Pat Bracken and Phil Thomas on hope
Openmind 130, November/December 2004
In this, our final postpsychiatry column, we want to explore the importance of hope. It isn't a word that features in NICE guidelines. It is too subjective for modern, evidence-based psychiatry. Nevertheless, we believe it is important for a number of reasons.
Many service users find that psychiatric diagnoses, especially schizophrenia, are life sentences, condemning them to years on medication and state benefits. The language of psychiatry abounds with words like 'relapse', 'deficits' and 'defects'. Abandon hope all ye who enter. However, it is clear from the experiences of survivors and service users that hope is profoundly important and a key ingredient of recovery.
The psychologist Peter Chadwick, writing about his own experience of psychosis, found the instillation of hope to be a critical part of his own recovery, as important as any pill. Medication simply wiped out his experiences, and left him feeling worthless and hopeless. Having the opportunity to discuss his delusions of possession with ministers of religion allowed him to explore the concept of forgiveness, and this rekindled hope.
Until relatively recently, engendering hope was arguably every doctor's single most important task. The roots of Western medicine (and other systems of healing) lie alongside the origins of religion, ritual and magic. The historian Roy Porter  points out that the words 'healing' and 'holy' share the same root, and through faith, both hold out the prospect of hope, the possibility of a better life and a more fulfilling future. Since its origins in the European Enlightenment, psychiatry has been anxious to proclaim that its treatments are based on scientific research, and has played down the importance of such things as faith, hope and the importance of values and meanings.
However, there is substantial evidence that drugs such as antidepressants work largely through the generation of hope. It would appear that what is called the 'placebo effect' accounts for most, if not all, of their efficacy. On the other hand, research on the outcomes of psychotherapy has consistently shown that it is not the therapist's theories or training that is most important but their ability to establish a relationship of trust and to generate a sense of hope. We believe that there is a need for greater honesty on the part of our profession when it comes to this matter. For too long, science in our field has been equated with biology, and because biology doesn't have the means to explore specifically human phenomena such as hope, we have ended up with confused pseudoscience in place of genuine enquiry.
We argue that a discourse centred on issues such as hope, meaning, values and relationships should be at the heart of mental health work. What we call 'postpsychiatry' is about a move in this direction. There are encouraging signs that things are staring to shift. The psychologist Rufus May argues that the widespread employment of survivor workers alongside mental health professionals can change services for the better. His own experiences of psychosis and of using mental health services have benefited individual patients as well as the team he works with by focusing more positively on patients' lives and allowing them to see hope in the future.
More generally, the rise of the user movement internationally has meant that alternative pathways, such as those involving creativity and spirituality, are now being explored.
Like all human beings, we hope too. We hope for change in services that seem without hope. At a more personal level, we hope that you have found our recent articles in Openmind useful, and that you may be interested to read our book, Postpsychiatry, to be published next year in the series on Philosophy and Psychiatry by Oxford University Press. Postpsychiatry would not have been possible without the opportunity to start developing our ideas in a public forum opened up by Sara Dunn and Openmind back in 1997.We were extremely privileged to be granted this.
But the most important things that have shaped our ideas have been the stories, lives and experiences of people (friends, colleagues and patients) who have gone through episodes of madness and distress. Postpsychiatry, if it stands for nothing else, stands in tribute to their courage, suffering, humour and strength.
1. P. Chadwick (1997) Schizophrenia: The Positive Perspective, London: Routledge.
2. R. Porter (1997) The Greatest Benefit to Mankind: A Medical History of Humanity from Antiquity to the Present, London: Harper Collins.
3. I. Kirsch and G. Sapirstein (1998) 'Listening to Prozac but hearing placebo: A meta analysis of antidepressant medication', Prevention and Treatment 1, article 0002a
4. D. Moerman (2002) Meaning, Medicine and the 'Placebo Effect', Cambridge: Cambridge University Press.
5. R. May (2000) 'Routes to recovery from psychosis: The roots of a clinical psychologist', Clinical Psychology Forum 146: 6-10.