovators within the current psychiatric system will, I suspect, be conversant with this insidious practice whereby proposals to radically change service provision are initially welcomed by managers but are then edited and revised as they pass through various groups and committees. Hence, when the final, sanitised version reaches the clinical teams it is commonly met with a ‘but we’re already doing this’ response, and existing practice continues untouched by the innovator’s efforts.

Adopting an organisational perspective, another important way in which forces for change are neutralised is via a misuse of power. Within the NHS mental health services, psychiatrists benefit from privileged access to resource power (enabling the control of finance and other assets) and positional power (by virtue of a formal role, such as medical director or team leader). As such, these promoters of bio-medical orthodoxy can determine which change projects are supported and which are left to wither (a fate suffered by Mosher’s Soteria initiative, mentioned above).

Similarly, funding is deployed by both multi-national drug companies and traditional psychiatric bodies (for example, the Royal College of Psychiatry in the UK, and the American Psychiatric Association in the US) to influence the practices of anti-stigma campaigns and service user/carer organisations (8).

So how can these pervasive neutralisation processes be countered, so as to allow innovatory ideas to take root and flourish? I will share my thoughts on this important question in my next blogpost.

 

References

(1) Mosher, L. (1999). Soteria and other alternatives to acute psychiatric hospitalization: A personal and professional review. Journal of Nervous and Mental Disease, 187, 142 – 49.
(2) Whitaker, R. (2002). Mad in America: Bad science, bad medicine, and the enduring mistreatment of the mentally ill. (pp220 – 226). Perseus Books, New York.
(3) Johnstone, L. (2000). Users and abusers of psychiatry: a critical look at psychiatric practice (2nd edition.) London: Routledge.
(4) Sidley, G. (2015). Tales from the Madhouse: An insider critique of psychiatric services. (pp 43 – 48). PCCS Books.
(5) Repper, J & Perkins, R. (2012). Recovery: A journey of discovery for individuals and services. In P. Phillips, T. Sandford & C. Johnston (Eds.) Working in Mental Health: Practice and policy in a changing environment (pp 71 – 80). Oxford: Routledge.
(6) Brown & Stastny (2016). Peer workers in the mental health system: a transformative or collusive experiment. In Searching for a Rose Garden: Challenging Psychiatry, Fostering Mad Studies (Eds. J. Russo & A. Sweeney). PCCS Books.
(7) Boyle, M. (2013). The Persistence of Medicalisation: Is the presentation of alternatives part of the problem? In S. Coles, S. Keenan & B. Diamond (Eds.), Madness Contested: Power and Practice (pp 4 – 22). PCCS Books.
(8) Goldacre, B. (2012). Bad Pharma: How drug companies mislead doctors and harm patients. (p266 – 271). London: HarperCollins.

 

Photo courtesy of David Castillo Dominici at FreeDigitalPhotos.net

 

2 thoughts on “The struggle for mental health reform (I): How are innovative ideas neutralised?

  1. Deirdre Oliver / Reply 7th December 2016 at 9:06 pm

    The assimilation also occurs when a peer run organisation operating on donations and using volunteers is given government funding. This is often applied for in good faith but once it happens the organisation must justify its expenditure to bureaucrats and thus becomes an arm of the establishment. Once people start receiving a nice salary, in a nice, renovated office, with a nice title, it is difficult to go back. BUT Corruption occurs only when people are prepared to be corrupted and denial is a great weapon against cognitive dissonance.

    • Gary Sidley / Reply 8th December 2016 at 10:54 am

      Spot on, Deidre. We clearly require donations/funding streams that are independent of government/NHS because, as you say, money from this source typically demands that the funded organisation maintains the traditional ethos (as well as all the bureaucratic, risk-averse nonsense).

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