Blockchain Papers

Courtney Buckler

I play the game a lot. I regularly translate my mental health work into language and structures that are recognisable and friendly to the ‘powers that be’. I do it to get access, leverage, legitimacy, and funding. Often it works, but I am beginning to wonder about the costs of this translation work. I regularly find the words, action and work of the user-led movement somehow co-opted, adopted, misinterpreted and otherwise used for purposes that seem to bolster rather than challenge the status quo. I think, for example, of tokenistic co-production initiatives or sanitised and professionalised peer-support roles that have popped up over recent years. These and other similar programs seem to emanate from the demands of the user-led movement, but implement them in a way that maintains power and resources in the places they have always been. They do nothing to challenge the structures that cause mental distress in the first place. It feels similar to pink-washing or green-washing, albeit in the mental health space. I talk about it with others in the movement. I’m not sure what to call it, but I don’t want to be part of it. Sometimes, in my playing the game, I worry I might be. The aim here is to think this through, experimenting with a piece of language from my academic work. The concept I draw on is called intentional institutional capture (Eastwood, 2006). The idea comes from a feminist research methodology called institutional ethnography (IE) (Smith, 2005), which is concerned with bureaucracy and power in contemporary corporate capitalism. Briefly, institutional capture describes the subtle trickery of dominant systems and their bureaucratic processes, in which our experiences, work or just our existence are co-opted and ‘captured’ by ‘the system’ in service of its own interests. As implied by the name, intentional institutional capture is similar (Eastwood, 2006), albeit describing our deliberate participation in that ‘capture’ for our own ends—this is what I mean by ‘playing the game’. These concepts have helped me to think about the broader implications of my organising and to think about how I can ‘system proof’ my work. My reflections are rooted in my multiple positionings in relation to lived-experience work. I am a survivor researcher in the midst of their PhD, in which I use a mad and disability justice lens to explore mental health policy in the UK. I am also co-founder and executive director of Make Space (2022), a user-led collective exploring liberatory and decarceral approaches to self-harm. As the title ‘lived-experience’ implies, all my work is based on and informed by ongoing experiences of mental distress and crisis—both my own and those of others I care/have cared for. I believe in a system of mental health care rooted in autonomy, liberation and justice. I am concerned about ‘white, western cultural beliefs and frameworks’ that have ‘discouraged [us] from viewing our distress through a holistic and non-medicalised lens’ (Kaufman-Mthimkhulum, 2022). I believe in grassroots, community-led responses to distress and crisis that have the spaciousness to be creative, bold and brave outside of the demands, interests and constraints of the institution. Nevertheless, whether as a researcher, organiser or survivor, I find myself regularly interacting with ‘the system’ and organisations that do not necessarily hold the same views as me (and sometimes—oftentimes—do work that undermines them). I interact with mainstream mental health provision for two main reasons. First, because I often find there people with good intentions and a desire to do good work, who are stuck within bureaucratic processes that require them to do acts and invoke ideas I see to be harmful. Secondly, because it is behind and through ‘the mainstream’ that leverage, resources and funding are held—it is often because I am beholden to it that I must continue to participate. My participation includes work with funders, local authorities, NHS trusts, universities or even my GP. Doing so includes adopting ways of talking, acting and relating that are familiar enough to the status quo that I can access the legitimacy and intelligibility in order to get the access or resource that I need. Professionally, I often frame my user-led work to funders and institutional partners as something about safety or prevention—despite the fact that a core part of my work is challenging the utility of ‘prevention’ as a goal and dominant notions of ‘safety’ that often cause more harm than good (see: #StopSim (2022)). I also turn up to spaces I am invited to as an ‘expert-by-experience’, knowing full well that this is likely to be a tick-box exercise, still with enough (perhaps naive) enthusiasm to believe that my being there could (and sometimes does, in little ways) make changes. Tokenism, ableism, lack of power exchange and unpaid labour are well-known issues when it comes to co-production and ‘user-involvement’ in the mental health sector (e.g. Brown and Ormerod, 2020; Heney and Poleykett, 2021; Waddingham, 2021; Batty et al., 2022). Nonetheless, I turn up and often advocate for there to be more involvement opportunities—even though I know, from personal experience, that they can be harmful. I also ‘play the game’ in my own healing. I use my diagnoses to access resources, despite having a general ambivalence toward my own psychiatric diagnoses and broader concerns about how psychiatric labels are used systemically to justify harm and mistreatment of others. Not everyone gets the privilege of choosing to bring up their psychiatric diagnoses—some people, despite their best efforts, cannot shake them, often with violent and catastrophic consequences. I am lucky in this case, that among my diagnoses is not a personality disorder, which I have seen in so many instances lead to removal and refusal of care (Baker and Beazley, 2022). Moreover, not can everyone be sure that seeking help will result in any help, or that which is actually helpful, at all (Heney and Sommer, 2021). I wonder whether ‘playing the game’ is worth it. I often make small wins and meet short-term goals that I genuinely believe are helpful. I meet a lot of people working within ‘the system’ who do good work, have good intentions and are genuinely receptive to the central tenets of user-led/survivor movement. I also believe in the value of top-down as well as bottom-up change. But at the same time, it can feel as though in my playing the game, or participation in ‘the system’, I am tacitly endorsing structures, concepts and ways of working that I actively oppose. Then again, I’m not sure if it’s that straightforward. Doing this work as someone with ‘lived-experience’ work makes it feel even more complicated. Having my work bound up in my identity makes it difficult to speak, to strategize and to decide which parts of my experience to bring forward and which to leave behind (Gupta, 2022). It is also makes doing the work seem more urgent and like there is more at stake. It is what has made writing this piece far harder to write than I anticipated. When your work and activism are connected to the most vulnerable parts of yourself, ‘getting it wrong’ is more than just a bad day in the office. I began joining up my experiences of ‘playing the game’ through reflections I was having as part of my PhD, which focuses on the impact of evidence-based medicine (EBM) on mental health policymaking. Specifically, my work explores the long and controversial update process to the National Institute for Health and Care Excellence’s (NICE) Guideline on Depression in Adults—which began in 2015 and was published in its final form in June 2022. As a document that has coordinated so much of my own care, I felt/feel invested in knowing what people have to say about it. I observed how those who tried to change the depression guideline were bringing important challenges to how depression care is ordered. I also saw how these groups seemed to be being tactical in their doing so. Seeing that NICE was concerned with being ‘evidence-based’, the guidelines’ detractors framed their arguments in those terms (Rost and McPherson, 2021). They published multiple public-facing position statements, lobbied MPs and garnered support across the mental health professions—all coordinated and framed as a critique of how NICE had used, analysed or dealt with ‘evidence’. In some ways, the tactic worked. Through their concerted efforts NICE were forced to hold multiple unprecedented consultations on the guideline, creating opportunities for hundreds of organisations to comment on its content. The campaign got issues around depression into parliament and in the press. The final guideline recommended a wider range of treatments than ever before, emphasised patient choice, and acknowledged for the first-time issues that had long been a source of concern in the survivor movement such as withdrawal effects of anti-depressants and their link to suicidality (NICE, 2022). The group made important and necessary wins. At the same time, the campaign did little to challenge underlying ideological issues the mental health care—unfair distributions power, tokenistic co-production, marketisation and privatisation in health care, or limited understandings of what gets to count as ‘evidence’. On the latter point, fact, it could be argued that some of the key issues raised by the coalition exist not in spite of NICE’s use of EBM but because of it. EBM is widely critiqued both in general terms (Greenhalgh et al., 2014; Boswell, 2018; Hanemaayer, 2019) and specifically in its application to psychiatry (Gupta, 2014; Court et al., 2017). The issues raised by the guideline’s detractors included NICE’s overreliance on results from large scale trials over other methodologies, increased anti-depressant prescription, linear models of recovery and emphasis on cheap and manualised treatments such as cognitive behavioural therapy (CBT). Each of these issues have been attributed elsewhere to (at least in part) the application of evidence-based medicine to psychiatry (Dumit, 2012; Dalal, 2018; Hovda, 2019; McPherson et al., 2020). It’s a shame, because the whole process seemed to me not only a controversy around the specifics but also a struggle over broader ideas of what it means to live well, whose knowledge gets to count, and what good mental health care should or could be. These broader ideological concerns, necessary now more than ever, were in and among the coalition’s work—but hidden behind their emphasis on methods and evidence. The coalition’s tactic to frame their arguments in relatively non-controversial terms, to translate them into the institutionally friendly and recognisable language of ‘methodology’ and ‘evidence’ meant that the bigger, broader and perhaps more pressing conversations, did not happen. NICE were able to selectively attend to the issues of evidence and ignore the broader ideological and political challenges the group was bringing. EBM—the underlying structure that caused (or is at least contributory to) many of the problems outlined by the coalitionary group—remains intact and unchallenged. Perhaps, EBM is even reified by the process (McGoey, 2010). Power remains in the same place. Business as usual. In my academic work, I have been using the idea of (intentional) institutional capture (Eastwood, 2006) to think through the tactical use of ‘methods’ and ‘evidence’ as a narrative structure by those who opposed the NICE depression guideline. Increasingly, I’ve been wondering whether the concept could be helpful for my own organising. The term comes from a method called institutional ethnography (IE) (for a clear overview of IE see Murray (2022)). IE is a method that calls researchers to bring their politics to work, take sides (Cupit et al., 2021), to avoid making grand theories and instead look at people’s everyday lives and the struggles they face (Smith, 2008). In my organising I hear a lot of people talk about ‘the system’—of sanism, ableism, racism, classism and queerphobia as both systemic and structural. These -isms reside both in the thoughts and acts of ill-willed individuals but are also somehow beyond them—embedded in and joined up by the fabric of our society. The question, however, is where? Where is this system? Where do we touch it, see it, change it? Institutional ethnography suggests that ‘the system’ can be found in the invisible bureaucratic architecture of our everyday lives. It is a seemingly neutral, authorless, impenetrable, unconnected and boring deluge of paperwork, forms, manuals and guidelines that join up and coordinate the actions of numerous individuals and organisations across time and space (Smith, 2005; Murray, 2022). It is these texts that act as a kind of orchestral conductor of the social ‘system’, making sure that no matter where or who we are, we all sing from the same hymn sheet—whether we like it or not. Bureaucracy reduces the messiness and meaning of our everyday lives to a limited set of tick boxes, categories and processes. Too often, people’s personhood and protection is determined by their (in)ability to fill out forms, to meet a threshold or to qualify as this and not that—I think for example of migration status, benefit eligibility or employment rights. Often, the course of a person’s life hinge on whether they filled out a form correctly, got it into a post-box on time or remembered to check their junk folder (see: Deaths by Welfare, 2023). Psychiatry is no different. Diagnostic manuals, care plans, mental capacity, sick notes, GP letters, rating scales, codes of conduct, funding applications, impact reports, clinical trials, academic research. It’s all texts—a limited collection of thresholds, forms, categories and vocabularies that we either meet or do not meet, fall into or do not fall into, can speak or can’t. Our lives are forced into the rigid and unimaginative categories these bureaucratic structures offer us. In IE, this process is called ‘institutional capture’ (Smith, 2005, p. 119). It is what is happening when I have to squeeze my work into the boxes offered to me by a funding application, or when I have to explain my need for solitude and rest as a depression, contorted into the weirdness and inapplicability a PHQ-9. Suddenly, my life and work become translated into uncontroversial categories and cogs in a system I disagree with. But I am not always passively ‘captured’ by ‘the system’. Sometimes, I allow or work to make it to happen. We tick the right boxes, talk the talk or playing the game because we know what the system wants us to do. We do it to get resources or to get leverage. This is what I mean when I talk about ‘playing the game’. It is what I am doing when I strategically invoke my diagnoses or word my work as ‘prevention’, and it is what the detractors of the depression guideline are doing when they frame their critique of NICE’s work as one to do with evidence. This process is called intentional institutional capture (Eastwood, 2006)—when we deliberately and tactically allow ourselves to be subsumed into a system or a worldview for the purpose of playing it at its own game. But there are costs to playing the game and allowing ourselves to be captured. While we (hopefully) get short-term wins, playing the game implicitly endorses its underlying tenets—requiring us to forego the broader ideological struggle in favour of the immediate needs of any given situation. I wonder whether that’s why doing so leaves me with a funny taste in my mouth. Then again, if we refuse to play along, we lose those short-term wins—like changing a guideline, accessing mental health care or getting funding to do oppositional work. Sometimes, especially when I’m working in ‘high-risk’ situations, the short-term needs have to take precedence. This double-edge sword is the violence of bureaucracy. You lose if you play and you lose if you don’t. There has to be a way out. I don’t know how, but I wonder whether thinking about institutional capture could help. I am lucky enough to spend a lot of time around people who are doing exciting and liberatory mental health work—despite and in spite of ‘the system’. I see the permissiveness, creativity and boldness of user-led work and am consistently humbled by watching what happens when people have access to care that is truly consensual, collaborative and self-determined. As the edifice of mainstream mental health care begins to crumble (Rose et al., 2020; Moncrieff et al., 2022), it is my hope that user-led work is what takes its place. But I often wonder how we do that—how we make this kind of care ‘mainstream’ without it being co-opted, watered-down or otherwise manipulated by the system in service of maintaining the status quo. It will take deliberate organising and strategy to identify, name and get out from under the subtle trickery of a system designed for business as usual—including thinking carefully about what we win and what we lose when we decide to ‘play the game’. I wonder if the language of institutional capture—intentional or otherwise—might be helpful (Smith, 2005; Eastwood, 2006). It has helped me at least, to join up seemingly unrelated incidents and try to begin to explore how I can take wiser action in the world. The answer might not be ‘institutional capture’, but I do believe it is important to be intentional about our interactions with ‘the system’. It matters because the more time we spend translating our work into institutional language, the less time we spend developing the vocabulary required for a just future—one not about safeguarding, cost-efficiency or evidence-bases, but about justice, autonomy and liberation for all. Courtney Buckler (she/they) is a white, able-bodied, working-class, queer person. Courtney was born and raised in the south of England.

Sanneke de Haan

Two Enactive Approaches to Psychiatry: Two Contrasting Views on What it Means to Be Human Sanneke de Haan (bio) Shared Sources and Different Aims The relevance and potential value of insights from enactivism for the field of psychiatry have been recognized for some time now. Recently, two overarching frameworks have been proposed, one by Nielsen (Nielsen, 2020; Nielsen & Ward, 2018, 2020), and one by me (De Haan 2017; 2020a; 2020b; 2020c).1 As mentioned by Nielsen (2021), we developed our approaches largely in parallel: I was not aware of Nielsen’s work, and he only became aware of my work in the last phase of his PhD. Nielsen (2021) compares our approaches and concludes that our frameworks are ‘largely compatible, do different work to one another, and are best understood as complimentary’ (p. 175). I think, however, that the differences between our positions run much deeper, so that they are, in fact, incompatible. These differences result from fundamentally opposed views on what it means to be human. But before I get into our differences, let me acknowledge what we share. Nielsen and I are attracted to enactivism2 for similar reasons. We are both critical of neuroreductionist views that depict psychiatric disorders as internal problems in individual brains, and instead stress the relevance of taking the individual’s whole body and larger (sociocultural) context into account. In enactivism, we find a framework that spells out how the mind is fundamentally tied to the body and to interactions with the environment (Thompson, 2007; Varela, Thompson, & Rosch, 1991). More specifically, ‘mind’ refers to the sense-making activities of an organism interacting with its environment, which it depends on for its survival. Enactivism, furthermore, argues that the organism in its environment is best described as a complex, dynamical system. Applied to psychiatry, enactivism offers a) an integrative perspective on the relation between body, mind, and world;, and b) a complex systems approach which acknowledges causal complexity without ascribing a priory primacy to any of the processes involved. Our aims—what we use enactivism for—are different though. My aim is to solve psychiatry’s integration problem, that is, the problem of how to relate the heterogeneous factors that are at stake in the development and persistence of psychiatric [End Page 191] disorders. Even though many people would be willing to embrace the (potential) influence of biological, psychological and social factors, the proof of the pudding will be in providing a proper explanation of how these factors work together and how (causal) interaction between them works. Enactivism provides an excellent basis for explaining such interactions, without resorting to either reductionism or dualism (de Haan, 2020a). As such it can offer an extended and improved version of Engel’s (1977, 1980) biopsychosocial model (de Haan, 2020c). My enactive approach to psychiatry is thus clearly not a ‘first person or phenomenological approach,’ as Nielsen (2021) calls it. Personal experiences are indeed vital when trying to understand and explain psychiatric disorders—but so are (neuro) physiological processes, sociocultural influences, and existential considerations. The purpose of my account is precisely to relate personal experiences to these other processes and explain how these four heterogeneous dimensions affect one another. Enactivism’s thesis about the continuity of life and mind and its concept of sense-making are useful to explicate how ‘matters of the mind’ are necessarily also matters of the body and matters of the world too (de Haan, 2020a, 2020b). Nielsen, in contrast, is primarily interested in solving the demarcation problem between mental health and mental illness, or: ‘why some behaviors should be considered disordered’ (Nielsen & Ward, 2018, p. 801). This should in turn help to carve out psychiatry’s ‘diagnostic entities’ (Idem, p. 813) and classify mental disorders accordingly. Nielsen mainly draws on enactive ideas to ‘naturalize normativity’ (Nielsen & Ward, 2020, p. 121) as he calls it. Because mere statistical rarity is not enough to establish a phenomenon as ‘disordered’, we need to adopt some norms to distinguish between ‘dysfunction and functionality’ (Nielsen & Ward, 2018, p. 811). Nielsen appeals to the enactive idea of organismic self-maintenance to establish such norms. Being alive is a precarious condition that requires constant, adaptive interaction...

Egondu R. Onyejekwe

No abstract is available for this record.

Benjamin R. Lewis

“The Drugs Didn’t Mix”:On the Overvaluation of Misvaluation Benjamin R. Lewis (bio) Keywords addiction, akrasia, misevaluation, psychiatric nosology In this well-researched, articulate, and compelling paper, Summers presents the position that addiction is a misvaluation upon which a pattern of behavior is based and which resists contrary evidence. This inability to change one’s values in response to contrary evidence is the prime wrong at stake, given its implied diminishment of rationality (and hence adaptive functioning). In approaching this conflicted set of issues, Summers carefully surveys an impressive range of sources—from clinical DSM-based diagnosis (and inherent limitations thereof) to neurobiological underpinnings of decision making and attention, to social determinants influencing the question as to what counts as ‘addiction’—and settles on the more modest goals of elucidating why difficult cases are difficult and what set of factors would be important insofar as settling the questions at stake. And the questions as to what counts as an addiction certainly are difficult, beset by social mores, classification limitations, and no clear demarcating neurobiological boundaries between so-called passions and addictions. I am reminded of a quote from Butch Trucks, drummer for The Allman Brothers, describing a collaborative concert they played with The Band and The Grateful Dead: “It’s one of the only times I can remember where the jam didn’t work because the drugs didn’t mix. The Band were all drunk. The Dead were all tripping. And we were all full of coke. So we tried to jam, but there was just no common ground” (Edwards 1999). The permutations here as to enhancing/inhibiting, adaptive/maladaptive, socially acceptable/unacceptable, and passion/addiction are truly complex (and perhaps unlikely to be parsed philosophically by the musicians themselves). The concept of akrasia, or weakness of will, is often invoked in philosophical discussions of addiction. This is not examined explicitly here, but is nonetheless active both in the discussion of misvaluation as well as the associated moral judgments. From the outset, Summers takes a broadly internalist position: motivation (and hence behavior or action) is driven by evaluative judgements. In this case, an addict’s behavior is determined by a wrongfully held value or values: say, the immediate hedonic pleasures of intoxication over and above the more abstract and long term values that sobriety may present (i.e., employment, maintenance of relationships, avoidance of legal issues, financial stability, health outcomes.) For Summers, [End Page 41] it is the fact that the addict ought not to hold this set of values that determines it to be ‘addiction’: it is a misvaluation. This misvaluation in inferred from a pattern of behavior that is maladaptive or dysfunctional: “Using ‘value’ and ‘valuing’ in an ordinary way, we can further distinguish as we must, between the value we claim to have and the values we in fact do have, those we demonstrate in our actions” (Summers 2015, 33). For Summers, the proof is in the pudding: your chosen actions announce your values. Had you valued differently, you would have acted differently. This is essentially the same internalist position presented by R. M. Hare, which precludes the possibility of akratic action in the first place. If an agent does action x, it necessarily follows that he judged x to be the best option available at the time: “it becomes analytic to say that everyone always does what he thinks he ought to [if physically and psychologically able]” (Hare 1952, 169). If an addict chooses to relapse on heroin, it necessarily follows that he determined this to be his best available option (at least at the time). Although resolving the seeming paradox of akratic action, this position is unsatisfying in that it fails to capture the clear apparent clinical reality of individuals struggling with substance use disorders: that they can indeed place full value in sobriety and yet still have difficulty acting in accordance with that value (all of the time). Externalist positions, such as that described by Alfred Mele (2002), argue that evaluative processes and motivational processes dissociate: action can be driven by more proximate rewards in a motivational sense despite having vague, unclear, inadequate, or conflicting reasons for action. Ainslie’s notion...

Elizabeth Welch

Much of the discussion of the ethical concerns involved in the care of those with Disorders of Consciousness (DOC) has been presented in terms of the dichotomous “right to die” / “right to life” (RTD/RTL) framework with nearly singular focus on (1) assessing whether the individual retains “consciousness,” and (2) making the “right” choices about the use of life sustaining treatments (LSTs). However, the lived experience of the family, friends and medical providers who have close contact with individuals with a DOC indicates that the ethical concerns involved cannot be reduced to the RTD/RTL framework, to proofs of consciousness, or to the right to make choices about treatment. Rather than advocate for a “right” choice in regards to use of LST in those with DOC, this essay utilizes the writings of Paul Ricoeur to illuminate the sources of our ethical confusion and to engage in deeper ethical reflection. I describe DOC from the perspective of neuroscience and review recent research. I then critique conceptions of autonomy and personhood within medical ethics, especially in so far as a model of consumer choice dominates conceptions of autonomy and cognitive capacity is considered a determinant of moral worth. I present Ricoeur’s understanding of autonomy as a relational project and his description of individuals as capable and fragile in varying degrees as an alternative. I proceed by examining the concepts of “sanctity of life” and “pain and suffering,” where I use Ricoeur’s description of all humans as acting and suffering, and his description of solicitude as the model for responding to suffering. I conclude with Ricoeur’s description of the ethical intention of “aiming at the ‘good life,’ with and for others, in just institutions” as an approach to analyzing ethical dilemmas and clarifying what it is at stake in various alternatives.

Kari Pylkkänen

The history of Finnish psychiatry has been characterized by polarizations: priority in hospitals vs. outpatient care, centralized vs. decentralized organization, independent vs. integrated administration, biological vs. psychological treatments, private vs. public production, special psychiatric policies vs. general health policies. The independent psychiatric organizations on District level lasted from the 1920s until 1990. Since then, the formerly independent psychiatry was subordinated to General Hospital administration and the centralized system of state planning and financing of healthcare was gradually decentralized and run down. During the heavy Finnish economic recession of the early 1990 s, the cuts of the public sector were unfortunately focused most heavily on psychiatric services. The main focus of research and teaching has shifted from earlier emphasis on psychoanalytical approach to biological psychiatry since the late 1980s. The administrative position of psychiatry has been repeatedly changing and unstable during the last 20 years. At the level of the contents of the services, however, there have been many very positive and promising developments. Psychiatry has come closer to other specialties from its formerly isolated position, when the separate administrations have been integrated. Provision of outpatient services has increased remarkably, while the number of hospital beds has decreased radically. Interest and resources in research have increased remarkably, and numerous new and good quality psychiatric research reports are being published.

M Thirunavukarasu

INTRODUCTION We, the generation living in the early years of the 21st century, occupy a special position in human history, in that we have witnessed unprecedented and unparalleled growth in the understanding and knowledge about the world around us and life on this planet. While we bask in that glory, let us not forget that there are some important and large questions that remain embarrassingly unanswered. The most conspicuous of those questions is one that is central to the field of psychiatry - “What is the mind?” Nevertheless, psychiatrists have brazenly avoided or ignored this question due to a learned lack of enthusiasm, given the historical inability to achieve a consensus about anything pertaining to the mind. Not to mention the inevitable criticism and/or possible ostracism that relentlessly pursues anyone who takes a stand on this controversial issue. Psychiatrists did not just want to open that can of worms! We simply hoped that if we managed to keep the can closed, the worms would suffocate and die and we would never have to face that uncomfortable question again. We believed that just like we managed to evade the exact definition of mental illness, we would be similarly successful in evading the definition of the mind. However, in the last several decades, human life has transformed so much that we are now faced with a relatively new concept - mental health, which too remains to be defined. The list keeps growing and our silence has been deafening. While our understanding of the human brain, human behaviour, and neurosciences has grown exponentially, the task of describing or defining the mind has also become increasingly difficult. Our wilful indifference or tactical retreat from confronting these tough questions is not helping us, one bit. Increasingly, we are educating ourselves with an explanation that any definition of mind or mental health is not even a possibility, let alone plausibility. Let me highlight the importance of this issue by discussing the well-known, controversial, yet insightful Rosenhan experiment. THE ROSENHAN EXPERIMENT In 1973, American psychologist David L. Rosenhan published the findings of his controversial study, ‘On being sane in insane places’ in the journal Science, stirring up a lot of reactions and criticisms among the psychiatric community.[1] It was a two-part experiment exploring the consistency and validity of traditional methods of psychiatric diagnoses. For the first experiment, Rosenhan arranged a group of 8 normal individuals called ‘pseudopatients’ who were known to have no psychological or psychiatric pathology. They included a psychology graduate student, 3 psychologists, a pediatrician, a psychiatrist, a painter and a housewife. Three of them were women and five of them men. Rosenhan was one among them. These pseudopatients appeared at 12 different psychiatric hospitals (11 university or state hospitals and 1 private hospital), reporting a false complaint of repeatedly hearing something such as “thud”, or “hollow” or “empty” and gaining secret admission. They used pseudonyms (false names) to feign their real identity. However, other than this fabricated complaint of auditory hallucination, no other and as would Rosenhan this experiment to if psychiatrists the pseudopatients with one fabricated as these were with the one who appeared at the private who was with of them were with and and at and to the study, these pseudopatients of the complaint admission. 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something that other has been to we the of our and psychiatrists to be called and to In to that of our we to to the psychiatrists are of and of methods of be to can such methods be if we have not the of our and the state of that a first have an to the as the - a concept that is different from other of the mind of these of the mind is the not not not the mind about that of the that and about from or not have used a different in psychiatric be is about the or that not have an by the of there is no with the or in that can be of a has a psychiatric or in the can be mental health and health to mental health can be also us to mental health just mental from an which is important our of mental around psychiatry are we have one at from the of the that is - a that has the in of is the the in psychiatry and Rosenhan has mental health this one is that and is For there is no and be given the is also no and are given the It is important to not just mental health, the of by the of in of psychiatry not be mental or not the of to the are and to be These are open to given the would in the and and/or of to mental health of the important would be to of the mental health and their can be as a concept by and which are and and in They in health can be as the of the about to with human and his or and are to as as at not to as as the of of in the and the

Juan Manuel Zaragoza Bernal

Marriage is about love, since the 19 th century onwards unless. If we ask people around us about the basis for a solid relationship, will be at the top of the list. What we look for in a relationship is a dependable, sincere, and affectionate partner. Someone to until death. Resentment is out of focus, here. It has nothing to do with real marriage. It has nothing to do with love. The romantic concept of we could find in this definition of marriage is the source of deep tensions between partners and, more interesting, into the subject itself. Confronted with difficult situations, love could be replaced with others (negative) feelings: hate, anger, and, commonly, resentment. The arousal of these feelings could generate a crisis within marriage, leading to the failure of the relationship. Or, in other situations, it could generate an identity crisis in one of the members of the marriage, putting his/her inner self at risk. I will explore the difficult conciliation of and resentment when one of the members of the marriage suffers a chronic disease. The narratives of the other part (the caregivers) show how this task is supposed to be the supreme proof of love, but at the same time, we can detect how resentment is repressed, as something that could damage the very identity of the caregiver. The case study will help to explore how the repression of resentment shapes the experience of disease, and is capital for the creation of the social identity of both: the and the sick. Arthur Conan Doyle will be my first case study. The story is well known. In 1892, just after a holydays in Switzerland, Louise Doyle (Arthur's wife) was diagnosed as having a severe case of tuberculosis. For the following fourteen years, Arthur cared of his wife. She had only been given three months to live in late 1893. If she lived for thirteen years more, it was because Arthur's care. This is a complex case, and we can approach it from different perspectives. Arthur Conan Doyle was a doctor, and he even attended a demonstration of a cure for tuberculosis by Professor Robert Koch in Berlin, in 1890. We know that he employed all his medical expertise in caring Louise. Care is not just about emotions, but also about technical skills. We can follow this path, but there are others we can explore too. Arthur was a rich man. Sherlock Holmes' adventures were a great success in late Victorian England, and Arthur became rich and famous. After Louise's disease, they travelled to Davos, Italy, and Egypt. He built a new house (Undershaw) in Surrey, where the weather was supposed to improve Louise's health. He bought the best medicines, and consulted with the best doctors. Care is an economical matter, and Conan Doyle had money enough to spend in Louise's treatments. But care is a social task, as well. The social self of the caregiver is at stake, and if he or she fails, the consequences could be the worst. This was Conan Doyle's case, also. He was the head of her family. Not only his wife and children, but her siblings and mother look at him for support. He had adopted this role from his childhood. He could not fail, his family and his own inner self were at risk. Technical skills, money, and social role. Care is about all that. And care is about emotions, of course, about love. We care of our loved ones, and we say their pain hurts us. We suffer with them, and we can cope with suffering because we them. But, what happens when fails? In 1897 Conan Doyle met Jean Leckie, and he fell in love with her. This relationship lasted until Louise's death. For the next ten years, Arthur tried to square his passion for Jean with his responsibility towards Louise. And here is where resentment (accompanied with selfdeception, frustration, and remorse) appeared. Through his letters and diaries, I will study this period of Arthur Conan Doyle's life, paying special attention to the emotional turmoil produced by this situation.

IRS Reddy

Respected chair persons and members of the Indian Psychiatric Society (IPS), I am extremely happy and privileged to be here at the 59th Annual Conference, before an enlightened gathering to preside over the prestigious IPS. It is a rare honour and it shall be my endeavour to prove myself worthy of being chosen for this prestigious and highly coveted honour among the psychiatrists. I know my limitations but I am also aware of the great role that can be played by our society and I make bold to place before you many of my experiences in the field to exhort my fellow psychiatrists that we have a great responsibility ahead. From what I have observed during these years of my active practice, I have no doubt in my mind that the psychiatry as a profession is slowly gaining ground and in the years to come it will play an effective role in disabusing the minds of the public of their wrong and ill conceived notions. I shall endeavour my best with the cooperation and support of all my fellow psychiatrists. There were quite a few topics that I short listed for my presidential address. Finally, I zeroed in on this topic titled “MAKING PSYCHIATRY A HOUSEHOLD WORD” as I feel the art and science of psychiatry has a great deal to offer society apart from treating the “crazy people”. To make that contribution, psychiatrists must continue to tackle society's most pressing problems and also raise the visibility of psychiatry and its perceived relevance to solving a wide range of personal, social and family problems. The image of psychiatry has been tarnished in the eyes of common man, thanks to the battering that the profession has received at the hands of the media, not to mention the apathy of the policy makers. Here is an example to prove my point. At the recently held conference at Jaipur, I was walking outside the convention center when I heard two young women talking to each other. One said to the other: “My God!!!…. He's so weird! He really should see one of those psychiatrists who are walking around here.” “That's it!” I thought. “People think you have to be ‘weird’ to see a psychiatrist.” The public tends to view psychiatrists narrowly, associating us chiefly with our expertise in mental illness. In reality, psychiatrists can promote coping and wellness in addition to diagnosing and treating mental illness. Many people today have significant stress in their lives and we all undergo crises and life-stage transitions as a normal part of life. Psychiatrists can help people assess how they are coping with current stresses and develop new skills and strategies. A lot of people find that their stress levels have increased in this era of wars, terrorism and natural disasters. We, as psychiatrists, could do much more to prevent problems by helping people learn to cope and build their resilience. I wondered what it would take to normalize our public image, that set me thinking and I looked into dentistry, which changed the public image of its profession in the 1980s when it teamed up with Colgate toothpaste in a public education campaign that promoted the idea of the dental check-up. This campaign led to major changes not only in the public image of dentistry but also in the very nature and public impact of dental practice. Dentistry moved from a focus on restorative dentistry to an emphasis on preventive dentistry. We have all witnessed the success of this transition. People no longer wait for a toothache to visit the dentist and employers routinely include preventive examinations and cleanings as a dental benefit. I am envisaging a day when people similarly take appointments for a “psychological check-up” akin to a general health check -up and when that day comes one can rest assured that the community has truly embraced our profession. At these check-ups they could address such matters as their stress level, their relationships, how they are caring for their children and ageing parents and health basics such as diet, nutrition, sleep and exercise. In my 30 years of practising psychiatry, I have had a unique vantage point from which to both observe and reflect on, the process whereby psychiatry responds to urgent societal needs and how these needs thus influence the evolution of psychiatry. As I see it, the scope of psychiatric practice is expanding and diversifying into new areas. In short, the stage is set for the public's as well as policymakers and health care payers' full embrace of our field and for the true integration of psychiatry into health care, Only if we make them aware of our scientific knowledge and professional skills. DISABILITY AND MENTAL ILLNESS The burden of mental illness on health and productivity throughout the world has long been profoundly underestimated. Data developed by the massive Global Burden of Disease study conducted by the World Health Organization, the World Bank and Harvard University, reveal that mental illness, including suicide, accounts for over 15 percent of the burden of disease in established market economies, such as the United States. This is more than the disease burden caused by all cancers.[1] This Global Burden of Disease study developed a single measure to allow comparison of the burden of disease across many different disease conditions by including both death and disability. This measure was called Disability Adjusted Life Years (DALYs). DALYs measure lost years of healthy life regardless of whether the years were lost to premature death or disability. The disability component of this measure is weighted for severity of the disability. For example, disability caused by major depression was found to be equivalent to blindness or paraplegia whereas active psychosis seen in schizophrenia produces disability equal to quadriplegia. The World Health Organization's Global Burden of Disease study reported that mental disorders comprise four of the top five sources of premature death and disability in 15-44 year olds in the Western world. Using the DALYs measure, major depression ranked second only to ischemic heart disease in magnitude of disease burden in established market economies. Schizophrenia, bipolar disorder, obsessive-compulsive disorder, panic disorder and post-traumatic stress disorder also contributed significantly to the total burden of illness attributable to mental disorders. The projections show that with the aging of the world population and the conquest of infectious diseases, psychiatric and neurological conditions could increase their share of the total global disease burden by almost half, from 10.5 percent of the total burden to almost 15 percent in 2020. Major depression is the leading cause of disability (measured by the number of years lived with a disabling condition) worldwide among persons age 5 and older. For women throughout the world as well as those in established market economies, depression is the leading cause of DALYs. In established market economies, schizophrenia and bipolar disorder are also among the top 10 causes of DALYs for women. The above stated facts, hopefully will be an eye-opener for all the concerned parties. From our side, we should do all that we can in whichever small way to reduce this enormous disease burden. My presidential address, I hope, will serve as an initiative to formulate ways and means to achieve this objective. IMPEDIMENTS IN MAKING PSYCHIATRY A HOUSEHOLD WORD There have been a lot of impediments in making psychiatry a household word. The main culprits are the age old concept of mind-body dualism and lack of integration of mental health care into primary health care, stigma, psychiatrists themselves, the apathy of the policy makers, failure of Consultation - Liaison psychiatry and media. I will make an attempt to briefly detail what resulted in these hindrances and some plausible solutions to overcome them. MIND-BODY DUALISM The earlier concepts of health glorifying mind-body dualism are bankrupt now and mind-body dualism has an enormous negative impact on our health care system. Because of it, our health care system does not systematically attend to the many psychological risk factors for both morbidity and mortality and it virtually ignores the psychosocial pathways that lead to unnecessary utilization of medical and surgical services. In addition, the psychological impact of a medical illness is not well by the health care is the that many people from a illness have psychological illness. Finally, the share of mental health problems are by primary care take a at some of the of the top health risk factors are diet, suicide, and of the leading causes of death have significant At as much as of all to primary care medical are for problems with a psychological those who with mental health problems and those who or for problems with a psychological component those with such as those with and those with medical one study found that than of had and A number of have that health care the utilization of medical and surgical The of people mental health are for by medical with in mental is a of the of psychological in a wide range of health including both and disease system and and In addition to being these are than across a wide of and including and that mental health can be in primary health care with and on but it is whether this is true of for persons with and mental illness. There is a long of in for persons with mental disorders that would be a single system of care that to medical and mental health services. Many mental health problems are seen as and thus the general health is a natural point for and treating mental health problems. Many also continue to find care for psychiatric problems more when by their primary care The and mental health care in an system also a that common and mental disorders will be and that and among will reduce and common of of The concept of a number of that are at the of health care them are the and A significant is that not be in a highly system of As medical are to be more and they have to to each and to know the and to the of problems that Because with conditions are and to their and they will not be with disabling mental illness will have to with who more and to deal with by and of these problems has but they are not can be to and with mental but this is a and can be to increase the of health care to disabling illness, but this must with many in an of new and practice by of public and is but effective in this objective. the that mental health for ill can be into the general health a and that are on at for the The is for persons with more and disorders. - A Psychiatrists should have been seen as and as an as they are so few in In are only psychiatrists for a population of over of psychiatrists to the of is which is quite Psychiatrists are seen in negative by the of the have been are seen as disease and not are seen as being seen as are seen as a on the most in the are seen as the to as not in and thus could them of their and being a are seen as making a a to their view are seen as not scientific psychiatrists in and are seen as are seen as only and not the have been up over and mental health of of and of including have contributed to these of by help has matters The of and of view has it from the the of psychiatrists themselves, the to formulate and not the focus from negative to and not our have it We of the of mental and disease in the but are not to prevent We of mental health but do not or we do not have or for mental health at the professional or We of well being and on The and do not have psychiatrists as the but are to our We would be to of and for but not in at the to preventive and health strategies. We can be if we are to The community of which is a part would be to allow us to lead if we have for and which are effective and We would have to hands with and community with to long solutions for the population than at a of only those who have extremely and We to be for the mental health needs of the and not only the for It is only that psychiatrists in and psychiatry in general would its place and a - PSYCHIATRY of the to with are and are for the cooperation and for effective is a on the part of some to the place of factors in the of the This be to and conditions that are to observe and or to is that mental health have long had a for The or at was in the many people the field in to their psychological problems. it and such an are to The that be and the of psychiatric The on of or at in many is with and One by many including psychiatrists, is that a will come in that the has a more disorder than the one and that the is on should the for psychiatric the the moved to this is not an the two care This is to the of if the psychiatric The should that lack expertise outside of and with psychiatrists is a that must be over a of the most here is to make but when called for an This reduce by the and allow to up in the psychiatrists have a for diagnosing as or the that they be to have some psychiatric problems of their The is not as many psychiatrists and mental health in make of fellow them or their A general way to many of these is for the to be in and to the of and medical and should that the is a in which the will have the The of with psychological problems in with should be and not The should not be or or that will be as very by the He should also be aware of the of the and than a take it or it I have found that with when I am by and does not medical the can find ways to make to the medical He should with and take the of these It is also to attend medical The of knowledge of one by psychiatrists and can during before such and can lead to the also the with an to the and of with their and AND MENTAL of people with mental disorders has throughout It is by to or or people with mental disorders such as It to and and to and It the public from and to In its most and in and it people of their and with their full in for in from the mind and by of in the of the mental health system in the United from the of an influence on and in the world. In the the public mental illness as a and an of mental illness. were not to as when with of who would have been said to be ill to the professional of the The public was not at mental illness from and and to see only of mental illness. illness great social stigma, with of and a that had scientific of mental illness. the in knowledge not social in comparison with the the public's of mental illness more This was true among those who mental illness to include psychosis view held by of the The also how of those with mental illness by The public was more to an with schizophrenia as mental illness than an with This people with mental disorders truly more some public but the of is The risk of is from those who have who have a mental disorder as well as a There is a small in risk of from with mental disorders if they are with their the risk of is much for a than for a family or who is to the with mental In is very risk of or to a from with an who has a mental Because the is to whether who is has of these or in the natural is to be to this all in the of mental disorders to the total of in society is Because most people should have to from those with mental illness, in its most is of so focus on and One of found that the public's and mental illness and people to from those with mental disorders. of the common with from psychiatric disorders are listed of mental illness of of It is not that psychiatry has a in its to mental illness, but that it has also to address its current of the psychiatry in their There is a of psychiatric on and and a to the are some in psychiatry, which are in minds and a great deal to the in psychiatry. A IN PSYCHIATRY and of and and for and help for mental disorders of all people with mental disorders do not the of mental health is among the many that people from to be in in to or and for mental disorder of is in the public's to for mental health services. to for mental health or has been public held in of the public a to for for with mental such as schizophrenia and than for conditions such as and the public to support for its support the that or would be In the of the to for mental illness is to be The public for mental disorders that for There is no or single to the with mental illness. was to with increased knowledge of mental illness, but the in some ways over the years of mental illness by to knowledge be to public is to that negative mental illness can be by on the and mental to of public education and with persons with mental illness and societal way to is to find causes and effective for mental disorders. this to be of and to are of mental disorders for which has The of an infectious and of led to the of when was to a and with was the was in the developed world. with had been in mental in the before its was no one has the of public these conditions over the and of this disease of its these also a more that the mental health field was when causes and were As were each was from the mental health field to medical For over of was moved to and in and over mental disorders was moved to The of this to is that mental health field over the years the for mental disorders was This the mental health field to by their medical that psychiatry was not part of and that psychiatric practice on and that for disorders them or the mental disorders not only but be by to mental health care only those conditions causes or To point this is not to that in mental health should be should be and The here is to some of the of the the general health and mental health that will continue to effective for mental disorders to be an effective people that mental disorders are not the of or will but are that are to much of the negative to to to be developed and science has much to to the and of As a in public should People should to should more to its most they should more to the that are the of this mental health and mental illness are part of the of health and they are a for all to would be the of the to who to mental illness regardless of from the of has been a in the success of on and AND MENTAL and medical profession have been in in the media. psychiatry and psychiatrists have not been so than the profession has been by media. illness has been the for and which the in the minds of the public mental illness and the the old some of the have psychiatry in extremely Psychiatrists are as who and for the most are not in their of mental illness. as as if is not in the minds of The is not in its of psychiatry and psychiatrists. I an by the which in the on the the no longer as a the Indian Psychiatric to do of that and it a measure of the of the profession of psychiatry in if you to a This of will the most from of psychiatric have been some of mental illness, the and both of which have been into the It is to that these have been well and psychiatrists are in a of will well for the mental health profession and for psychiatrists as a There are no to tackle this It is for all of as psychiatrists, to a to this It is our responsibility to more in the mental illness. For we should no as the of this can be of you must have seen in the and for public health causes you seen psychiatry in which I think of a when mental illness and the impact that will have on the common I feel that is a and we in are some to that I all members of to the and come more with a and the psychiatry and do all that you can to the image of psychiatry, which is for the public to embrace our IN PSYCHIATRY In this I would briefly some of the success in the field of mental The that come to my mind are the by the psychiatrists in the of the The has a lot of for psychiatry and psychiatrists. This is significant as this of will a long way in making the public more and in psychiatry. The by psychiatrists during the and and the so called in the Indian of and is a in point. a long way in the with the policy and the public I also the of and that is on in the and I also the of all the psychiatrists who have in the community mental illness and to the PSYCHIATRY IN must a with a as its more than psychiatry at the of a of has such a of as psychiatry This of both and is our and we must not up one for the of the other. health must more for Indian and psychiatry do not develop in a but they develop in a social psychiatric of and and to are all on This is not a very for a with its no has the of the and the of mental the way we have in we continue to concepts and these are in our We to on these and a truly to mental from such an will more with ground in of is its and psychological well being of the community for a and of the and we as mental health should that MENTAL I of this has a to a and an which to an of and family community and care or or in the that of mental health care with primary health care into the and of mental illness and into the of and effective and overcome the with mental illness public and Health to effective must be the for people with mental illness as for medical to mental health care should be across including the and to be with and should be to and to an of psychiatrists, to the current and needs of the population I psychiatry as my profession with a lot of and I am very happy I do feel to the way in which psychiatrists are in the society A day should come when we should be to that am a and in are psychiatrists and are psychiatry. This will if we to offer solutions to a wide range of personal, family and pressing social in and and the of in some of our role in We should make the that their health the to their should be on long solutions for the population than at a of only those who are extremely and We should make the community what we are is what our minds are the which the To this the with a the is a the mind is so to it is that we it to the is the medical profession to the with such emphasis on the In this who the of by in the is by and has to a to at the of the mind and all that it has I a day not in when people make appointments for general health check We to be for the mental health needs of the community and not only the for In these of I would to the the that you to see in the we play our role as psychiatrists, I a when psychiatry in general and psychiatrists in would their place and a household word. My to all of you is that each one of you needs to in this of a household one and all IPS.

José Luis Vázquez‐Barquero, José Gregorio Oliva García, Francisco Torres‐González

OBJECTIVE: The objective of the paper is to describe the impact of Spanish psychiatric reform on the organization and functioning of mental health services. METHOD: This paper is based on official administrative reports and on relevant related publications. RESULTS: The most significant achievements of Spanish psychiatric reform have been: (i) the development of a new organization of mental health care, decentralized in character and territorially based; (ii) the integration of psychiatric patients in general health care; (iii) the creation of an extensive community network of health centres; and (iv) the development of more positive attitudes towards mental illness. However, our analysis also reveals the existence of significant deficiencies. CONCLUSION: Analysis of the Spanish experience shows that the process of psychiatric reform depends basically on long-term commitments, which in a system such as Spain's must come from central administration and also from the autonomous communities.