Barney Carroll on domesticating psychosis

Although posted only a couple of days ago, my presentation from Royal Edinburgh Infirmary, Division of Psychiatry, University of Edinburgh is now passing the benchmark of over 1000 views.

chrys
Chrys Muirhead

You can also find an interesting Storify of my lecture by a mental health activist and correspondent for the Critical Psychiatry Network, Chrys Muirhead. I’m sure she’ll also be presenting an alternative view of my lecture at her blog.

In one of my introductory slides , I acknowledge a number of go-to’s to whom I am indebted. I actively engage with the go-to’s through social media with questions and requests for feedback. They have kept me from what would have been embarrassing gaffes.  They allow me to present and write smarter than I am, when I let them. However any excesses or inaccuracies in my work are entirely my own.

One of these go-to’s is Bernard “Barney” Carroll. In future blogs I will be saying a lot about his influence on me, although we have never actually met. In hindsight, it’s too bad that my decade at the University of Michigan Mood Disorders Program that he developed started only after he had left.

Barney has

made major contributions to research on the biology and treatment of depression. He is best known as a pioneer of the neuroendocrine research strategy for depression, and as developer of the field of laboratory markers in psychiatry.

Barney often says profound things with a relaxed elegance, particularly when engaging in debate. Long before Kris Kristofferson, I’m sure those with whom he disagreed saw him as the original silver tongued devil.

I realize this comment dates me, because few of my younger readers even know Kris Kristofferson is, not even that he wrote Me and My Bobbie McKee that Janis Joplin made famous. So, here, distract yourself with some 70s music.

 

domesticating-page-0Anyway, on slide 37 of my presentation, I used Barney’s term domesticating psychosis as a heading for some direct quotes from Understanding Psychosis and Schizophrenia, the British Psychological Society Division of Clinical Psychology document that I  critiqued in coming slides. Here is the elaboration on that graphic phrase that Barney provided on my Facebook wall July 27, 2015.

Barney Carroll, in his own words:

I guess I am the person who gets the credit for characterizing the BPS report Understanding Psychosis and Schizophrenia as domesticating psychosis. Ronald Pies called it romanticizing psychosis and Joseph Pierre termed it trivializing psychosis.
The BPS folks, and Lucy Johnstone in particular, deserve all the frowns and brickbats that are coming their way for this misstep. It is an appalling document: Self-neglect due to impaired frontal executive function is niced down to “When people are in a state of distress and confusion they can sometimes need help to maintain an adequate diet, or look after their home.” That does not begin to capture the clinical reality of decompensating psychotic patients smashing furniture to stop the voices, smearing faeces, living in filth, going to the streets, eating out of dumpsters…. The report’s pervasive focus on just hearing voices as emblematic of psychosis is a domesticating strategy: One hallucination does not a schizophrenia make. This domestication distracts attention from the more serious features of psychosis such as negative symptoms, social and occupational decline, first rank positive psychotic symptoms, formal thought disorder, formal language disorder, catatonia, cognitive impairment, affective lability, delusions, and loss of ego boundaries in psychotic decompensations. These get short shrift in the terminal niceness of the BPS report.

fear my squirreley wrathI can only agree with James Coyne that the BPS folks, and Lucy Johnstone in particular, have been squirrelly in their responses to challenges. We saw that earlier this year. Look at the threads linked here on the 1Boringoldman blog: http://tinyurl.com/q7lw8md; and http://tinyurl.com/nq4ws5b. They are especially reckless in their glossing over of completed suicide in psychotic states. I discussed that on Joseph Pierre’s blog earlier in the year: see the several comments on this thread – http://tinyurl.com/ofcsr4j.

1 Boring Old Man » which side of the street?…

You can read Barney’s set of comments at Mickey Nardo’s 1 Boring Old Man website, along with Barney’s engagement with critics. But here’s an excerpt

… This approach is what I call domesticating psychosis. The BPS document fails adequately to convey the range of symptoms and associated behaviors in psychosis/schizophrenia. Even when these are mentioned, they are not addressed in a way that matches their clinical salience. Thus, decompensating psychotic crises are discussed unhelpfully in the framework of poor sleep habits. Acute inpatient psychiatric units are discussed in a patronizing way and are faulted as being unhelpful for some patients – never mind their rescue function. Catatonia as a common feature is not acknowledged. Psychotic terror and panic are not acknowledged. Formal thought disorder with truly crazy speech is not acknowledged. The 10% lifetime incidence of suicide among schizophrenic patients is not acknowledged. Core negative symptoms are brushed away as demoralization or as neuroleptic drug side effects. All of the recommendations made in the BPS document for improvement of psychological and social services are admirable but none are really new – they all fall within the traditional biopsychosocial model of psychiatry. We can all agree that psychiatry has not implemented that model consistently, in large measure because of underfunding, but that does not invalidate the model.

Their intellectual bias is further evidenced by their halfhearted endorsement of the need for antipsychotic drugs. They go out of their way to emphasize that, even though these are sometimes helpful, “… there is no evidence that (the drugs correct) an underlying biological abnormality.” Well, bless my heart, we can say the same of most drugs used in medicine: steroids for autoimmune diseases; bronchodilators for respiratory diseases; anticonvulsant drugs for seizure disorders … So, what is their point here, exactly, beyond gratuitous negative innuendo? It seems to me that the BPS document is a manifesto in the professional turf wars, heavily slanted towards gaining funds from the U.K regulators, rather than driven by an understanding of the classic psychotic disorders

Well said.

From Where's NAMI?
From Where’s NAMI?

4 thoughts on “Barney Carroll on domesticating psychosis”

  1. Whether we speak of domesticating or trivializing or romanticizing psychosis, the essential point is that the BPS report does not rise to the level of a serious clinical discussion. By the way, trivializing was the term used by Ronald Pies, while romanticizing was used by Joseph Pierre. My bad for mixing these up.

    What is lacking conceptually in the BPS report is an understanding of the state transition from prodromal or low-level psychotic features on the one hand to frank psychotic disorganization on the other hand. The former is a compensated equilibrium state with generally preserved function, while the latter is a decompensated state of allostatic collapse with loss of multiple cognitive and psychological functions. A good parallel from general medicine would be the state difference between the hyperglycemia of stable diabetes mellitus and the allostatic collapse of diabetic ketoacidosis – an infinitely more complex and dangerous state.

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