Perhaps you could call for ex service users who are not involved in anti psychiatry groups to contact you, to open out the debate from the binary impasse you describe here.
Yes, I’m encouraged to see that. I haven’t had much contact with psychiatrists myself, however. I’ve never been in a psychiatric ward or received a diagnosis for a major psychiatric disorder. It just never happened. I responded well to an antipsychotic prescribed by my GP after my first episode over 2 decades ago. My second episode, after a head injury, also came to an end with a GP prescription, and I was only referred to a psychiatrist afterwards as a one off appointment to assess if I needed further help. I received some one to one therapy appointments on the NHS with a counsellor, and Prozac for the aftermath. May Poehler and Leif Gregersen have better experience of the system from the service user’s end.
These can be uncomfortable conversations, but I applaud you for doing it and I urge you to continue. I know that the reason why there are so many entrenched views in anti psychiatry is due to the hurt and the loneliness that the current treatment for severe illness entails. These are difficult matters, and resolving them requires an identity crisis for everyone involved (something that most people don’t want to face). There is progress, though, after we go away and process painful interactions. Psychiatrists are rejection averse, while sufferers often have a lifetime of rejection by other people to live with. I can recommend a new blog I have come across called Mad Philosophy that describes the pitch black reality of severe mental illness from the perspective of a philosopher. Keep going, Awais, and encourage your colleagues on here to take criticism on board and make connections with people who do want to talk about their own insights. You have to go through all the stages of full grieving when you have suffered from severe mental illness, and where you catch the person during that process really affects how hot the interaction goes. Of course, the stages of grief model is just a rough guide, and some people experience all the emotions at once. Why grief? Because you are grieving the life you could have had if you hadn’t been ill. This is real grieving indeed for many with years lost to severe mental illness. I believe that psychiatrists need to go back to first principles in order to help these people live more productive and fulfilling lives, which is what we all want. I think that every WRAP plan should contain this issue (grieving for what has been lost) but with extra work for tackling the added issues of shame and stigma to the usual emotions connected with loss. Instead of “here’s your medication for life, goodbye”, a better psychiatric practice would surely be “here are your stabilising drugs, now the real psychological work starts, with me, or with your outpatient team”. Surely that would make a more fulfilling career for everyone involved.
"Gipps: A particular interest of yours has been in bridging the gap between the fields of philosophy of psychiatry and critical psychiatry....
"Aftab: In the introductory chapter to this book I’ve tried to show how the gap between philosophy and critical thought can be bridged conceptually..."
I get the impression that the "philosophical" questions are practically all ontological, without much thought given to philosophy of science and epistemology. Do you think this is accurate? If so, should more attention be given to the epistemology of psy-sciences? (E.G., this Spielmans & Kirsch paper on the inadequacy of FDA standards to assess the effectiveness of antidepressants: https://psychrights.org/research/digest/misc/FDAPsychDrugApprovalProcessSpielmansKirschARCP2014.pdf - note, I'm not endorsing any claim to the effect that SSRIs categorically do not outperform placebo, which, so far as I know, Kirsch never claimed; this paper examines how the efficacy of various antidepressants was assessed.)
“the "philosophical" questions are practically all ontological, without much thought given to philosophy of science and epistemology”
In my chapter or more generally? In the chapter I do touch on some of the epistemological issues (especially in the context of inclusion of lived experience).
I think the issue of FDA standards or standards of medication efficacy usually gets covered under debates around “evidence based medicine.” I plan to write at some point about the clinical vs research perspective on these things.
"practically all ontological" was overstating it, but ontology and phenomenology seem to be the focus, e.g., the first question here being "... Might you begin though by telling us what you mean by ‘conceptual competence’ and what it looks like in the clinical psychiatrist? ..." and your answer to it; your "integrative and critical pluralism" approach to critical psychiatry, which seems to emphasize conceptual frameworks and value differences, while minimizing possible factual disputes; and a general "vibe," based on a dearth of epistemological questions/concerns appearing non-interview blog posts and your collaborations with other psychiatrist-writers.
Naturally, interviews and guest posts are not conductive to questioning guests' claims of fact, but the topic of epistemological challenges in the psy-sciences also seems under-represented in your writing. This isn't necessarily a bad thing - not every author needs to give proportional attention to every topic in their niche, of course, and their work might be worse, if they tried. However, "bridging the gap between the fields of philosophy of psychiatry and critical psychiatry" requires addressing questions of facts within and the methodologies of the psy-sciences, at some point, so I thought it was a question worth asking.
I so appreciate this, Dr Aftab, especially this passage:
" This is philosophy ‘as a way of life’, to borrow the title of Pierre Hadot’s book: philosophy as the pursuit of wisdom, the cultivation of virtue, the art of living, and the embodiment of percipience. It is, I think, wise percipience which patients most often appreciate in their best psychiatrists and nurses, and the absence of this is what they most deplore in their poorest. An important aspect of such valued discernment is, I think, not so much reflective conceptual competence—in fact, we can readily imagine humanely wise clinicians who enjoy little of that intellectual facility - but something more like what psychologists call ‘reflective function’. (Which is to say: the ability to make sense of another’s predicament-aroused emotions without simply parsing that sense-making through one’s own person but instead by genuinely encountering the patient as an other, with her own values, experiences and sensibilities.) Now, I think it fair to say both that psychiatry as a field—and here, I should say, I’m not at all contrasting it with the field of psychology!—is not stacked full of wise percipience, and that the education of the virtues is no simple business. Sometimes—and I confess to finding this frustrating—psychiatry styles its practice in merely technical terms and attempts to outsource the business of an anyways now rather deprecated wisdom to the domain of the psychotherapist. And yet I rather feel—but what do you think?—that within the best of psychiatry’s own spirit or ‘eidos’ there lies the idea of a form of straightforward humane wisdom that’s rather distinct from what one finds in psychology or psychotherapy. This importantly includes the ability to remain thoughtful, realistically hopeful, and agential in the midst of even psychotic levels of anxiety. At any rate, my question is whether you can see a way forward for the profession to develop such philosophical wisdom in its practitioners?
Aftab: I completely agree with you about the need for such humane wisdom and the importance of inculcating it in practitioners. I am somewhat pessimistic about the prospects of bringing about such a transformation in the profession. Medical and psychological training not only takes place within a system governed by all the problems of capitalism but also the system increasingly emphasizes efficiency, productivity, uniformity, documentation, and risk averseness. The space to engage with another in a deeply human way has been steadily shrinking. Even when training programs try to create spaces of reflection and nurture such virtues, the clinic offers little to no opportunity to exercise them. So, the challenge is how to create systems that incentivize and nurture such virtues on an on-going basis. I don’t think anyone has quite figured that out yet! Technical knowledge and practical skills are easy to teach and measure, but thoughtfulness and wisdom are difficult to impart and assess. The solution likely involves attracting trainees with such virtues to join the profession and then reinforcing them through a variety of norms."
I'd love to get your thoughts about how to cultivate percipience in our trainees and mentees. I often think that the creation of "pre-med" as an undergraduate major traded a foundation in the humanities and philosophy for science as a preamble to med school (I had a different path, I was a psychology undergraduate before going to nursing/NP school). I think I'd rather have a palliative care doc or psychiatrist that read Tolstoy's "The death of Ivan Illich" over another text on palliative care.
I appreciate the acknowledgement that the technocratic-capitalist skills of diagnosing, prescribing medications, charting, and billing have decreased the perceived value of deeply connecting with another human being. How do we teach this thoughtfulness that you so carefully examine in this conversation?
Thanks Andrew! Sorry for the late reply. Important question and difficult to address practically because the push towards efficiency and standardization in medical education & emphasis on technological solutions and treatment algorithms is not conducive to creating environments that emphasize the human dimensions of the clinical encounter. Creating spaces in training for reflection, for literary and philosophical engagements with suffering, and having good role models among educators are good starting points, short of a radical reform of healthcare systems!
"as politics around abortion and the COVID-19 pandemic has revealed, science can easily be sacrificed in the service of political rhetoric."
I am in total agreement that scientific evidence has often been disregarded in the discussion of COVID, but how does that relate to the abortion issue? I don't know anyone who disagrees that human life progresses from a fertilized cell to a clump of cells, to an embryo, to a fetus, to a viable preborn baby. The only question dividing opinions on this issue is when that developing entity should be regarded as a human being possessing the rights that other all human beings are granted. How could that be a scientific question?
II am trying to develop analogies: In the United States we regard horses and dogs as pets deserving of humane care. I don't know of any state where it is legal to slaughter a horse for human food. That's the American sense of ethical responsibility toward horses, and science has nothing to do with it.
Perhaps you could call for ex service users who are not involved in anti psychiatry groups to contact you, to open out the debate from the binary impasse you describe here.
Open invitation from my side! The very first guest post I published was from Lisa Wallace: https://www.psychiatrymargins.com/p/guest-post-a-psychiatric-survivor
Yes, I’m encouraged to see that. I haven’t had much contact with psychiatrists myself, however. I’ve never been in a psychiatric ward or received a diagnosis for a major psychiatric disorder. It just never happened. I responded well to an antipsychotic prescribed by my GP after my first episode over 2 decades ago. My second episode, after a head injury, also came to an end with a GP prescription, and I was only referred to a psychiatrist afterwards as a one off appointment to assess if I needed further help. I received some one to one therapy appointments on the NHS with a counsellor, and Prozac for the aftermath. May Poehler and Leif Gregersen have better experience of the system from the service user’s end.
These can be uncomfortable conversations, but I applaud you for doing it and I urge you to continue. I know that the reason why there are so many entrenched views in anti psychiatry is due to the hurt and the loneliness that the current treatment for severe illness entails. These are difficult matters, and resolving them requires an identity crisis for everyone involved (something that most people don’t want to face). There is progress, though, after we go away and process painful interactions. Psychiatrists are rejection averse, while sufferers often have a lifetime of rejection by other people to live with. I can recommend a new blog I have come across called Mad Philosophy that describes the pitch black reality of severe mental illness from the perspective of a philosopher. Keep going, Awais, and encourage your colleagues on here to take criticism on board and make connections with people who do want to talk about their own insights. You have to go through all the stages of full grieving when you have suffered from severe mental illness, and where you catch the person during that process really affects how hot the interaction goes. Of course, the stages of grief model is just a rough guide, and some people experience all the emotions at once. Why grief? Because you are grieving the life you could have had if you hadn’t been ill. This is real grieving indeed for many with years lost to severe mental illness. I believe that psychiatrists need to go back to first principles in order to help these people live more productive and fulfilling lives, which is what we all want. I think that every WRAP plan should contain this issue (grieving for what has been lost) but with extra work for tackling the added issues of shame and stigma to the usual emotions connected with loss. Instead of “here’s your medication for life, goodbye”, a better psychiatric practice would surely be “here are your stabilising drugs, now the real psychological work starts, with me, or with your outpatient team”. Surely that would make a more fulfilling career for everyone involved.
"Gipps: A particular interest of yours has been in bridging the gap between the fields of philosophy of psychiatry and critical psychiatry....
"Aftab: In the introductory chapter to this book I’ve tried to show how the gap between philosophy and critical thought can be bridged conceptually..."
I get the impression that the "philosophical" questions are practically all ontological, without much thought given to philosophy of science and epistemology. Do you think this is accurate? If so, should more attention be given to the epistemology of psy-sciences? (E.G., this Spielmans & Kirsch paper on the inadequacy of FDA standards to assess the effectiveness of antidepressants: https://psychrights.org/research/digest/misc/FDAPsychDrugApprovalProcessSpielmansKirschARCP2014.pdf - note, I'm not endorsing any claim to the effect that SSRIs categorically do not outperform placebo, which, so far as I know, Kirsch never claimed; this paper examines how the efficacy of various antidepressants was assessed.)
“the "philosophical" questions are practically all ontological, without much thought given to philosophy of science and epistemology”
In my chapter or more generally? In the chapter I do touch on some of the epistemological issues (especially in the context of inclusion of lived experience).
I think the issue of FDA standards or standards of medication efficacy usually gets covered under debates around “evidence based medicine.” I plan to write at some point about the clinical vs research perspective on these things.
"practically all ontological" was overstating it, but ontology and phenomenology seem to be the focus, e.g., the first question here being "... Might you begin though by telling us what you mean by ‘conceptual competence’ and what it looks like in the clinical psychiatrist? ..." and your answer to it; your "integrative and critical pluralism" approach to critical psychiatry, which seems to emphasize conceptual frameworks and value differences, while minimizing possible factual disputes; and a general "vibe," based on a dearth of epistemological questions/concerns appearing non-interview blog posts and your collaborations with other psychiatrist-writers.
Naturally, interviews and guest posts are not conductive to questioning guests' claims of fact, but the topic of epistemological challenges in the psy-sciences also seems under-represented in your writing. This isn't necessarily a bad thing - not every author needs to give proportional attention to every topic in their niche, of course, and their work might be worse, if they tried. However, "bridging the gap between the fields of philosophy of psychiatry and critical psychiatry" requires addressing questions of facts within and the methodologies of the psy-sciences, at some point, so I thought it was a question worth asking.
I hope that's more clear. Thanks!
I so appreciate this, Dr Aftab, especially this passage:
" This is philosophy ‘as a way of life’, to borrow the title of Pierre Hadot’s book: philosophy as the pursuit of wisdom, the cultivation of virtue, the art of living, and the embodiment of percipience. It is, I think, wise percipience which patients most often appreciate in their best psychiatrists and nurses, and the absence of this is what they most deplore in their poorest. An important aspect of such valued discernment is, I think, not so much reflective conceptual competence—in fact, we can readily imagine humanely wise clinicians who enjoy little of that intellectual facility - but something more like what psychologists call ‘reflective function’. (Which is to say: the ability to make sense of another’s predicament-aroused emotions without simply parsing that sense-making through one’s own person but instead by genuinely encountering the patient as an other, with her own values, experiences and sensibilities.) Now, I think it fair to say both that psychiatry as a field—and here, I should say, I’m not at all contrasting it with the field of psychology!—is not stacked full of wise percipience, and that the education of the virtues is no simple business. Sometimes—and I confess to finding this frustrating—psychiatry styles its practice in merely technical terms and attempts to outsource the business of an anyways now rather deprecated wisdom to the domain of the psychotherapist. And yet I rather feel—but what do you think?—that within the best of psychiatry’s own spirit or ‘eidos’ there lies the idea of a form of straightforward humane wisdom that’s rather distinct from what one finds in psychology or psychotherapy. This importantly includes the ability to remain thoughtful, realistically hopeful, and agential in the midst of even psychotic levels of anxiety. At any rate, my question is whether you can see a way forward for the profession to develop such philosophical wisdom in its practitioners?
Aftab: I completely agree with you about the need for such humane wisdom and the importance of inculcating it in practitioners. I am somewhat pessimistic about the prospects of bringing about such a transformation in the profession. Medical and psychological training not only takes place within a system governed by all the problems of capitalism but also the system increasingly emphasizes efficiency, productivity, uniformity, documentation, and risk averseness. The space to engage with another in a deeply human way has been steadily shrinking. Even when training programs try to create spaces of reflection and nurture such virtues, the clinic offers little to no opportunity to exercise them. So, the challenge is how to create systems that incentivize and nurture such virtues on an on-going basis. I don’t think anyone has quite figured that out yet! Technical knowledge and practical skills are easy to teach and measure, but thoughtfulness and wisdom are difficult to impart and assess. The solution likely involves attracting trainees with such virtues to join the profession and then reinforcing them through a variety of norms."
I'd love to get your thoughts about how to cultivate percipience in our trainees and mentees. I often think that the creation of "pre-med" as an undergraduate major traded a foundation in the humanities and philosophy for science as a preamble to med school (I had a different path, I was a psychology undergraduate before going to nursing/NP school). I think I'd rather have a palliative care doc or psychiatrist that read Tolstoy's "The death of Ivan Illich" over another text on palliative care.
I appreciate the acknowledgement that the technocratic-capitalist skills of diagnosing, prescribing medications, charting, and billing have decreased the perceived value of deeply connecting with another human being. How do we teach this thoughtfulness that you so carefully examine in this conversation?
Thanks Andrew! Sorry for the late reply. Important question and difficult to address practically because the push towards efficiency and standardization in medical education & emphasis on technological solutions and treatment algorithms is not conducive to creating environments that emphasize the human dimensions of the clinical encounter. Creating spaces in training for reflection, for literary and philosophical engagements with suffering, and having good role models among educators are good starting points, short of a radical reform of healthcare systems!
"as politics around abortion and the COVID-19 pandemic has revealed, science can easily be sacrificed in the service of political rhetoric."
I am in total agreement that scientific evidence has often been disregarded in the discussion of COVID, but how does that relate to the abortion issue? I don't know anyone who disagrees that human life progresses from a fertilized cell to a clump of cells, to an embryo, to a fetus, to a viable preborn baby. The only question dividing opinions on this issue is when that developing entity should be regarded as a human being possessing the rights that other all human beings are granted. How could that be a scientific question?
II am trying to develop analogies: In the United States we regard horses and dogs as pets deserving of humane care. I don't know of any state where it is legal to slaughter a horse for human food. That's the American sense of ethical responsibility toward horses, and science has nothing to do with it.