will be interesting to see of this round of questioning psychiatry will be able to mount any kind of substantial legal/political front/organization or languishes yet again as theoretical complaints, if anything the powers of big Pharma and all are more daunting than ever, will there be a serious civil/human rights campaign, I certainly hope so.
At the end of the talk Bracken says that its no good if the space that could open within psychiatry just got occupied by psychology. Unfortunately, I think this is precisely what is going to happen. The endless DSM debate is all too often an attempt by psychology to do what it couldn’t in its infancy: become the dominant psych-discipline.
here in the States they are all hyped up by the promise of finally being a ‘true’ science, the End of philosophy and all finally arriving, the so called existentialists here never really came to grips with the prophetic importance of Heidegger’s work on technology and against cybernetics and so are truly impotent to making real changes/resistances all while feeling pumped up by their supposed philosophical superiority, ugh…
I’ve not listened to the talk, but what does the science of psychology have to say for itself? For most non-psychotic psychological complaints, (1) any therapy is better than no therapy in reducing symptoms, (2) therapy is only partially effective in alleviating symptoms, and (3) no particular type of therapy gets dramatically better results than the others. Therapy is most effective if both the therapist and the client believe that the treatment will be effective. Is that fair?
At a more gross level of resolution, most of the individual variance on psychological variables can be attributed to a combination of genetic and cultural factors, which aren’t additive but interact in complex ways. So, e.g., in contemporary Western society both obesity and depression are on the rise. Some individuals are more genetically prone to these problems, but the population genetics haven’t shifted over the past generation, so the rise in incidence is most likely attributable to sociohistorical factors.
Pharmaceutical treatment attempts to adjust brain biology, which is probably more affected by the hereditary component. Interpersonal therapy establishes a sort of mini-culture between therapist and client, predicated on shared focus, values, and beliefs. But this mini-culture is surrounded and overwhelmed by the larger culture in which it is embedded. It would seem that a post-psychiatric milieu would need to establish non-pathological cultures that are larger and stronger than those that are established for an hour or three per week in the heterotopic space of the therapist’s office.
That’s a fair assessment of psychology. The problem though is that it remains as caught up in power and class antagonisms as psychiatry and is, and always has been, competing with psychiatry for dominance. I think I’d prefer a mental health service driven by psychology (formulation rather than diagnosis, for instance) but the critical psychiatry perspective is one that seeks to cede space to the “service-user” themselves, rather than one more expert. Of course, this isn’t to say you’d have psychotics running the hospital/hospital alternative but I think it would broadly be in line with the principle that those who are affected by a decision should have proportionate control over that decision.
The attempt to produce non-pathological cultures/spaces is one that I think is part of any radical political agenda. This is part of why I’m interested in the TAZ as a starting point. The nonpathological spaces already have models though don’t they? In terms of things like the Sotoria project. How to generalise non-pathological conditions is a question far beyond me.
ktis, that’s close enough and now you may understand why there isn’t much hope for such modernist projects of social-engineering and why we need more radical (in the way that the more extreme zen teachers are radical buddhists) disciplines that can come to terms with real/oldschool epic tragedies/collapses and the heart-rending limits of our all too human capacities/response-abilities for reform, not that there is any guarantee of success in such experiments but such is life.
I don’t follow your inference, dmfant. If some cultures are demonstrably more pathogenic than others, then isn’t it possible to evaluate which variables distinguish those cultures, then attempt to replicate through social engineering the health-inducing variables while minimizing the pathogenic ones. So, e.g., obesity and depression are both associated with poverty; a social engineering intervention that reduces poverty rates might be worth a try. Easier said than done, of course.
Radical Zen-like disciplines sound like another variant of individualized therapy or analysis: certainly better than nothing but not necessarily better than psychoanalysis or CBT. Or are you calling for the installation of a healthier, less pathogenic Buddhist culture in which Zen practice rather than therapy provides individual support for participating more fully in that culture?
leaving aside the dubious claim of the demonstrable differences in cultures (assuming that there are such things/agents as “cultures”, and I don’t) I’m saying that there is no evidence for our having the kinds of powers of reorganization that you are prescribing, think how wide and deep say the powers/reach of multinational companies are, who/what is outside of such webs of influence?
Instead of “cultural” call it environmental or ecological: we’re referring the social and physical and economic milieu in which the individual is embedded. Certainly there are geographic and demographic variations on obesity that aren’t reducible to genetic or familial influences, yes? Colorado has the lowest obesity rate; West Virginia has the highest, nearly twice that of Colorado. What are the differences? Can any of the characteristics of the Colorado food ecosystem be replicated in West Virginia? The point being, if genes and environment combine for such a high percentage of individual variance in these sorts of individual variables, for better or for worse, wouldn’t it be reasonable to assume that interventions to improve the situation would be more successful by addressing causal factors — genes and environment — rather than relying on individually focused change tactics? I think so, but I agree that achieving the desired environmental changes is pretty intractable.
But aren’t there more modest social engineering moves that can be taken? E.g., if hydrogenated fats and corn syrup increase obesity, then reducing their availability in the eating environment would be expected to reduce obesity incrementally. Certainly the huge tobacco tax has reduced smoking rates dramatically in a generation. Are there environmental features associated with depression that could also be addressed through social engineering? Fewer wars and less unemployment would help, but those are harder nuts to crack. Maybe there are others. In part it’s a question of whether incremental improvements are a net good or merely a way of continuing to evade necessary radical change.
Even if you can’t yet envision the shape of the radical new disciplines, dmfant, can you describe any of the features these disciplines might enact? You say that they “can come to terms with real/oldschool epic tragedies/collapses and the heart-rending limits of our all too human capacities/response-abilities for reform.” Are you saying that we can’t yet envision these disciplines we’re still all too human, that unless and until immanence or transcendence lifts us beyond our humanity we won’t be able to create or discover these radical new disciplines? So we need first a discipline that takes us beyond our humanity, either individually or collectively? I mean this is the sense I get from, say, Deleuze & Guattari and Zizek, and maybe even Land: a sort of hermetic or esoteric praxis that takes people into the posthuman, presuming that humanity is shaped not by natural limits and capabilities of the species but by structural constraints that are socially and psychologically constructed. We’re trapped inside our humanity, and the only way to get outside or beyond ourselves is to ride some force that’s not human. And maybe that’s where your Zen allusion gets traction: a discipline that penetrates both inward and outward to something else: the One, or the Zero, in which humanity is embedded and with which some inhuman part of ourselves resonates.
k, your suggestions of more ‘modest’ engineering possibilities seem to leave out factors like say actual/existing politics (everyone seems to be grasping for some post-political ways/means which would literally be post-human), and so no I’m not suggesting some extra-human means/source of transcendence, which is why I don’t mean actual zen or the like, but wondering if there isn’t some aspect/degree of mindfulness that could so fully come to terms with the limits of our all too human capacities (maybe something like coming to see human activity like we used to experience weather before we knew about global warming), I’ve been practicing various modes of attention (including zazen) for over 25yrs now and haven’t been able to make such leaps (falls?) but it still seems an open/undecided empirical matter
Reblogged this on synthetic_zero and commented:
don’t read me, read Arran:
TAZ? Sotoria? Google came up empty for me on both.
In US academic psychology the clinicians have a perspective that’s nearly inimical to the scientific side of the house, almost as if they’re from different disciplines. I don’t think the researchers have much interest, on the grounds either of demonstrable effectiveness or of professional solidarity, in siding with the clinicians in power struggles for attaining dominance over psychiatry in the clinic, but I understand your point.
Soteria, sorry. http://www.moshersoteria.com/
Having now watched the talk (though not the Q&A) I’ll try to summarize some of what came to mind.
Bracken begins by asserting that psychiatrists are “losing faith” in their treatments. He then goes on to claim that the big problem facing contemporary psychiatry is an Enlightenment-driven emphasis on the science and technology of psychopathology and therapy. I suppose it makes sense that science would precipitate a loss of faith: the practice of science is predicated on probing doubts in knowledge sustained by faith and tradition. Certainly over the past 300 years the true believers have often regarded science as the enemy of the faith. Perhaps this loss of faith means that psychiatrists are only now entering into a scientific self-critique of their own traditional theories and praxes.
Bracken sketches the “fundamental assumptions” of the technological paradigm in psychiatry: (1) psychopathology is regarded as a “faulty mechanism in the individual;” (2) the mechanical failure can be modeled in causal terms that are universal and independent of context; (3) interventions are “instrumental” – they disregard values, opinions, relationships, and priorities in which the interventions are delivered. But if these assumptions aren’t exposed to doubt and aren’t being questioned logically and empirically, then they are matters of faith, not of science. Bracken isn’t exposing failures intrinsic to the sci-tech paradigm; he’s revealing features of bad science. And in fact the three assumptions have been and are being subjected to empirical investigation of pathology and therapy.
Bracken contends that “evidence-based practices” represent the epitome of the sci-tech paradigm. Then he contends that, paradoxically, evidence is what has called into question the fundamental assumptions. E.g., pharmaceuticals aren’t as effective as the drug reps claim them to be; specific therapeutic techniques aren’t as important as the placebo effect shared by therapist and client. Okay, then the evaluation of evidence is doing the job for which it’s intended, subjecting unverified assumptions predicated on tradition and faith to systematic scrutiny – no paradox at all.
Though he claims to be advocating “radical change,” Bracken remains locked into the psychiatric paradigm of treating individuals. In describing the placebo effect meta-analyses, he says, “don’t get me wrong: psychotherapy works.” Fine: that conclusion is supported by the evidence. Then he continues by asserting that “what really matters” in therapy is “the quality of relationship,” such that the patient feels “valued” and that the therapy is “meaningful.” On what basis can he claim that these relationship variables constitute an accurate interpretation of the placebo effect? Does he have evidence to support it, or is this what he believes, that in which he has faith?
Bracken wants psychiatry to build collaborative partnerships with the “service user movement,” rethinking pathology not just as something broken but as societally unacknowledged sources of unique strength. That’s fine. He says that the recovery movement is discovering that factors like work, leisure, relationships, sport, travel, spirituality, creativity, friendship, and acceptance are more important contexts for dealing with pathology than is therapy. (As an aside, in the US, user-driven therapists are increasingly being asked by clients to help them change not themselves but others whom they perceive as the sources of their problems: bosses and co-workers and subordinates, spouses, children.) Consequently Bracken recommends that psychiatry get involved in community development work. One wonders whether disciplines other than psychiatry are better positioned to take this community-based approach to rethinking pathology, prevention, and recovery.
‘ Bracken isn’t exposing failures intrinsic to the sci-tech paradigm; he’s revealing features of bad science’.
Perhaps the technological paradigm is bad science and bad therapy.After all, it is less sci-tech that is taking flak here and more the reduction of problems in living to technological problems that require technological solutions. That the science is bad might itself be a result of unexamined presuppositions of this technological paradigm. That said, I’m not entirely comfortable with his monolithic understanding of this technological paradigm. It sounds like he’s really asking for a humanistic psychiatry. Well, fair enough but would such really lack ‘technological’ techniques? Isn’t therapy itself a matter of technical intervention. It seems like his real problem is the assumption that there is a ‘broken mechanism’ somewhere. In the end this sounds pretty similar to the neurodiversity movement: our experience is not something that requires “fixing”.
Bracken’s claims about evidence based practices are pretty well founded, and the critique pre-exists him. It isn’t that evidence needs to be ignored, eschewed or that we can otherwise dispense with it… the real emphasis is on the way that research has come to dominate the therapeutic fields, and how “evidence” is constructed. Usually, it comes down to the question of whether treatment X has been tested in randomised controlled trial settings on diagnostic population X, Y and/or Z. The problem being that this kind of fetish for a certain form of evidence excludes the broader network of types of evidence. Its for this reason that SSRIs are the champion treatment for mild to moderate depression with relatively little evidence of their efficacy.
This kind of EBP is also that which is championed by, and maintains the position of, the people that fund most of this research, and produce most of the psychopharmacological treatments that are being tests: the pharmaceutical industry. Essentially, psychiatry is held to the evidential standards of pharmaco-capitalism. That much of the evidence is now showing the deleterious effects of these medications is only because of journalists like Robert Whitaker who have uncovered a lot of suppressed findings. Let’s remember that in this evidential regime, if a finding contradicts the advertising it is never published. The “evidence base” of evidence-based practice is thus often slim, narrow, and ideologically oriented. Against this EBP is an idea of values-based practice which does not eschew evidence but sees no reason to elevate it to the level of final arbiter of therapies. After all, who would reject evidenced findings?
On the idea that therapy has little to do with the type of theory and more to do with relational and extra-theoretical aspects of the therapeutic relationship there is actually a glut of evidence. Richard Bentall discusses this at length in his Doctoring the Mind . The phenomena is known as ‘the dodo bird verdict. It isn’t uncontroversial, but it allows for a pluralist and/or integrative approach to therapy.
As he says, a fair amount of the service-user movement is opposed to psychiatry, while some do attempt to work within to reform it. I think it is a good thing that people like Bracken and the Critical Psychiatry Network are wanting to reform psychiatry, even if those reforms are still not as radical as we might want. At the same time, I share a sense of unease about all this. For people like Ron Coleman, Marion Aslan and Mike Smith the “recovery” movement has already been recuperated by psychiatry to the extent that it has lost its political dimensions and emphasis on autonomy; while Anthony and Deegan (the originators of the term “recovery”) would probably not recognise recovery-oriented practice as precisely what they envisaged it as. So I am always suspicious when psychiatrists start sounding like they want to get on board with critique.
On the last point, I’m not sure that we should see the question of community development in terms of disciplinarity. This is sort of the point a lot of service-users have been making: their lives aren’t a play thing for the psychdisciplines to argue hegemony over. Obviously there will need to be some kind of disciplinary presence in these areas but why not have something akin to psychiatric councils like the old worker’s councils? Most practitioners already operate within a multidisciplinary capacity, so adding in service-users and/or their families might upset them but it would hardly be a trauma.
Certain kinds of interventions are more likely than others to be subjected to evidence-based scrutiny. As a big-money industry, pharma has the resources and the incentive to sponsor and conduct such studies. Pharma can also control the release of information from the studies they support, actively promoting findings that support their products while either ignoring or actively suppressing negative results. The last time I checked pharma spent 4 times as much on marketing as on R&D.
That pharmaceutical treatment came so quickly to dominate psychiatric practice testifies empirically to the effectiveness of direct-to-consumer advertising, drug detailing, and other tried-and-true marketing strategies. Marketing too is driven increasingly by evidence-based best practices, where “best” means greatest return on investment in achieving increased prescribing. A lot of it has to do with the nature of the relationship established between the drug rep and the doctors/nurses. That’s why pharmas tend to hire college cheerleaders and others with outgoing cheerful dispositions to go on rounds to doctors’ offices with the pizzas and the sample cases.
While physicians receive training in basic sciences, in general they aren’t particularly scientific in their treatment practice. They tend to rely on what they learned in training, as well as what others in their practice do. It’s one reason they’re so readily influenced by pharma sales pitches, even though they believe they’re immune to such manipulation. Even if the drug rep provides the doctors with reprints of studies supporting the product, the doctor often doesn’t make the effort proactively to compare those results with findings from other studies or with studies evaluating other treatments. To push back, some provider organizations mount active counter-detailing programs, limiting access of drug reps while also disseminating information of comparative effectiveness of various treatments.
Certainly characteristics of the therapeutic relationship have been investigated empirically. I just found it curious that Bracken never alluded to these findings when asserting that it’s the quality of the relationship that matters in treatment effectiveness. He observed that the effectiveness of drug treatment is, in at least some subpopulations, largely an artifact of the placebo effect. What sort of relationship factors can be in effect in that context, where the physician might see the patient for 10 minutes, write the prescription, and follow up maybe 2 months later? It must have to do with the authority and confidence of the doctor in dx and rx, and the trust of the patient in this professional self-assurance. A therapeutic relationship predicated on respect for the patient’s self-awareness, mutual trust, the establishment of meaning, concern, even love: all of these relational factors can provide an alternative milieu in which the placebo effect can emerge. In contrast, a Lacanian will avoid establishing that sort of relationship, playing the “dead hand,” not acceding to the analysand’s demand for interpersonal engagement. However, the Lacanian will be the desire for the analysand, insisting that treatment continue even if the analysand resists or is indifferent — one might call this salesmanship. Lacanian treatment too can be a successful beneficiary of the placebo effect: if both the analyst and the analysand believe the treatment will work, it probably will.
The strength of the placebo effect in psychotherapy has been well documented in the literature for at least 30 years. That’s one reason why day-to-day treatment is often not provided by the high-priced MDs and PhDs: their instrumental techniques aren’t all that important. What’s important is that they lend their legitimacy and managerial control to the treatment that is delivered under their authority. And so the MD prescribes, the PhD conducts the diagnostic tests, and the nurses and techs actually engage the clients in therapeutic relationship. As in other fields, the professionals with the power continue making disproportionately more money in these arrangements, such that the underlings work for them while they skim off the profits earned by the staffers’ labor. And so the cost of care goes down while the price goes up.
I have an uncomfortable sense of being perceived as antagonistic in my remarks here, at once defending the science while at the same time interpreting the findings cynically. If the placebo effect works therapeutically, the negative interpretation is that all therapy is a kind of sham, like Scientology or faith healing, reliant on shared credulity for achieving its results. On the other, more optimistic hand, the power of the placebo effect implies that the therapist can adopt a style or technique or system based on some criteria other than expected treatment effectiveness. A therapist might on principle refuse to rely either on exerting his/her authority as expert or on satisfying customer demands, both of which might generate good placebo-inflected therapeutic outcomes for clients who believe in those approaches. Instead the therapist can adopt on philosophical or ethical or political grounds a more egalitarian collaborative position that’s not a staging of power differentials: producer vis-a-vis consumer, or parent vis-a-vis child, priest vis-a-vis parishioner. The therapist who adopts the egalitarian approach can then accept the likelihood that the work will be therapeutically effective especially for clients who already prefer this sort of interaction, and less so for those who don’t.
not many folks get a choice about therapeutic modes these evidence-based days of managed care in the US and too many are committing fraud by reporting one thing to insurance agencies and doing another rather than taking an honest/principled political stand, we could use a bit of focuault style fearless-speech on such matters.
this guys Jung is a bit philosophically naive but thought this might interest you:
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