Madness Contested: Power and Practice (Review by Jonathan Gadsby)

Madness Contested coverJonathan Gadsby, PhD candidate at Birmingham City University, reviews Steven Coles, Sarah Keenan and Bob Diamond, eds., Madness Contested: Power and Practice (Ross-on-Wye: PCCS Books, 2013):

It was impossible for me to read this new collection dispassionately and I will not be the only one. I found myself in turns punching the air and nervously chewing my fingernails. I loved it. If you are looking for a gentle introduction to the politics of psychiatry, with diplomatic suggestions for conservative change, then this book is not for you.

These 21 chapters are directly the work of perhaps 100 people, with different interests in and experience of psychiatry and madness. The styles of writing vary from presentation of research data to personal narrative and poetry.

Across the contributions are a number of repeated themes. As we turn away from reductive biological explanations, the horizons of what may be considered important in viewing madness suddenly expand to include… almost everything. In particular, social and political themes become of paramount importance in understanding not only madness but also the shape of the institution to combat it: contemporary psychiatry. Madness ceases to be primarily a property of persons but rather of ‘a complex web of agents and interests’.

One of the recurring ideas is that the rise of psychology has not altered the political landscape of mental health services and several authors suggest it is unlikely to in the future. For those who see the use of ‘talking therapies’ as a significant tool of empowerment, this may be uncomfortable. Indeed, there is an implied sense in many chapters autonomy itself is a somewhat dubious final aspiration. This critique moves beyond the complaint that Cognitive Behavioural Therapy replaces broken brains with faulty thoughts similarly in need of expert correction (described as a difficult ‘spot the difference’), and includes a view of psychologists invested in protecting their professional interests: mud more usually slung at psychiatrists. There is also a strong sense in which even the language of empowerment conceals a relocation of a problem in a way which suits society and psychiatry, ultimately continuing to disempower those deemed mad. One nurse-educator speaks of disillusionment with the tokenism of user-involvement. There is a chapter by the individually anonymous collective Midlands Psychology Group, who note that the idea of willpower plays a key role in nearly every talking therapy and yet question whether there is any such personal characteristic, preferring to see social resources as the primary power for change. This brings much of the language of coping and resilience into question and gives inequality and justice primary relevance.

Many chapters focus on positively different ideas to promote either better mental health services or better communities for mental health. There are suggestions for professionals, especially around noticing and challenging the falsely de-politicized nature of mental health services, challenging the influence of the pharmaceutical industry on the way we have come to think about madness, and being considerably more aware of language use. There are hints of a radically different understanding of the idea of evidence, and the voices that are currently excluded from it. There are examples of groups that have empowered themselves and found healing and direction with new understandings of society and madness, including but not limited to the international Hearing Voices Movement, whose history, structure, knowledge and values are eloquently summarised. There are stories of surviving psychiatry. There are moments in which one glimpses both the optimisms and the disappointments of the authors. There are warnings about replacing the ‘explanatory bankruptcy’ of biological psychiatry with explanations containing no biology: a missing body. With the door wide open to the moral and political there is concern about the brain or blame dichotomy.

An enjoyably controversial moment in one chapter sees diagnosis described, with deliberate condescension, as a quaint notion. The reader may be left with a question, in some ways the question of the moment:  When will collections like this one no longer need to contain so many repeated demolitions of the medical model of psychiatry?

_____  excerpts from the collection _____________________________________

From Steven Coles, “Meaning, Madness and Marginalisation”:

The roots of madness lie in marginalisation; diagnosis conceals this disempowerment and initiates and maintains relations of domination.

For individual practitioners a first step to creating space so as to make madness meaningful involves informing people within services and their families that professional conceptualisation of madness is contested.  

From Midlands Psychology Group, “Manifesto for a Social Materialist Psychology of Distress”:

There is, surely, enough evidence of what a distressing place the world can be for us to avoid the necessity of concluding that the distress we experience is somehow mistaken.

The one reliable finding [about psychiatric and/or psychological interventions] is that emotionally warm and attentive practitioners are more appreciated and get better results – an observation that applies equally to politicians, salespeople and prostitutes.

From Steven Coles, Bob Diamond and Sarah Keenan, “Clinical Psychology in Psychiatric Services: The magician’s assistant?”:

 [P]sychiatry uses the biogenetic model to attempt to vanish the social, material and historical causes of distress. 

From David Pilgrim and Floris Tomasini, “Mental Disorder and the Socioethical Challenge of Reasonableness”:

…[A] good case could be made for a curfew on all under 30s to be off the streets between dusk on Fridays and dawn on Mondays. This would save many lives from the reduction of road traffic accidents, rates of sexually transmitted diseases and unwanted pregnancies would drop, as would the rate of sexual offences and violence… perpetrated by sane citizens [and] replayed every weekend in town centres and urban homes. But legislation that enforced such a curfew would, understandably, be met with derision and scorn by most of us. However, for those deemed mentally disordered the law warrants intrusions of this sort on their freedom… and is simply accepted as being justifiable and even claimed to be a form of social progress.

Rebecca Smith, in Rufus May, Rebecca Smith, Sophie Ashton, Ivan Fontaine, Chris Rushworth and Pete Bull, “Speaking Out Against the Apartheid Approach to our Minds”:

I was first admitted into hospital at the young age of 17, after a psychiatrist wrote something down in a file which neither my loved ones nor I was allowed to see. The staff put me on ‘antipsychotic medications’ even though when I asked them ‘what was wrong with me?’ they didn’t answer.

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