Double standards

Psychiatrist Duncan Double was once suspended from his NHS trust for "deficient" practice. In a new book which he co-edits Double argues the suspension was political, largely because he practiced "critical psychiatry", an approach refuting the biomedical understanding of mental illness. The book lays out the foundations of critical psychiatry and its contributors include the most influential names in this field. In an interview with Adam James, Double talks candidly about his suspension and argues it is time traditional psychiatry stopped seeing psychiatrists such as himself as a "threat".

April 26, 2006

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If you or I were so distressed to be referred to a psychiatrist, he or she is unlikely to assist you in the way of Duncan Double, one of a handful of vocal “critical” psychiatrists working in the NHS.

Sceptical of the medical and scientific validity of psychiatric diagnoses and benefits of psychiatric drugs, such psychiatrists understand their patients from, they argue, a perspective which is more humane and less stigmatising. So, for example, they are less inclined to diagnose schizophrenia for a patient hearing abusive voices and prescribe anti-psychotics. Instead, they might try to help that person understand what their voices represent, and work out ways to help them control such voices.These men and women have, in effect, taken over the baton of “anti-psychiatry”, famously represented by the thinking during the sixties and seventies of psychiatrists and writers Ronald Laing, Thomas Szasz and David Cooper.

But – as Double learnt - opposing the traditional biomedical thinking on the nature of mental illness, can carry severe consequences. Despite being a consultant psychiatrist and honorary senior lecturer at the University of East Anglia’s medical school, Double was suspended in 2001 for six month from his NHS job. It followed GPs raising concerns over how Double was working with suicidal patients. Double says his employers told him his practice was “deficient” and “unsafe”, that he needed re-training in “organic psychiatry” and that he must undergo clinical supervision for one year. Double says he was told that if he did not agree he would be disciplined.

For Double, the stress brought on by the suspension was "absolutely horrendous” - for him and his family. Yet, with five years to reflect, Double is adamant that his suspension – which was supported by his professional body the Royal College of Psychiatrists – was political. Double says that psychiatrists like him are seen as a “threat” by the biomedical hegemony gripping contemporary psychiatric practice.

Moreover, Double believes that colleague distrust - and outright anger - towards him was enflamed by two factors. First, Double had launched an “antipsychiatry” website documenting the approach of critical psychiatry, and secondly, he was the psychiatrist of Kay Sheldon who, in February 2001, received an out-of-court settlement of £58,000 from Norfolk Health Authority after she claimed she was wrongly diagnosed and treated [by a previous psychiatrist] for schizophrenia over a 15 year period. Moreover, Double says that the slurs made against his practice were never formally investigated. “Basically I was regarded as different,” Double said. “I was using less medication than many psychiatrists and was not so concerned about arriving at diagnoses. In the end the person who the Royal College of Psychiatrists referred me to for retraining in organic psychiatry refused to do it because, he said, the whole matter was political.”

Debates about the aetiology of mental illness have raged within psychiatry and academia ever since psychiatry endeavoured to carve itself out as a medical discipline in the 17th century. The term “critical psychiatry” was coined in 1980 by David Ingleby, professor of intercultural psychology at Utrecht University in the Netherlands. And what critical psychiatry shares with anti-psychiatry is its refute that the mentally “ill” have an intrinsic brain disorder and that physical intervention is of highest clinical importance. Instead, critical psychiatry – similar to Laingian existential psychology - attempts to understand (and treat) severe distress within the “psycho-social” context of a person’s experience.

Within academia, rigorous debate over such philosophy-of-mind concerns and implications for practice is both expected and encouraged. Within actual psychiatric practice, however, such critical views can be demonised, says Double. In fact, this was something Double learnt early on in his career. When a trainee psychiatrist in Cambridge he attended seminars to discuss journal articles. During one seminar he questioned the traditional medical understanding of mental illness. “I remember my psychiatry tutor saying to me ‘this is dangerous talk’,” remembers Double. “Yet all I was doing was trying to work out how we should be psychiatrists.”

Such an austere rebuff to intellectual enquiry can be contrasted to Double’s “liberating” years from 1989-92, when he was a lecturer in psychiatry at the University of Sheffield. At that time, the department of psychiatry was headed by Prof Alec Jenner, co-founder of the voluntarily-run radical mental health magazine Asylum (which this year celebrated its 20th anniversary). “Jenner was in tune with my views, and there was nowhere else in the country that I could have gone,” says Double.

Nevertheless, despite such a positive experience of academia, Double chose to combine it with continuing a practitioner path. “If critical psychiatry means anything it should be involved in practice,” he stresses. And, in what some might see as an intellectual riposte to the questioning of his practice incurred by his suspension, Double is co-editor of a new book, Critical Psychiatry; Limits of Madness. It traces the philosophical, scientific and historical foundations of critical psychiatry, and Double contributes three chapters. The other nine are by some of the leading thinkers and practitioners in both critical psychiatry and psychology. They include a chapter by Lucy Johnstone, academic director of clinical psychology at the University of Bristol, who argues that acts of making psychiatric diagnoses are social judgement lacking medical objectivity. In a strikingly similar experience to Double, Johnstone says her dissenting views on psychiatric practice led to her once being hounded out of clinical NHS work. Another chapter by psychiatrist Joanna Moncrieff, senior lecturer in social and community psychiatry at University College, London, critiques the evidence base for psychiatric drugs; and Phil Thomas, senior research fellow at the centre for citizenship and community mental health, University of Bradford, co-writes a chapter arguing that, under postmodernist scrutiny, psychiatry’s modernist foundations are untenable.

Importantly, Critical Psychiatry draws out how critical psychiatry is distinct from anti-psychiatry which, Double argues, eventually became preoccupied with exploring existential paths to personal enlightenment rather than pressing for progressive psychiatric practice. Moreover, Double says that – unlike anti-psychiatry - critical psychiatry is willing to engage meaningfully in scientific debate over the validity of psychiatry’s biomedical evidence base. “Critical psychiatry engages with the data” is how Double puts it. “I do see myself as a scientist, and I so see my approach as scientific – not just in an empirical sense, but a broad sense of making enquiries.”

Moncrieff’s chapter – entitled The Politics of Psychiatric Drug Treatment - characterises this “broad” enquiry. It examines how the billion pound pharmaceutical industry has formed an alliance with a prestige-yearning psychiatric profession and successive British governments eager to “transform social and legal problems [of the mentally ill] into scientific and technical ones”. One consequence, argues Moncrieff, has been the consistent overplaying of the benefits of psychiatric drugs. After examining the data on drug efficacy, Moncrieff concludes: “The psychiatric community appears to have lost the ability to imagine that life with serious mental illness is possible, and maybe sometimes better, without [psychiatric] drugs.”

Double decided to document his suspension in Critical Psychiatry in a bid to convince mainstream psychiatry that it should not judge psychiatrists like him as a “threat”. He tells readers: “The aim is that by the end of the book you will be able to decide for yourself whether critical psychiatry is really such a threat. In my view, the book will have succeeded it it makes plain the self-deception, albeit unconscious, of much of biomedical psychiatry, and encourages instead a more open mental health practice.”

Surely now - as head of a multi-disciplinary community mental health team in Norwich, a wealth of journal articles and a co-edited book to his name - Double should have no fear that the validity of his practice will again be put under the spotlight? Alas, not so. Double remarks: “If there were power struggles again [within the trust] it would be an easy thing to open up again.” Being critical comes at a price.

* Critical Psychiatry; Limits of Madness is published in hardback on May 19, priced £50, by Palgrave Macmillan (0230001289)
* Critical Psychiatry Network: www.critpsynet.freeuk.com

A shortened version of this article was published by the Times Higher Education Supplement

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Willing to be 'compliant' - as long as it's not just medication

Comment by: Susanna Wild (requested not to use real name to protect identity), computer programmer, UK

Date: August 13, 2006

I applaud Doube's courage. I was diagnosed as bipolar a year ago at age 42. I agree that the diagnosis applies to me and feel fortunate that I became aware of the nature of my problem without undergoing some of the more obvious and destructive experiences that so many other patients relate. That said, the impact my symptoms have had has been considerable and damaging.

I accepted medication and conventional treatment for 10 months. I was fully compliant and cooperative. I followed instructions precisely and consulted my doctor frequently. Over the course of that time, my sense was that the cycles of mood and behavior I experience were not ameliorated by the medication, but that many of the primitive coping strategies that I'd developed were no longer possible due to the disorganizing side effects of the medication. Over that period, I went from a competitively employed person who was deeply troubled, to an unemployable individual who was unable to think clearly or function in any area of skill or competency.

I went to my doctor and requested a withdraw schedule. I was facing severe economic circumstances, my savings were gone, I had no private insurance and I may have been helped by some lingering sense of what my circumstances would mean to my ability to care for my daughter.

The doctor was in deep disagreement with my choice. However, she agreed to give me a tapering schedule...along with a different perscription choice. I told her the choice to resume would be made based on the experience of withdraw, my personal research into the suggested medication's effectiveness and on my economic ability to support the medication. As it turns out, even had I chosen to accept the recommendation, I could not have! afforded it.

I was clear of medication in March of this year. My symptoms are still present, as are my dysfuntional thought patterns and social functioning deficits. I am again competitively employed in my field. I am currently undergoing the process of attempting to find legitimate supportive care for my condition. My feeling is that; as I have never been in trouble with the law, have never been irrecoverably financially irresponsible, am not a substance abuser and am able to function reasonably in society, that I should have the right to explore options other than medication. I think if my history included some sort of violence, or if I were to behave in a way that more than merely irritating to those around me, that the argument that medication should be a mainstay of my treatment would be more jusitifiable.

I have asked to maintain contact with my doctor. My feeling is that this will provide a 'safety net' and motitoring in the event I am unable to appreciate my symptoms' severity. I have also begun biofeedback in an effort to control anxiety, attentional issues, and to increase my sense of self control. I requested a referral for a cognitive therapist to work on life skills and social issues that I face.

I felt this was responsible and had a chance of being helpful. Biofeedback has been a success...the nurse training me is affiliated with my doctor's practice and has expressed satisfaction with my progress.

However, my other request for referral for cognitive therapy has so far been ignored. And at my recent biofeedback appointment, the nurse took the opportunity to harangue me about the need to go back on medication. I asked if she felt my present behavior was in any way inappropriate or concerning. She said it was not. Yet, she persisted in attempting to frighten me about what I could expect if I did not resume medication.

I did explain my reasoning! and experiences on medication to her. Primarily I feel that I am functional at the moment and unwilling to do anything which may impact my employment, my ability to care for myself and my daughter, or which might worsen my condition. I explained that the side effects of the medication previously taken had impacted on those goals seriously. I told her I'd consider her suggestion.

I left feeling somewhat upset. I have significant doubts about my own perspective. I had hoped that my treatment providers would be a good 'reality check' for me. But if I am to be given advice based on theory rather than on observed behavior...it really defeats the trust I have in when I may need to rely on their judgment to resume a medication. I also felt belittled and a bit offended.

My sense is that, during the phase of treatment where I was medicated, any loss of function, cognitive impairment, employment impact, etc. would be considered acceptable so long as I was on the medication. And, that it is still viewed in this way.

So, I'm having a crisis of sorts. All the standard medical advice supports the doctor's view. Many patient experiences do detail very terrible results for patients that are not medicated. I'd be a fool to ignore this. Yet, my personal view is that I may not be unreasonable in trying to seek to be compliant in 'treatment' rather than merely 'medication compliant'.

It is very difficult for me to find mention of a physician willing to guide this process enthusiastically. It is equally difficult to have to sort out the quackery from things that might actually help me manage myself more effectively. And, I feel an enormous lack of self confidence in the matter.

The notion that someone might be pursuing a legitimate alternative treatment paradigm to offer patients seems highly encouraging to me.

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