Friday 16 November 2007

Draft reply to Damiaan Denys

I am grateful to Damiaan Denys for the friendly tone of his critical response to Natalie’s and my paper and for his mention of my own contribution to the International Perspectives in Philosophy and Psychiatry book series: Essential Philosophy of Psychiatry.

In fact, the friendly tone appropriately reflects a large measure of underlying agreement alongside surface disagreement. We all agree that philosophy and psychiatry can stand in a useful mutual relationship. We all agree that there has been a history of interrelation especially within the phenomenological tradition. (Natalie and I mentioned this in a preliminary way though it was not our topic.)

But while Natalie and I saw grounds for optimism in the new developments in broadly Anglo-American philosophy of psychiatry, Professor Denys emphasises the grounds for pessimism in the diminution of philosophy within psychiatry itself. Aside from the suggestion that the rise of the new philosophy of psychiatry is the direct result of its loss within psychiatry – ‘Philosophy has left the psychiatric building. It is exiled from psychiatry, externalized and sequestered in the “new” philosophy of psychiatry’ - which seems unlikely, there is little substantial to disagree about. We see the glass half full (and the focus of our review was that full half), Damiaan Denys sees it half empty. All of us would like it to be fuller.

So what practical steps can we take to improve matters? A recent discussion of the World Psychiatric Association’s Institutional Program on Psychiatry for the Person that took place in London suggested some possibilities. The main focus of the meeting, organised by Juan Mezzich (and the Department of Health), was to find ways to augment a narrow criteriological model of diagnosis with a broader, more explicitly person-centred, approach to psychiatric formulation. But in the meeting different views were also expressed (mainly by psychiatrists) questioning the general need for diagnosis and also pointing out the view of some service users that their conditions should not be seen in negative, pathological terms at all. Such debate, although leading to no quick answers, suggests a positive and practical way to improve our understanding of mental health and mental health care but also the positive practical steps that this might underpin.

Professor Denys comments that most of the work of the new International Perspectives in Philosophy and Psychiatry book series is critical, for example ‘critically analyzing the conceptual foundations of academic psychiatry’. This is true and surely a good thing. What would be the point of a philosophical or conceptual engagement which was not critical, reflective, thoughtful? But he also suggests that such criticism, ‘coming from the outside’, is often perceived to be negative.

It is worth noting that most of the authors or editors we reviewed are qualified psychiatrists (with a couple of clinical psychologists, also) so the criticism is not in the sense implied external to psychiatry. But if it is perceived by some to be negative that suggests that there is work to be done in examining the assumptions about change and development of psychiatric services and about the shared and divergent values of those involved. In this process there is an important role for the new philosophy of psychiatry.