Increasing criticism of the medical model on scientific grounds, coupled with developments in critical psychology and psychiatry have created an appropriate climate for a renewed evaluation of Laing's work. The current paper considers the relationships between social constructionist and post modernist streams of thought and the ideas which Laing developed during his career. Despite similarities between Laing and constructionist ideas, several key differences are highlighted, and the implications of these for both theory and practice, explored. Laing's views on sanity and madness, and the means for investigating these retain a modernist flavour, in contrast to most contemporary critical approaches which can be construed as relativist and post modern. Attempts within psychiatry to don a critical mantel suggest little change to psychiatric hegemony is on offer. Outside of psychiatry, critical approaches, in common with Laing are distinctly hermeneutic, and question the terms in which the language and practice of biomedical psychiatry deals with its human subjects. In addition they recognise the failure of psychiatry to acknowledge and represent mental health system users in a democratic discourse. Laing's differences with contemporary approaches revolve around the nature of the self, madness as a discernible existential state and the realist implications to be drawn from his demystification of family praxis. Consequently it is thus argued that Laing's work still provides the more secure foundation for a sustained critique of biological psychiatry, and the necessary pre-requisite for a transformation of practice towards those in distress.
"We believe that the shift of point of view that these descriptions
embody and demand has a historical significance no less radical
than the shift from a demonological to a clinical viewpoint
300 years ago"
- R.D. Laing & A. Esterson (1964, p.13)
One of the enigmas of post-modern critical psychology lies in the continued, and some might argue deliberate, neglect of the work of Scottish psychiatrist Ronnie Laing. To find Laing's name virtually expunged from contemporary accounts of the crisis in Psychiatry strikes one as more than a little odd. And yet his presence lurks uneasily in the shadows of all contemporary critiques of psychiatric theory and practice. Invocations to examine the social context, to recover and discover meaning in the behaviour and experience of those whose conduct is called into question by psychiatrists, is today the rallying cry of those who posit, not the antipsychiatry attributed to Laing and his followers, but postpsychiatry. Consider the following from Bracken and Thomas (2001, p.726-727) writing in the British Medical Journal;
"Contexts, that is to say social, political, and cultural realities, should be central to our understanding of madness. A context centred approach acknowledges the importance of empirical knowledge in understanding the effects of social factors on individual experience....Postpsychiatry opens up the possibility of working with people in ways that render the experiences of psychosis meaningful rather than simply psychopathological".
Compare this with Laing, speaking at the Dialectics of Liberation conference at the London Roundhouse in 1967;
"A fundamental lesson that almost all social scientists have learned is that the intelligibility of social events requires they be seen in a context that extends both spatially and in time..The fabric of sociality is an interlaced set of contexts interlaced with meta contexts... One moves for example from the apparent irrationality of the single 'psychotic' individual to the intelligibility of that irrationality within the context of the family. The irrationality of the family in its turn must in be placed within the context of its encompassing networks. These further networks must be seen within the context of yet larger organisations and institutions" (Laing, 1968, p.15).
So, if deconstructing social context to find meaning in madness is the sine qua non of post psychiatric theory, what exactly is it that differentiates this post modern venture from the unsuccessful attempts of the 1960's to develop a science of persons and redraw the parameters of psychiatry? Before we attempt to answer this, we must first remind ourselves of why this issue is of pressing concern now - the crisis and impending demise of the biomedical model of psychological disturbance.
Schizophrenia and 'Junk Science'
Belief in an impending scientific breakthrough in the search for the biological basis of schizophrenia has been a constant feature of the psychiatric literature for as long as the concept has been in use. That this belief may be futile is perhaps beginning to occur in the minds of some whose careers have been made in biological psychiatry. Criticism of psychiatry is of course nothing new - but the old critical climate rooted in European existential and political philosophy has given way to an empirical discourse, the very tradition thru which psychiatry has proclaimed itself victorious against its opponents. What characterises these new debates is an appeal to scientific rationality, not to support psychiatry, but to reject it and with it, the medicalisation of psychological distress.
The charges against the legitimacy of the medical model begin with unanswered questions about the validity of the classification of mental disorders - several hundred of them now enshrined in the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (APA 1994). Here it is stated that mental illness "must not be an expectable response to a particular event". The clear problem is that this presupposes an extensive and detailed knowledge of how people 'ought' to respond to a wide variety of traumatic and distressing circumstances, the consequences of which could in principle be moderated by any number of permutations of possible personal characteristics and circumstances. To illustrate this, we might consider the outcome for someone following physical or sexual abuse in childhood (bearing in mind that this could take many different forms). Do we know how they will come to react given a knowledge of their gender, age, ethnicity, physical size, family position, social class, place of birth, prior or later feelings of being unloved, later career success/failure, educational success/failure, beliefs and fears about mental health/illness, the changing values, attitudes and beliefs predominating in a culture over a period of time, the lack of knowledge of other (dominant) cultures' 'ways of seeing', and how this lack of outside understanding interacts with existing psychological distress? Patently the answer is no. So, if we cannot determine what is an expectable response to a particular adverse event, we can be in no position to categorise behaviour in such a way that leads to pronouncements on the existence or otherwise of mental illness. Furthermore even if by some stroke of good fortune, we were in such a position to know what constitutes a normal response to distressing psychological phenomenon - something that could carry meaning only in the statistical sense of normal - then as Walker (1983, p100), reminds us
"If maladaptive behaviour in the same circumstance(s) is characteristic of a species then it is part of its 'normal' rather than abnormal psychology".
With shaky foundations for the theoretical concept of mental illness, workers such as Slade and Cooper (1979) and Boyle (1990, 2002) have cast considerable doubt on whether the validity of the concept of schizophrenia can ever be affirmed. Slade and Cooper demonstrated that the observed correlations between symptoms purported to delineate a schizophrenic syndrome, exhibit nothing more than random clustering and can be accounted for solely on the basis of chance. Meanwhile thru a careful historical analysis, Boyle has shown that there has never been a satisfactory empirical justification provided for the validity of the schizophrenia concept as no correspondence rules for inferring the construct from other independent criteria have ever been presented. Without such rules, schizophrenia is cast adrift from the mainstream of science, an unfalsifiable scientific construct, and one which has failed to meet even basic criteria of reliability (e.g. Davison and Neale 2001). Invalid and unreliable measurement are perhaps the most serious criticisms that can be labelled against a field of scientific activity, and the data show unequivocally, that neither of these have been established where schizophrenia is concerned.
To add to the above conceptual shortcomings, data from biochemical, genetic and neuroimaging studies have, contrary to the claims of proponents of the biomedical model, failed to reveal any consistent evidence that schizophrenia is best conceptualised as a brain disease (BPS, 2000). In fact on closer examination what characterises this research is slipshod methodology, untested and unwarranted assumptions, circular argument, sloppy inference, not to mention inappropriate statistical analyses and a serious failure to take on board valid criticisms from other scientific fields (See Joseph, 2003, Bentall, 2004). But of course, a concept with no demonstrable validity, cannot be rendered scientific by virtue of some technological slight of hand, which argues that somehow, use of the latest high tech' resources can somehow confer legitimacy and rescue the concept from extinction. Not all have been fooled by the emperor's new clothes, with some commentators (e.g. Bracken and Thomas 2002) summarising the value of the body of evidence produced to support the schizophrenia concept in one word - 'worthless'. To add to this woeful state of affairs, treatment options seem to bear little logical relationship to diagnostic classification of serious psychological disturbance (Bentall, Jackson and Pilgrim 1988), whilst Thornley and Adams (1998) concluded a large proportion of the clinical trials of interventions relevant to the treatment of schizophrenia were inadequate, poorly designed, of limited duration, showed little agreement on outcome measures, and were biased in the conclusions drawn regarding the efficacy of pharmacological agents.
If one stands back and appraises the system by which the schizophrenia concept has been supported, then it bears more than a passing resemblance to what Robert Parks (2000) has described as 'junk science' - a process whereby certain branches of research activity become increasingly isolated from critics, where despite extensive time and effort no real progress is made in understanding the putative phenomenon, where key findings are unfailingly open to plausible alternative explanations, and where breakthroughs are always seen to lie 'just around the corner'. Parks cites cold fusion and parapsychology as exemplars, but the descriptions fit the biomedical literature on schizophrenia equally well. Junk science is a belief system, resistant to change, that continues irrespective of whether progress is made - in Boyle's terms, belief in schizophrenia is a 'scientific delusion' and its days as the dominant discourse in mental health and well-being may now be waning. Junk science it may be - but despite this the concept is still with us. Numerous reasons abound for this. Poor science and failure to consider alternative interpretations of data, we have already mentioned. Like its junk science counterparts, adherents cannot face the full weight of opposing evidence. Open debate with those who don't share axioms and assumptions of psychiatry is refused. Medical students' and doctors' access to other points of view during training are severely restricted. Once training has been completed this often takes form of denying funding for non-biologically based treatment alternatives. I had the misfortune to witness this first hand on several occasions while lecturing on a joint Psychiatry/Community Medicine firm in a London Medical school. One psychiatrist expressed outright disbelief that viable critiques of the Danish Adoption studies existed, as he had not heard of them. When offered the opportunity to borrow my own file of research articles detailing their flaws, he took several steps backwards, declaring as he did so, that the papers, which were now in my hands did not exist. With that he disappeared from the room. Perhaps he was psychic, for in a few weeks I was relieved of my teaching duties and thanked for my contributions over the previous 2 years of lecturing. With this, my presence and the critical literature did indeed cease to exist in the medical school. Other gambits routinely employed, include accusing adherents of opposing viewpoints, of denying the suffering of the mentally ill. If that fails, then opponents themselves are deemed to be unhinged or crazy.
Post Modern Psychiatry
Postpsychiatry is the latest neologism bequeathed to us from the world of post modernism. Like some of its linguistic relatives, it takes us to a paradoxical brave new world, where we struggle for meaning, enmeshed in a system of social relationships stripped bare of the struggle for power between oppressed and oppressor, paradoxical because the old inequalities of power remain - arguably in the most brutal form for more than half a century. We debate post-feminism in a world in which women vie to sell their bodies in the global multimedia sex and pornography market; post-industrialisation where inequalities in wealth and death are manufactured with celebrity endorsement, precision marketed and cheap (and dangerous) industrial production has allied itself, or should I say foisted itself, onto the majority of the planet which actually resides in the developing (underdeveloped) world. And now for the chattering classes, comes post psychiatry - the latest commodity discipline to herald the death of the old modernist world, while as Galileo might have said "eppure si muove". The king is dead, long live the king. One could be forgiven for thinking this is an act of mystification writ large. According to Laing (1965);
"This entails the substitution of false for true constructions of what is being experienced, being done (praxis), or going on (process), and the substitution of false issues for the actual issues… If we detect mystification, we are alerted to the presence of a conflict of some kind that is being evaded. The mystified person, in so far as he has been mystified, is unable to see the authentic conflict…. He may experience false peace, false calm, or inauthentic conflict and confusion over false issues." (p.344-345).
For Laing, as for Marx the function of this trickery was clear - to enable
".. a plausible misrepresentation of what is going on (process) or what is being done (praxis) in the service of the interests of one socioeconomic class (the exploiters) over or against another class (the exploited)." (Laing, 1965, p.343)
In reading the postpsychiatry of Bracken and Thomas, it is difficult in the extreme to find signs of conflict, or discrepancies in power. Instead what we get offered is yet more psychiatry. For them postpsychiatry
"does not seek to replace the medical techniques of psychiatry with new therapies or new paths towards "liberation." It is not a set of fixed ideas and beliefs, more a set of signposts that can help us move on from where we are now - and an increasing number of psychiatrists are becoming interested in philosophical and historical aspects of mental health care. Indeed, psychiatry, with its strong tradition of conceptual debate, has an advantage over other medical disciplines when it comes to the postmodern challenge." (Bracken and Thomas, 2001, p.727)
So that's clear - no liberation, no end to psychiatry - just some lip service to a bit of philosophical aspects of mental health care, a tad recognition that the patients' problems actually mean something, and 'keep taking the tablets'. It should be no surprise to learn that both are consultant psychiatrists - no doubt rewarded in their careers for not upsetting the apple cart too much and not being too critical of the kind of biomedical nonsense that has littered the pages of countless journals for years. So despite having earlier (Bracken and Thomas, 1999) called on medicine to abandon psychopathology, remove schizophrenia from the lexicon, and set in motion a fundamental shift in the power relationship between doctor and patient, one can only be amazed that Bracken and Thomas continue to countenance any role for medicine and drug wielding psychiatrists, in any so called alternative to the present arrangements. They appear blind to the sacred role which schizophrenia plays in the legitimation of psychiatry as a pseudo medical discipline (Szasz, 1979), and that without the pseudo scientific medical framework, there is no justification for psychiatry, which is after all a branch of medicine. For them to call for an end to current psychiatric practice, for the demedicalisation of psychological care, would be like turkeys voting for Christmas. The result? More confusion than enlightenment.
The brand of psychiatry offered us by Bracken and Thomas is nothing new - as some critics amongst orthodox practitioners have acknowledged (e.g. Smith, 2001). We have in fact been here before - it is same brand peddled by Littlewood and Lipsedge (1997) - the gurus of 'exotic' transcultural psychiatry, who find meaning in the madness of their ethnic minority patients, but seem unaware that the cultures and meanings in the lives of their 'psychotic' non-ethnic white working class patients, inform their everyday behaviour and their distress too. Like their racist psychiatric forebears, psychiatric disorder in black people is different - different symptoms, different causes, different 'meanings', only this time 'culture' is responsible. A little bit of social constructionism is fine - just so long as we don't apply it to everyone. Were this to happen - the inescapable conclusion would be the realisation that psychiatry, transcultural, postmodern and all, is past its sell by date. Championing the discovery of meaning in madness, these recent varieties are a sham - they do not see beyond psychiatry, because they are still rooted firmly within it - locked into a sterile scientific wordplay, a language game as Wittgenstein might have had it - and let's face it, he has had it. Stripped of rhetoric, the function of postpsychiatry is a public relations exercise, tolerated by the gatekeepers of institutional psychiatry, in the hope it will keep the critics at bay, while the real issues of power remain hidden behind ever more sophisticated technologies of control. Psychotherapy as Burston (2000) believes may or may not be in crisis, but psychiatry most certainly is. It is not postpsychiatry that is needed - but no psychiatry.
Laing and the Post Modern Perspective
Over three decades ago Laing and Esterson (1964) opened their controversial study Sanity Madness and the Family by remarking
"In our view it is an assumption, a theory, a hypothesis, but not a fact that anyone suffers from a condition called 'schizophrenia'...We do not accept 'schizophrenia' as being a biochemical, neurophysiological, psychological fact, and we regard it as palpable error, in the present state of the evidence to take it to be a fact." (pp 11-12).
For Burston (2000), Laing's best work (his analysis of family processes) still languishes in obscurity, much maligned, misrepresented and misunderstood, a threat to "business as usual" from the customary purveyors of psychiatric truth. His name exists in absentia, a void in the historical record of conventional psychiatry - and in other quarters is mentioned in passing only by those who wish to pay lip service to the radical projects of yesteryear, but give scant credence to the value or continuing strength of his ideas (Burston, 2001). It is somewhat ironic then, that in the new millennium there appears considerable merit to those opening remarks. This absence owes something to a fear - a fear that the mere mention of his name will automatically call forth the demons of rejection for any intellectual opinion henceforth offered.
Laing's rejection of the Kraeplinian system and method of classification for psychological disturbance, upgraded we might now say and refined in the current DSM, so eloquently criticised in The Divided Self (Laing, 1960) is the starting point for his contemporary relevance for post modern theory. Here, Laing recognised that the human condition, in whatever circumstances, is not reducible to a depersonalised natural scientific formulation. What he saw as 'outside the investigative competence of the natural sciences', included, as he later put it;
" love and hate, joy and sorrow, misery and happiness, pleasure and pain, right and wrong, purpose, meaning, hope, courage, despair, God, heaven and hell, damnation, enlightenment, wisdom, compassion, evil, envy, malice, generosity, camaraderie and everything, in fact, that makes life worth living." (Laing, 1982, p.18)
Human experience, for a hope of genuine understanding to emerge must be contextualised, whether that be in dyadic relationships, the family, culture, or other micro or macro institutions of society. As an illustration, consider the present time in London. We have been informed that the chances of a terrorist attack are high, with a bomb on a train a distinct possibility (I write some 3 weeks after the attack in Madrid). Intellectually this is not difficult to acknowledge, and yet I have noticed that, although I use the trains frequently, emotionally I am giving this little credence. A clear example of splitting between thoughts and emotions. For other people who share a knowledge of the circumstances, this response isn't difficult to comprehend. However what happens when others do not share an understanding of the context in which such splitting functions to assist coping with distress? Removed from the meaningful social context in which they arise, peoples' responses to distress risk being misconstrued as evidence of pathology. In conventional psychiatry however, splitting of emotions from thoughts, constitutes one of the principal symptoms of schizophrenia.
Laing's early work contextualised the self in relation to others (Laing, 1961), an idea congruent with contemporary analyses of identity. For post modern theorists however, and here we may include Lacan and Foucault, the self is an illusion - a narrative fiction constructed by ourselves to account for the illusion of the continuity of consciousness in time (Appignanesi and Garratt, 1996). In Baudrillard's (1994) terms it is a simulacra, a simulation of a self that does not exist in the first place. Here the Laingian dichotomy of true versus false self is superfluous. The modernist search for authenticity has been abandoned, for in the consumer hyper-real post modern world there is no distinction to be made between real and manufactured identities. All are manufactured. Witness the triumph of spin, public relations, deception, celebrity, marketing hype, virtual reality, virtual warfare (Baudrillard, 1995), and public image. A cornucopia of false selves for our edification and consumption. It is ironic therefore to find Jenner (2001), at times a sympathetic critic of Laing, taking issue with his view of the self, because in the contemporary mirror of illusions that constitutes our society, we would all struggle to discover a true self.
With this in mind we can now see Laing's move from his earlier existential-phenomenological analyses of madness in The Divided Self to the social phenomenology of Sanity Madness and the Family, The Politics of Experience (Laing, 1967) and The Politics of the Family (Laing, 1971) to be a clear nod in the direction of post modern ideas on the production of identity. The individuals trapped in the dysfunctional dynamics of the nexus of relationships that is the family, are psychologically fragmented, lacking a solid foundation for being - ontologically insecure as the early Laing might have said - ready to be re-identified as psychotic and schizophrenic by agents of the wider system (psychiatrists, parents, police etc). In Sanity Madness and the Family the fictional, inauthentic selves that reside in the designated non-psychotic family members have yet to be called fully into question. But it is a logical consequence of his social phenomenology that they will be. Rather than The Politics of Experience representing then a complete departure from his previous analyses, it is logical development of the recognition that in the emerging post-modern world, the drive for authenticity is thwarted by the entire social system in which our lives are embedded.
It is not, as has been misrepresented, that the mad are sane and the sane mad - but that we are all estranged from the possibilities of authenticity, of living in balance with our psychological, social and ecological surrounds. Perhaps for Laing, sanity may yet be redeemed, but for some, only through a tortuous process of rediscovery, a metanoic voyage a la Jung, may it be found. So, for Laing there is still some way back to an authentic being in the world. For the post modernists this estrangement has become a given condition of existence, and as such, it makes no sense to uphold a distinction between sanity and madness. The terms and their referents should be discarded or at least recognised as being entirely socially constructed, with no biological basis to either. Notions of organic pathology, psychopathology or group pathology are surplus to requirements (Laing and Esterson, 1964). Laing's writings in effect deconstruct the social processes whereby people come to be understood as mad, and for this reason his work has been described by some (e.g Burston, 1996) as social constructionist, but it is important to remember that for Laing the terms sanity and madness have real existential referents.
The idea that we are all severely estranged from reality or that there are no longer unequivocal states of sanity or madness, sits uneasily with the managerialist 'scientific' goals of clinical psychology which aspire to containment as a viable therapeutic aim, and which today, provides much of the opposition to orthodox psychiatric theory and practice. Within this managerialist climate lie the best hopes for the survival of (pure or post) psychiatry as a branch of medicine. Ironically the superceding of the medical model by the new scientific champions of clinical psychology may postpone the demise of the concept of mental illness, whilst it heralds the destruction of the neo Kraeplinian system that is DSM. But if we are to take seriously the claims of social constructionism and post modernism and fully appreciate what the social contextualisation of all our experience implies there is a different way forward. With it we have a means for making sense of the differential distribution and variety of psychological disturbance by social class (Hare, 1956, Harrison et al., 2001), ethnic group (Littlewood and Lipsedge, 1997) or gender (Brown and Harris, 1978, Ussher, 1991) for example. We may locate such disturbance as a function of the meanings and power relationships which suffuse the lives of people whose existence is marginalised either indirectly by the organisation and institutions of society, or directly by the actions and interactions of others. For example, examination of the contents of auditory hallucinations reveals that these are frequently persecutory and abusive - revelatory not of brain disease, but of literal recorded experience - experience of sexual, physical and verbal abuse that is distressing and difficult to live with (Ellenson, 1986, Nayani and David, 1996, Birchwood et al., 2000). All of these things do occur in families as well as outside them. To deny this, is to deny the real world we live in. The article of faith in modern psychiatry which denies that families or other 'social systems' can, and do, drive people crazy'', is an act of collusion with the perpetrators of psychological damage, and an act of mystification on those driven to psychological extremes by them. The post modern perspective must therefore reclaim literal as well as figurative and symbolic meaning in the utterances and actions of people and not only those people who use the mental health system. Whether it can do this is unclear. Critically however the enterprise must venture beyond the gates of meaning and enact radical alternatives to contemporary management or therapy.