The Importance of Alternatives: Critical Psychiatry and Narrative Therapy

There’s more than one way to skin a cat. But, still, people in the feline flaying business can get so accustomed to the accepted techniques they forget there may be alternative approaches available.

That this idea can be applied beyond the delicate art of cat skinning has been the subject of a couple of the articles I’ve written during my three month long absence¹ from My Last Nerve. Both of these articles relate to psychiatry and our approach to mental illness and I’m going to build on them here.

Critical psychiatry: Thomas Szasz and an alternative to the disease model

Dr Thomas Szasz

The idea that psychological and behavioural problems are diseases of some description is now firmly embedded in the popular psyche.

We’ve all heard about depression being some sort of neurochemical imbalance, or how attention deficit hyperactivity disorder (ADHD) is likely caused by faulty genes. In this view, people with schizophrenia are wired wrong and need to be dosed with heavy meds (whether they like it or not) to keep those buzzing live wires from shorting out.

It might not enjoy the same level of publicity or acceptance but there is an alternative approach to mental illness. Many of its proponents belong to the “critical psychiatry” movement and some of them go so far as to reject the legitimacy of the phrase “mental illness” outright.

The best known of these is Thomas Szasz, one of the fathers of critical psychiatry, and a man for whom the words “radical”, “controversial” and “maverick” could have been invented (some of his critics might be inclined to add “mad” to that list).

In the first article I’m going to build on here – a debate published on the Elements website – I present and defend a particularly Szaszian version of critical psychiatry against the protestations of my fellow Elements health editor Lorna Powell.

Critical psychiatry (popularly but misleadingly known as “antipsychiatry”) is a diverse school of thought and many of its adherents might shudder at association with Szasz. Nevertheless, Szasz’s central thesis doesn’t require any specialist medical knowledge to be understood. For that reason² I mostly used arguments pilfered from his writings in the debate.

Szasz’s central claim is that the term “mental illness” is a metaphor: the mind, as it is immaterial, cannot truly be ill; behaviours might be symptoms of disease, but they are not diseases in themselves. By attempting to treat metaphorical illnesses as they would bodily ones, says Szasz, psychiatrists hinder rather than help patients in living better lives.

Hold on, say his critics, the mind is a product of the brain, which can be diseased, so by treating the brain (with drugs, more often than not) we can treat mental illness.

But, replies Szasz, you’re assuming an underlying neurological defect where none may be present, so you’re “treating” a somatic condition which may not even exist. And even if it did (Szasz is open to this possibility in the case of schizophrenia) then treatment would be administered by neurologists who would – and here’s the crux – treat the brain directly, not the mind.

Psychiatrists pretend to do this but as knowledge of the neuropathology of mental illnesses is incomplete, in reality they can’t. To cover for this, compounds that numb the emotions are called “antidepressants”, and drugs that obliterate almost every neurotransmitter system going are labelled “antipsychotics” as if both were magic bullets against the mental illnesses they seek to treat.

As this little one-two between an imaginary Szasz and his imaginary critics shows, it’s a complex debate. But that shouldn’t obscure the fact that there are rival viewpoints to the dominant disease model of mental illness.

Still, we may ask, if Szasz thinks that “depression” and “schizophrenia” are more descriptions of how people act than diagnoses of genuine diseases, how does he think that people might be helped to surmount them?

First of all, Szasz places the responsibility for overcoming “problems in living”, as he calls them, squarely on the shoulders of the person confronted with them. In this way, they are just like most other problems that can arise in life: we can overcome them only by choosing an appropriate course of action, by making an attempt at living a better life.

Doing so isn’t easy for anyone, let alone those people subject to extremely troublesome mental states and so it might be a good idea to seek some advice.

This is where psychotherapy comes in³, but Szasz’s version of that art is radically different from most other approaches. Importantly for Szasz, the therapist should not be considered to be in any position of authority over the patient.

As Szasz said in an interview with Reason⁴ magazine when asked about his approach:

To me the whole idea of calling it “therapy” is crippling. So there was a kind of understanding between the other person and me that we were having a conversation about what he could do with his life. That obviously involves adopting different tenets of sorts: different ways of relating to his wife, his children, his job.

The premise was that the only person who could change the person was the person himself. My role was as a catalyst. You are making suggestions and exploring alternatives: helping the person change himself. The idea that the person remains entirely in charge of himself is a fundamental premise.

This is different from both the medical (doctor diagnoses disease and prescribes a form of treatment) and classically Freudian psychotherapeutic (therapist’s analysis is the “correct” one and the patient should see things that way) approaches. Here the therapist has no authority of interpretation, but rather “makes suggestions” and, in collaboration with the patient, “explores alternatives”.

Narrative therapy: Paul Wallang and existential choice

Dr Paul Wallang

Patient/ therapist equality and the importance of alternative viewpoints are also key themes in narrative therapy, a burgeoning therapeutic method that is the subject of the second feature on Elements I want to build on here.

Narrative therapy is a young art, formulated in the 1990’s by the late Australian psychotherapist Michael White. As White’s obituary in the New York Times relates:

The technique is based in part on having a patient externalize a condition or problem — like obesity, loss of a parent or resentment of a sibling — and come up with stories and metaphors to re-evaluate the situation, usually from a more positive perspective. Narrative therapy has been used successfully to help bed-wetting children distance themselves from shame and anxiety, so they can consider their condition more objectively and not necessarily as a permanent character flaw.

Some practitioners encourage patients to write stories, letters, essays or poems and to recall actual events in which they vanquished a concern or responded to a family member with cathartic satisfaction.

My piece on narrative therapy was assembled subsequent to an interview with Dr Paul Wallang, a psychiatrist and proponent of the technique. His paper on the subject, published in The Psychiatrist last year, is as fascinating for its historical and philosophical sweep as for the responses it generated.

Dr Wallang proved to be the big picture thinker that his paper suggested he would be and the resultant audio piece strove to transmit his reflective nature by intertwining his commentary with the meditative solo guitar of Elliott Sharp.

At one point Dr Wallang contrasted narrative therapy with Freudian psychoanalysis:

I know that not everybody is an admirer of Freud, but I think that one thing that he did do was give the patients a voice. But the important element there is that they’re given a voice through the analyst, through the therapist.

What narrative medicine tries to do is liberate the patient’s voice so that you no longer need the therapist. [That’s] important because the therapist inevitably puts certain biases on the voice or will ultimately misinterpret what the patient wants to say.

Now, I’m sure that neither Dr Wallang nor any other narrative practitioner would thank me for making the link, but I can’t help sensing some sort of kinship with psychotherapy Szasz-style. In both approaches the therapist loses the authority of interpretation and in both the patient is encouraged to take responsibility in order to overcome his or her problems (in Wallang’s words, narrative therapy “spearheads a philosophy of patient autonomy”).

But the most striking similarity between the two approaches is that they both encourage patients to consider alternatives to the way they currently view or live their lives. This came across particularly strongly in a section of the interview left out of the final cut and which I’m posting below. This excerpt also includes Dr Wallang’s thoughts on a response to his paper suggesting that narrative therapy was really all about embracing spirituality in psychiatric practice.

Dr Wallang disagreed. From my own point of view, there are more obvious concordances with a worldview positioned at the other end of the ideological spectrum from “spirituality”: existentialism^{5, 6}.

Much of existentialism is based around a kind of anti-determinism best expressed by Sartre’s famous dictum that man is “condemned to be free”. In other words, each person has to make the choices that will define who he or she is. Such complete freedom is a terrifying prospect (not least because it carries with it the burden of responsibility) and people deny this freedom and their obligation to make choices by a mechanism that Sartre called “bad faith”.

You’ll probably hear Sartre roll in his grave midway through this sentence but bad faith is all about convincing yourself that there’s only one way to skin a cat, about denying there are available alternatives.

Is this really so different to the concept of “thin narrative” – where a patient will imagine that a situation “must be this way” – that Wallang described during our interview?

And, to return to the perspective of critical psychiatry, is there any thinner narrative, any more flagrant example of inducing bad faith in people than by telling them that they act in a certain way, or have problems in their lives because they’re victims of an ill-defined “mental disease”?

I’d say not.

Interview with Dr Paul Wallang:

A transcript of this interview can be found below and a stand alone version of the original audio feature for the Elements website is available here.

Notes:

1. Yup, the last My Last Nerve missive was penned back in January. Clearly, my intention to post only original content on here (and not just knee-jerk reactions to stuff going on elsewhere) doesn’t sit well with the gargantuan workload that my MA course entails. I will, however, be getting on My Last Nerve a lot more in the forthcoming month.

2. OK, it was more than that: I do have a genuine soft spot for Dr Szasz. That said, I disagree with him a fair amount and – in common with almost everyone apart from the man himself – wouldn’t ever want to be described as a Szaszian.

3. It would be wrong to surmise from all this that Szasz is against people taking drugs in some way. He’s certainly not, he believes that people should have the right to take whatever drugs they want if they find that helpful, they just shouldn’t mistake doing so for “treatment”.

4. That interview is an excellent primer on Szasz’s thought.

5. This is actually rather contentious and you could debate how existentialism relates to spirituality until les vaches rentrent. I say existentialism is a fundamentally godless worldview (that’s also contentious) and spirituality is always godful in some way.

6. Szasz is also strongly influenced by existentialist thought.

Transcript of the audio:

[Intro music]

Paul Wallang: The core element of narrative therapy would be trying to come to alternative narratives. That’s very important in narrative therapy and it’s what’s called thickening the narrative.

Thin narratives are single viewpoint, single interpretation:  “It must be this way.” Thickening the narrative involves the therapist and the patient in collaboration trying to think about alternative viewpoints, alternative narratives: “Could it have been like this? Would it be better to think of it like this? Would your life at the present time be better if we thought of the narrative in a different way?”

And that’s a more useful way, I think, to think about… that’s the crux of it, that’s what you’re trying to get at.

James Brooks: OK. I know that since your paper on narrative therapy was published there were a few responses: in the main positive, but also negative. Could you just sum up for me what those responses were and the kind of reaction that you got?

PW: Well, I think you’re right; on the whole the response was very positive. I think a lot of the responses I had were from people who felt that psychiatry, the practice of psychiatry on an everyday basis, had become – for want of a better word – too clinical.

And when I say that I mean that the humanism had been removed from psychiatry so that we weren’t really putting the patient at the centre of our method. We were putting diagnoses first, we were thinking about outcomes, we were thinking about throughput. And I think a lot of the people who responded very positively were the ones who saw narrative as a means of regaining that humanism within psychiatry.

I think the ones who were more critical were the ones who felt that maybe narrative would usurp their expert role and that possibly their influence on interpretation, or their authority on interpretation, would be challenged by it.

There was one very prominent psychoanalyst who wrote a response to that effect, basically saying that he thought that what I was saying was simply psychoanalysis or psychodynamic psychotherapy by another name.

And I wrote a response to that to say that, actually, it was completely different because in narrative therapy there is no interpretation: It’s about equality; it’s about allowing the patient to express their voice; it’s about liberation of the voice. It’s completely the opposite, really.

JB: With regard to the more positive responses, I know there was one that mentioned the more spiritual angle and read something into what you were saying there. How do you feel about that word, “spiritual”, and how do you feel about that word applying to psychiatry?

PW: Well, this has been a long running debate in psychiatry about spirituality in particular: whether psychiatrists should be exploring spirituality in everyday clinical practice, in their assessments of patients, and there is a bit of a schism.

Some people think it’s a very useful thing to do because it helps patients and they get a lot of comfort from it and there are others who think that psychiatry is a truly scientific discipline and therefore we should not be at all involved in looking into spirituality, certainly on a diagnostic level or in our assessments.

My take on this is that as a physician, first and foremost, I deal with suffering and I think anything which lessens somebody’s suffering is always useful. I think a lot of people get lot of comfort from their spirituality and therefore they shouldn’t be denied that and I do think that psychiatrists should be – “helping” probably isn’t the right word – allowing space for patients to express their spirituality if they want to. I think that is important.

Now, coming to your question of whether… you did talk about a response to the paper which basically said actually what I was getting at, really, was just asking people to explore people’s spirituality.

I disagreed with that, actually. And I disagree with that because narrative is not about exploring their spirituality or their belief system, it’s about allowing them to express their suffering and trying to devise ways of coping with that suffering.

[Outro music]

Photo credits: Thomas Szasz by Zsolt Bugarszki (Flickr), Paul Wallang by James Brooks (all rights reserved)

Reference:

Wallang, P. (2010). Wittgenstein’s legacy and narrative networks: incorporating a meaning-centred approach to patient consultation The Psychiatrist, 34 (4), 157-161 DOI: 10.1192/pb.bp.109.027474