Postpsychiatry and postmodern psychotherapy: Theoretical and ethical issues in mental health care in a Polish context

Key propositions of postpsychiatry

Bracken and Thomas (2001) begin their widely discussed article with the important statement that modern societies are characterized by a growing distrust of science (and its objectivity) and technology in general. Therefore, “postmodern” science, including medicine and psychiatry, has to focus not only on scientific evidence, but also on ethical values. It needs to include a new subject in its enterprise: the well-informed (sometimes also misinformed), conscious and skeptic patient. It seems this may be even more difficult in the case of psychiatry as its accomplishments have already been questioned, and the authority of psychiatry currently relies to a great extent on the alleged value-free quality of scientific methodology.

A key theoretical proposition of postpsychiatry is the differentiation between technology and ethics. “Technology,” according to this view, denotes the set of tools possessed by a psychiatrist, such as definitions, diagnoses, procedures, medicines, or even therapeutic techniques, and the conviction that mental disorders are a consequence of faulty internal psychic or neural mechanisms. Ethics, on the other hand, implies consideration of the wider context of a disorder, its meaning for the patient, and the inclusion of ethical values in the process of therapy (conscious of both the fact that ethical values may affect therapy and that they are always present, even if not acknowledged). According to postpsychiatry, ethics should take precedence over technology.

The practical demands of the postpsychiatric movement could be summarized as follows: (a) in the emergence and form of symptoms a greater emphasis should be put on the role of the social and cultural context; (b) causal explanations should be preceded by an explanatory exploration of the meaning and values behind certain behaviors; (c) the patient’s perspective should be incorporated in the overall diagnostic evaluation, including the spiritual and religious aspects of the problem; and (d) a critical evaluation is needed of the implementation in psychiatric theory and practice of a scientific model borrowed from the natural sciences (Bracken & Thomas, 2005).

Postpsychiatrists devote much of their reflection to the social, economic, institutional, and political aspects of psychiatry and pay particular attention to the financial and organizational ties between psychiatry as a whole, many psychiatrists themselves, and pharmaceutical companies. These ties are strengthened by all parties’ mutual interest in sustaining the image of psychiatry as a strictly medical, evidence-based, and scientific discipline that deals with brain abnormalities that cause symptoms that should be eliminated with drugs.

Philosophical background and assumptions

It seems that the work of British psychologist David Ingleby (1980) could be considered the main inspiration for many of postpsychiatry’s assumptions. Ingleby claims that simply juxtaposing the medical model of psychiatry against the non-medical one is not enough and is, in a way, misled. He emphasizes that classical psychiatry is modeled on positivism, rather than on medicine per se. Drawing on Kuhn, he argues that we are in fact facing a conflict between two paradigms: the positivist and the interpretative. This makes the dialogue between supporters of opposing views even more difficult as they start with fundamentally different interests, values, and assumptions about the nature of human beings and science. Eventually it leads to major misconceptions, misunderstandings, and attempts to unjustifiably invalidate one mentality from the standpoint of the other. While agreeing with Ingleby’s critique of the positivist stance in traditional psychiatry, postpsychiatry strives to overcome the problem of conflicting paradigms by proposing a new one or a synthesis of both.

Most importantly, Ingleby (1980) states that the prescriptions of the positivist paradigm regarding both observation and theory construction are uniquely inappropriate to psychiatry’s subject matter. First, according to Ingleby, objective observation and data collection is impossible in psychiatry, thus rendering its value-free character impossible. The division between the subject and the object is impossible in psychiatry as every scientific or clinical set-up is a social situation which the scientist or clinician cannot avoid influencing. The other problem is that psychiatry relies on descriptions which cannot be reduced to a finite set of formal rules from which a reader could reconstruct (from material classified by a researcher) the precise observations on which the description is based. Ingleby recognizes, analyzes, and thoroughly criticizes the different strategies that are used to solve this problem; however, according to Ingleby, all of them fail to address the issue of subjective data collection.

The other thing Ingleby (1980) criticizes is psychiatry’s sole reliance on the causal explanations present in both biological and social psychiatry. Ingleby shows that neither genetic and physiological studies nor biological treatments allow causal relationships and implications to be drawn. He also notes that treating social or psychological factors in such a causal way is in fact a reification and robs patients of agency. However, this maneuver is important for traditionally oriented clinical practice in psychiatry because it allows for a certain degree of dehumanization of patients and their actions. Behavior conceptualized as stemming from faulty psychological or biological processes means that these mechanisms can be manipulated without the need to argue, reason with, or understand the agent behind them. Paradoxically, this kind of reification, i.e., patient reports being controlled by outside factors and forces, is considered a symptom of a mental problem (delusion of control).

While Ingleby (1980) speaks of Jaspers as an example of the interpretative approach in psychology and psychiatry, the Polish philosopher and physician Andrzej Kapusta (2010) claims that postpsychiatry’s ideas are closer to Husserl’s work, and Bracken and Thomas (2005) contest Jaspers’ separation of hermeneutics and phenomenology. Discovering the universals of human nature was the goal of Husserl’s “transcendental project,” while Jaspers used Husserl’s phenomenology as a tool for developing a descriptive empirical and scientific psychology, so the method had to be transformed into something rather more systematic and verifiable. Thus, according to Jaspers (1963), phenomenological descriptions had to be communicable, falsifiable, and provide clear and strict definitions of symptoms.

This approach, which is accepted by mainstream psychiatry to this day, is evident in modern conceptualizations or classifications of mental problems. It relies primarily on identification of symptoms, while their understanding (and even explanation) is secondary or completely omitted. Instead, postpsychiatrists propose hermeneutic phenomenology inspired, among others, by Heidegger and Swiss psychoanalytic psychiatrist Medard Boss. This approach tries to illuminate singular phenomena and events in the context of individual human existence, being in the world, and the important relations and meanings involved. Postpsychiatry, thus, begins with the context but does not completely abandon causal biological explanations; it assumes, however, that a hermeneutic search for meaning and essence should take priority because psychiatry, more than other branches of medicine, relates to the sense of patients’ suffering (Kapusta, 2010).

Diagnosis, then, becomes something other than a definition of patients’ worlds from the cold and distanced perspective of a seemingly objective expert, for whom definitions and demarcations are crucial. Postpsychiatrists argue that it should be a process undertaken in dialogue with a patient as an equal partner, as his or her cooperation may help to expose different perspectives on a given situation. Postpsychiatry also shifts the focus from the question of the ontological status and scientific validity of diagnosis to the problem of power relations and the consequences of a diagnosis for a patient (Bracken & Thomas, 2005). Therefore, postpsychiatry’s goal is to stop the “monologue of reason about madness” (as Foucault, 1965/2005, p. xii, put it) in both clinical and research practice. In more practical terms, that means, among other things, establishing meaningful cooperation with psychiatric survivors’ movements and peer-support groups such as the International Hearing Voices Movement (Romme & Escher, 2012).

Kapusta (2010) concludes that we are currently facing a blurring of distinctions between a phenomenological-hermeneutic approach, looking for implicit assumptions and core sources of our experience, and Nietzschean poststructural hermeneutics questioning the dogmatism of all assumptions aimed at weakening the power of the “scientific” discourse in psychiatry. The latter seems closer to a postmodern approach to psychotherapy.

Postmodern psychotherapy

One of the merits of postmodernism is the assertion that objective knowledge (and the world’s monoversity), which was postulated until recently, could, at least in some fields, turn out to be an illusion or cultural artifact. Similar remarks are often met with fierce objection or accusations of extreme relativism, nihilism, or solipsism. Nevertheless, this approach turned out be enormously inspiring in the field of psychotherapy, leading to completely new conceptualizations (even if a theoretical preference for avoiding them was declared) and a number of propositions to modify and reformulate previous theories and their practical applications in both the psychodynamic and cognitive-behavioral (CBT) approaches (Wachtel, 2013). This was, however, most evident on the grounds of systemic family therapy.

Different approaches that could be labeled as postmodern therapy exist; however, Harlene Anderson (Anderson & Gehart, 2007) and Klaus Deissler (2008)—both of whom are prominent and characteristic figures of the postmodern family therapy community—are recognized to some extent and involved in projects in Poland, so we will use their work as an example that reflects most of the ideas present elsewhere.

Postmodern psychotherapy postulates cooperation with patients in the process of discovering (or re-creating) conceptual frameworks for the description of patients, their families, or even wider systems. Influenced by the writings of thinkers such as Mikhail Bakhtin, Gregory Bateson, Jacques Derrida, Jean-François Lyotard, Lev Vygotsky, and Ludwig Wittgenstein, proponents of the social constructionism approach in family therapy are in fact speaking about the same thing that postpsychiatrists claim as one of their main postulates, i.e., treating the patient as a partner or even as an expert on his or her problems. While CBT approaches also emphasize collaboration, they construct it in a much narrower way that is closer to compliance and essentially makes the patient use the techniques provided by the therapist and uphold the therapist’s understanding of the therapeutic process.

Anderson (2007) calls the type of therapy she practices “collaborative” or “dialogical”; the idea of collaborative relationships and dialogical conversations and the avoidance of presupposed techniques or methods are central to her approach. The problem brought to therapy (e.g., schizophrenia in the family) exists in language, which also means that it is constructed and developed in language, but it does not mean that there is no experience or suffering beyond language. Since language de facto creates problems, it follows that these problems can also be solved with language, and that is the purpose of therapeutic conversation.

This approach, in the spirit of postmodernism, does not focus on the search for one final, objective, historical or “best” truth about a given situation (as it is probably impossible to unearth); instead, it assumes a multiplicity of truths, i.e., many truths not only in the therapeutic situation (the truth of the therapist and the patient and/or the patient’s family), but also within each of the partners involved in the interaction. This aspect is somewhat similar to Hermans’ (2001) concept of the dialogical self. The authors of the preface to the Polish edition of a book about postmodern therapies claim that application of Anderson’s philosophy may even lead to self-contradictory statements expressed towards a patient by a therapist (Chrząstkowski & de Barbaro, 2011).

Klaus Deissler, who works with Anderson in the Taos Institute, developed some of her ideas further. He abandoned the traditional assumption of systemic therapy which says that a system (a family) creates a problem (an illness): he stated that it may work the other way around as well, i.e., the problem organizes the system. In fact, this German therapist thinks in terms of recursive units, which means he does not dwell on the question of primary cause (i.e., what happened first), but instead sees the family and its problems as components of a single feedback loop: the problem produces the system, the system produces the problem, etc. (Deissler, 1989). Wachtel (2013) used a quite similar approach in his cyclical psychodynamic psychotherapy.

However, in the context of postpsychiatry, postmodernism, and ethics, Deissler’s (1988) concepts of “power metaphor” and “psychiatric language games” seem most relevant and interesting. The power metaphor notion refers to an indirect hidden assumption about the objectivity of a perceived phenomenon, which leads to the clinician imposing and enforcing meanings on patients under the guise of discovering them. According to Deissler this is anti-therapeutic. It is, however, possible to abstract from this by giving up the attitude of observing the world “as it really is” in favor of creating—or rather co-creating with the patient—an understanding of reality and the nature of his or her problems. This may be particularly hard to adopt for clinicians who are used to directing and leading their patients on the course they perceive to be suitable. Abandoning the objectivity of the clinician’s judgment may also be perceived as a forfeiture of some professional and personal authority in the therapeutic relationship, which may be personally problematic for some practitioners. While postpsychiatrists are clearly inspired by Foucault’s (1965/2005) work, Deissler instead chooses to point to Lyotard’s (1984).

It is important to note that not only a clinician may implement the power metaphor: a system itself—or in this case a family—may use the metaphor and anticipate that the clinician will uphold and reinforce it. Symptoms become a power struggle within the system and the family persists in treating the illness as an objective fact and reality, expecting that somebody from outside (psychiatrist, psychotherapist, or psychologist) will fix the problem in a way an engineer fixes a broken car. This notion of a power struggle within a family which delegates its weakest member to perform the role of a mad person who reflects (represents) the family’s problems is especially close to the radical critique of family that is present in the antipsychiatry writings of Cooper (1968) and the somewhat less radical Laing (Laing & Esterson, 1964). According to postmodern therapists, in such situations a clinician may act as if he or she believes in a sickness metaphor (e.g., schizophrenia), recognizing that the family may not be ready to take responsibility for solving the problem and that its members demand to be objectified. Eventually, proposing new constructions of the problem will hopefully lead to a solution, created both by the therapist’s intervention and the contribution of the system (nota bene a therapist is considered to be a part of it). The therapy, more often called a “series of consultations,” is a process of turning a “problem system” into a “problem-solving system.” This, of course, reflects the narrative character of most postmodern psychotherapies.

Deissler’s (1996) “psychiatric language games” are clearly inspired by Wittgenstein’s Sprachspiele: the meaning of the patient’s behavior is constructed in discussions between the clinician and the patient. According to Deissler (1996), the metaphors imposed in these situations are those of social control, power and coercion, helping and caring, and biochemical and organic cerebral metaphors. They are said to lead to conversational dead ends and block conversation as they do not comply with the essence of conversation, i.e., partners creating meaning together. These psychiatric language practices, claims Deissler (1996), rely on a reified and objectified diagnosis that is removed from the conversation and accompanied by equivalent psychiatric interventions directed at physical processes. Deissler (1996) emphasizes the aspect of social control (or even coercion) and a lack of a real dialogue within modernist psychiatric and psychotherapeutic interventions and proposes that practice should take a collaborative ethical stance. The leading metaphor for organizing therapeutic practice should be a “collaborative self-organizing conversation” in which what is benevolent for those participating in it should be jointly negotiated by all participants because all of them, including the patient, are experts. Diagnoses are considered to be only dialogical conventions as there are no individual concepts outside (interpersonal) language games: a representation of the physical world, in the sense of denotations expressed in words, does not exist.

Clearly, despite pointing to different inspirations and being motivated by different factors, postmodern psychotherapy and postpsychiatry seem to reach similar conclusions that emphasize the importance of cultural, ethical, and societal factors in the process of constructing psychiatry’s position, power, and knowledge and their importance in the therapeutic process. Of course, since postmodern psychotherapy is an older phenomenon, it is possible that it influenced postpsychiatry, even though proponents of postpsychiatry do not seem to point to it as a source of inspiration.

Some ethical problems associated with pharmacotherapy

Patients diagnosed with psychotic disorders often refuse to take their drugs and treatment adherence is extremely low. This is often thought to be the effect not only of the adverse effects of neuroleptic drugs, but also of delusions, lack of insight, and patients’ inability to properly judge a situation and care for themselves, i.e., symptoms of the disorder itself (Haddad, Brain, & Scott, 2014). However, in light of reports concerning the harm possibly associated with long-term use of neuroleptic drugs (e.g., reduction of brain volume; Ho, Andreasen, Ziebell, Pierson, & Magnotta, 2011; increased risk of diabetes, weight gain, and obesity; American Diabetes Association, 2004; and a decrease in lifespan of 8 to 17 years for psychiatric patients; Chang et al., 2011), should patients’ complaints about being poisoned automatically be regarded as a symptom of psychosis and a display of poor judgment? Furthermore, since psychiatric drugs have a plethora of well-documented harmful and even scary (as in the case of brain volume shrinkage) side effects, not to mention that their efficacy is sometimes reported to be comparable to placebo (as in the case of a well-known meta-analysis of SSRI drugs; Kirsch et al., 2008), is it ethically justifiable to prescribe them at all, and, more importantly, is it ethically justifiable to medicate patients against their will? Of course, a cost–benefit ratio could serve as a guideline, but a reasonable calculation of this ratio seems to be very difficult. For example, about one-third of patients who took lithium for 10–29 years had evidence of chronic renal failure (Aiff et al., 2015), but it is hard to estimate if the drug actually prevented relapses as the data supporting maintenance therapy with lithium and other drugs is somewhat weak and shows minor or no improvement over placebo (Moncrieff, 1995; L. A. Smith, Cornelius, Warnock, Bell, & Young, 2007; Thase, 2007), and research suffers from methodological problems (as, among other issues, patients assigned to placebo groups are usually first stabilized on drugs that are often abruptly withdrawn when the blinded phase of the study starts; Moncrieff, 1997). As for neuroleptic drugs, Harrow, Jobe, and Faull’s (2012) longitudinal study findings may even suggest that those drugs worsen long-term outcomes in people diagnosed with bipolar disorder and schizophrenia. Who should then judge the often ambiguous indicators and contradicting research findings? Should not the patient—the recipient of the treatment—have the last say? In psychiatry, the assumed (or, in a way, forced) lack of reason in the treated person is used as an excuse to make the decision on their behalf and often against their will, or at least without any real informed consent. The multiversity of the world that is postulated by postmodernism, the lack of definite answers and solutions (especially in the field of health and mental health), and even more so, when it concerns such elusive concepts as wellbeing and phenomena such as subjective psychological states, make the issue even less clear and call for exceptional caution in passing judgments and decisions which may cause real harm to others’ health.

Symbolic and physical violence – The situation in Poland

That being said, in Polish psychiatric practice a patient is most often reduced from a subject to an object of treatment who is not asked for their opinion and is held against their will. Forced treatment is possible in Poland based on the opinion of one psychiatrist and confirmation of this opinion by the head of a psychiatric ward. It can legally last until a court reaches a verdict on the case, but the length of time the court has to reach a verdict is unspecified, therefore it is possible to hold someone in a hospital against his or her will, without a court verdict, for years. Moreover, a person can be forcefully held in a mental institution “for observation” for up to 10 days based on only the opinion of a psychiatrist and confirmation of the head of a ward; even people willingly admitted to a psychiatric hospital may be refused discharge and held virtually forever using the mechanism described above. Importantly, the court may base its verdict on the opinion of the psychiatrist who committed the patient in the first place. Patients can be forcefully medicated (it is legal to use force in order to make somebody unwillingly take medication or be injected). Use of force is allowed when a patient “seriously disrupts the functioning of a unit”; in the absence of a doctor this decision may be taken by a nurse (Dziennik Ustaw Rzeczpospolitej Polskiej, 2017). However, Poland is not unique in this aspect as similar discriminating solutions are present in many Western countries, some of them even more radical in controlling patients and depriving them of core freedoms, even after they have been released from psychiatric institutions (New York Lawyers for the Public Interest, 2005; Szmukler, 2010). Also, decisions regarding treatment in Polish psychiatric practice are usually made behind closed doors without patients’ involvement; sometimes they are not even informed of what kind of medication they are being given and are refused the right to access their medical records, even though such access is theoretically guaranteed by law. This legal situation seems to reflect not only social interest in controlling and isolating people deemed to be potentially dangerous, but also psychiatry’s power in convincing legal powers—or at least providing an excuse—that scientific knowledge proves that forced treatment is the best course of action and that psychiatrists are able to accurately predict violent behavior in people with mental health diagnoses despite evidence suggesting otherwise, even in inpatient units (Chung et al., 2017; Janofsky, Spears, & Neubauer, 1988).

The Polish media regularly publishes distressing stories about unlawful use of force and violence in mental institutions, or even about staff terrorizing patients; the fact that it happens predominantly on youth mental wards is particularly worrying. Recently, a feature describing such a case (in which, among others, a boy was found to be restrained in seclusion for a total of 1,871 hours; Kopińska, 2015) received the European Press Prize (2016). The article also addressed the problem of patients and their relatives not being able to legally pursue their rights due to prosecutors’ indifference, institutional and personal ties between attorneys and doctors, and courts relying on the opinions of doctors acquainted with those charged of wrongdoing. The patients’ testimonies were questioned as unreliable since they were given by people with mental health diagnoses. Also highlighted by the media was the shocking case of Krystian Broll, an engineer who claimed that when he was about to expose corruption in a major investment he was accused of verbal threats and, despite a lack of witnesses and proof, committed to involuntary treatment and then held and medicated against his will in a psychiatric hospital for 8 years (including 2 years in a high-security ward). Only after exposure of his case was he first moved to another unit and then quickly discharged (Garaj, 2015; Pilip, 2015). A report by the Supreme Audit Office revealed that in 83% of controlled psychiatric units even the fairly loose involuntary treatment procedures were not upheld, and there have been numerous cases of the use of force without proper justification and documentation (Najwyższa Izba Kontroli, 2012).

The Polish critical contribution and social context

The symbol and the means for the objectification of a patient is a psychiatric diagnosis. Perhaps the tendency to label others as “ill” is a reflection of some psychiatrists’—to use the language of cognitive psychology—strong need for closure and the fact that diagnosis allows a sense of control to be regained. This phenomenon was described by Polish psychiatrist Antoni Kępiński (1978). He deplored the interview traps (e.g., tricky questions aimed at demonstrating—proving—a patient’s delusions or hallucinations; stereotypical questioning about place and time; derogatory testing of intellectual abilities) deployed by psychiatrists whom he described as “afraid of the unknown.” What is more, for Kępiński this peculiar coping mechanism may be considered to be a form of psychopathology itself. He compared it to obsessive-compulsive behavior and claimed that the act of diagnosis shares similar mental characteristics with delusional thinking—an interesting similarity to Ingleby’s (1980) reflections described earlier. Abstracting from the questions of diagnoses’ ontological status and their “objectivity,” it is also important to note that knowledge of a diagnosis alone narrows clinicians’ (and the patient’s) perspective and may even lead to a self-fulfilling prophecy and self-stigma. That is why in Deissler’s Langenfelder Kooperationsstudienseminar the team facilitating therapy sessions has no information about the identified patient’s formal diagnosis (Wachtel, 2013).

Kępiński, a concentration camp prisoner during World War II, was disturbed by the similarities he noticed between the camp and realities and customs of the psychiatric unit in which he began his work shortly after the war. He strived to change this and introduce as many psychotherapeutic and common life activities in the life of the unit as possible: personal freedom, dancing, and social events were encouraged, while hierarchy was discouraged (Bonowicz, 2012). Kępiński spent most of his life working as a clinician and began writing his most important books only when he was practically no longer able to tend to his patients due to his own ill health (Ryn, 2001).

According to Kępiński (1978), psychiatrists should avoid a narrow scientific stance in their relations with patients in order not to objectify them; he distinguished two types of knowledge which require different methodologies and approaches: natural sciences and humanistic sciences. The first is suited to situations in which an observer (subject) can manipulate an observed object, but the object cannot manipulate the observer; in the second case, these interactions occur in both directions, and acquiring knowledge relies heavily on intuition, empathy, and other elusive factors. An ideal approach for a psychiatrist would be to synthesize these two approaches, whilst also simultaneously treating oneself as an object of observation. These reflections remind one of Dilthey’s (Palmer, 1969) standpoint and resonate well with the ideas of Ingleby, postpsychiatrists, and postmodern psychotherapists. What is important is that Kępiński stresses that psychiatrists must also place themselves under scrutiny as an object of study.

Kępiński (1978) emphasized that psychiatric diagnoses are only conventional or customary tools whose main utility comes down to simplifying and shortening communication between clinicians. No definite predictions or decisions can be made on the basis of a diagnosis: they may only provide a rough description of a set of symptoms, while their etiology and pathogenesis remain unknown and may vary in each case. In clinical practice, empathy, a non-judgmental attitude, authenticity, hope, and the desire to really understand the other should be crucial.

Kępiński was unable to change the biomedical approach already dominant in Poland; his books became popular only after his death and his career was devoted mainly to clinical activities, but he did manage to train and influence the psychiatric community in Kraków (Orwid, 2002). However, even before Kępiński, another psychiatrist, philosopher, and psychologist, Kazimierz Dąbrowski, who was described as an excellent organizer, could have perhaps succeeded in shaping Polish psychiatry in a different way had he not been forced to emigrate in 1962 when the community mental health units he was establishing throughout Poland were closed (Nasierowski, 2005). It is also important to note that despite the fact that Poland had a rich psychotherapeutic and psychoanalytical tradition (Dobroczyński & Dybel, 2016; Marcinów & Dobroczyński, 2010), most psychiatrists did not survive the war as many were executed by the Nazis and the Soviets in organized efforts to exterminate the Polish intellectual elites, and the new generation had to be educated in compliance with dialectical materialism or Marxism-Leninism (Nasierowski, 2005). The majority of the technical, industrial, medical, and scientific infrastructure and written sources were destroyed and only a dozen out of 110 psychiatric institutions survived World War II (Jęczmińska, 2018).

Dąbrowski (1979) was an author of the concept of positive disintegration, which saw mental distress as a way of intensive psychological growth and development through crisis; accordingly, he considered (re)establishment and (re)construction of the patient’s system of hierarchy of values to be a core aspect of therapy. His views are today sometimes called antipsychiatric and—even more radical—comprehensive and earlier than Laing’s (Dziekanowski, 2010).

According to Dąbrowski (1986), average people and psychopaths find themselves on the lowest possible level of psychological development and personality structure. This is termed “primary integration,” and those at this stage are described as unconscious, lacking a hierarchy of values, and influenced primarily by biological and environmental forces. As a hierarchy of values is absent on this level, these people rarely experience inner conflicts over their values or their actions.

Some people, however, possess certain “overexcitabilities” (psychomotor, sensual, imaginational, intellectual, and emotional); on one hand these may facilitate neuroses, but on the other hand neuroses are considered to be the early phases of development. Still, if they are not dealt with accordingly by the individual, they may lead to a serious mental disorder (Dąbrowski, 1979). Eminent and creative adults, as well as gifted students, have a greater abundance of overexcitabilities (Dąbrowski, Kawczak, & Piechowski, 1970). Dąbrowski hypothesized that five levels of personality integration or disintegration can be distinguished; if primary integration is destroyed, three subsequent levels of disintegration have to be overcome in order to reach a multilevel integration, achieved, according to Dąbrowski, by very few people. Serious mental disorders occur at the level of primary integration and the lowest level of disintegration, but Dąbrowski claimed that long-term psychotherapy is usually not necessary and that people may be helped to achieve a sufficiently developed personality structure within a few meetings. Such people will then be able to successfully deal with their problems themselves (Dąbrowski, 2013). Dąbrowski (1979), however, stressed that his levels represent only a heuristic device.

Dąbrowski’s controversial ideas also gained some popularity outside of Poland and are still sometimes mentioned, particularly in the field of the care and development of gifted children. However, some of the most influential figures in Polish psychiatry after World War II were probably Tadeusz Bilikiewicz and his son Adam Bilikiewicz, who edited a handbook of psychiatry which presents a rather narrow, biologically oriented approach (Nasierowski, 2005) and was for decades the most widely used handbook in Poland.

Whereas Dąbrowski and Kępiński developed their ideas largely independently of contemporary Western critical psychiatric thought (even though Dąbrowski spent much of his life abroad and Kępiński studied in Edinburgh), Kazimierz Jankowski was probably the first notable Polish psychiatrist who was directly influenced by the Western antipsychiatric wave of the 1960s and 1970s. Kępiński’s impact on Polish psychiatry, mostly in Kraków, was a side effect of his phenomenologically oriented works and clinical training and activity; however, Jankowski conscientiously set changing the nature and role of psychiatry and psychiatrists in Poland as one of his main goals. Jankowski’s most important book, first published in 1975 and reissued with some new content in 1994, was entitled From Biological to Humanistic Psychiatry; in his own words, it aimed to prove that “psychiatric disorders are a logical consequence of frustrated human needs” (p. 19).

Jankowski studied the impact of hospitalization on patients; he came to the conclusion that an iatrogenic effect arose due to the reduced demands of this monotonous environment, together with deactivation from neuroleptic drugs and the stigmatizing and auto-stigmatizing influence of psychiatric labels. He considered chronic schizophrenia to be caused mainly by people adapting to their role as patients. According to Jankowski, medication could be useful in the initial stages of treatment when the person needs to be calmed down, but recovery requires active effort from the client, and is made difficult by neuroleptics as they increase apathy, indifference, and fatigue. Jankowski’s disillusionment with psychiatry was so deep that for a few years he quit practicing and took a teaching and research post at the University of Warsaw’s psychology department. However, while he ultimately trained several psychotherapists who later became influential in Poland, he was unable to make significant changes to Polish psychiatry and in 1994 admitted that his optimism of 20 years earlier was gone and that things were getting worse (Jankowski, 1975/1994).

The fall of the Iron Curtain and the Polish transition into a free market economy was accompanied by a steep rise in the prevalence of psychiatric disorders, number of inpatients (Heitzman, 2010), and financial cuts to already underfunded services. The biomedical model—now widely promoted by the pharmaceutical companies establishing their branches in Poland—fit well with the neoliberal agenda of the Polish governments and media after 1989, thus allowing those impoverished by the radical economic reforms to be labeled as ill and placing the responsibility for their mental struggles within their own biology. A similar process occurred in the West (Moncrieff, 2008b), but it seems it was even more evident in light of the economic shock-therapy implemented in Poland. Even Kępiński’s ideas were reinterpreted in a biological fashion (Ceklarz, 2018). While prescription of antidepressants and other psychiatric drugs by general practitioners is now considered to be one of the most important causes of overprescribing (B. L. Smith, 2012), an executive board member of the Polish Psychiatric Association published a brief guide on using antidepressants for primary care in which physicians were encouraged to diagnose and treat depression themselves. The article won an award for the most read paper in the general practitioners’ journal in which it was published (Murawiec, 2017). This may be justified by the fact that Poland now has one of the highest suicide rates in Europe: the mental health system is severely underfunded, beds and specialists are lacking, there is virtually no community care, especially outside of major cities, and conditions in many psychiatric units can only be described as appalling (Waszak, 2017).

A contemporary critique of Deissler’s ideas, particularly his reflections on psychiatric language games, was provided by a Polish team of clinicians and researchers working in a closed ward of a university mental hospital once headed by Kępiński (Opoczyńska et al., 2009). The authors concentrate on the assumed dichotomy of monologue about vs. dialogue with the patient in psychiatry. They claim that, instead of speaking about the incongruence of these two discourses, we should think of them as alternating, or even about the simultaneous and parallel existence of psychiatric language games and dialogue. They assert that the existence of closed inpatient wards and the rationale for forced treatment alone make the conflict inevitable and insolvable. In their opinion, the solutions proposed by Deissler, which they call antipsychiatric, mean the problem is dismantled in a way that does not really solve it, but only avoids it, while refusing to actually face it. Instead, they propose that clinicians adopt an attitude of constant critical reflection on their actions and decisions. They frame the conflict between postpsychiatry’s postulates and modernist psychiatry as a conflict between humanitarian values of freedom and self-determination and the Enlightenment’s prioritization of human health and life. This critique, however, seems to perfectly reflect and represent the set of assumptions and practices Deissler actually criticizes.

First, when Opoczyńska et al. (2009) write that clinicians must choose between the values of freedom and health, it is obvious that they ascribe expert knowledge to hospital staff and deprive patients of it, treating them as if they are unable to make decisions and judgments for themselves. This supposed expert knowledge of psychiatrists first allows patients’ freedom to be taken away and then, after careful consideration, gradually given back when it is deemed the patient no longer presents a threat to himself or to others. Infantilized patients become people whose health and safety should be paternalistically controlled by psychiatrists who possess legal power, authority, and an allegedly more objective and more realistic assessment of patients’ mental conditions than all other agents. Psychiatric diagnosis is real as it is precisely this diagnosis that justifies actions to be taken and forced treatment to be given even against the patient’s will. All these conditions, according to Deissler, make dialogue impossible: it cannot take place when one side of a conversation is forced to take part in it against their will, and sincerity (e.g., expressing thoughts classified as symptoms) may lead to even longer deprivation of freedom. Therefore, to claim that dialogue alternates with psychiatric language games seems to be a misunderstanding of Deissler’s concept. Moreover, it seems that when Deissler proposes methods of dissolving psychiatric language games, he is not saying that they will cease to exist as they are an inevitable part of the social construction of the sense, meaning, and reality of a psychiatric institution (and other institutions with their own language games); what he proposes is a radical transformation of the set of beliefs governing these games, while Opoczyńska et al. (2009) seem to propose in good faith that from time to time clinicians could for a while pretend and act as if they did not exist.

Concluding remarks

One of the key arguments against postpsychiatry—if not the only serious one—calls on the idea of the allegedly well-established biopsychosocial model, which, according to the critics, already sufficiently answers most, if not all, of the demands and propositions of postpsychiatry. If anything is wrong, it can be solved by better training or by being more attentive. According to this view, the main problem of contemporary psychiatry is its underfunding. “We ask for bread and you offer us postmodernism” as Bagley (2001, p. 450) puts it. Though underfunding of mental health care is definitely a major issue in Poland and many other countries, it is doubtful that only increasing the amount of funds available will solve problems such as the scandalous treatment of patients mentioned earlier. In order to improve relations between patients and clinicians (or to gain or restore their trust) and thus improve treatment outcomes and adherence, a fundamental change of mentality is required; this also means a deconstruction and reconstruction of the philosophical, ethical, medical, and even legal assumptions and principles behind the questions of mental disorders and the practice of psychiatry. It seems that despite the fact that in the Polish press and at scientific conferences some psychiatrists present and seemingly support progressive ideas such as those of postpsychiatry, psychiatric practice resists any real changes. Also, many clinicians, even Polish ones (e.g., de Barbaro, 2007), argue that the biopsychosocial model is mostly a theoretical entity, while psychiatric practice is almost solely focused on the biological level. This attitude is so prevalent that some researchers speak about the “bio-bio-bio model of psychosis” (e.g., Read, Bentall, & Fosse, 2009). Read, Mosher, and Bentall (2004) insist that the integration and balance of different approaches and levels of understanding and intervention in the biopsychosocial model is in fact a myth sustained from the 1970s. They argue that the core element of the biopsychosocial model is the “stress-vulnerability” concept, which treats environmental factors and life events merely as triggers of underlying genetic disorders. According to these authors we should be speaking about the “colonization” of the biopsychosocial model by biologism, rather than about the integration and balance of these models. This colonization is so strong that the research and the compelling evidence of the importance of contextual factors in the etiology of mental disorders is often overlooked and almost completely ignored. Training and workshops for patients and their families that, according to authors, led to the “invention of the euphemism ‘psychoeducation’ are in fact more evidence of the domination of the biological model, as the image of mental illness they promote is that of a chronic disease whose origin is biological. All this, while models of treatment based on an understanding of mental problems similar to that proposed by postpsychiatry and postmodern psychotherapy provide treatment results at least comparable and sometimes superior to traditional approaches that emphasize or limit themselves to biological treatments. These models, such as Finnish Open Dialogue and Soteria houses, or even Cognitive-Behavioral Therapy, promote dialogism and systemic therapeutic interventions and strive to reduce or even completely avoid pharmacotherapy (e.g., Calton, Ferriter, Huband, & Spandler, 2008; Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012; Seikkula et al., 2006).

It seems that the emphasis of traditional psychiatry on biological underpinnings and causes of mental distress may contribute to incidents of violent and inhuman treatment of mental health patients. Speerforck, Schomerus, Pruess, and Angermeyer (2014) have shown that—despite the hopes of many mental health awareness and anti-stigma campaigns, which usually present mental health problems as mainly medical and biological issues—this biological kind of framing of mental illnesses may create more stigma than conceptualizing them as reactions to adverse life events. It is possible that perceiving a person labeled mentally ill as someone with an inborn biological flaw—someone constitutionally different—makes dehumanizing and inhuman treatment easier to rationalize as affecting someone perceived to be worse, faulty, and in a way not fully human. Diagnostic classifications such as the ICD and DSM seem to reinforce this phenomenon as they are based on Kraepelin’s nosology, which is in turn based on and inspired by the methodology of Linnaeus’ taxonomy. Instead, it seems that the kind of framing of mental distress proposed by Dąbrowski, Kępiński, and Jankowski may have an empowering value for those suffering and may also lead to them being perceived not as “faulty sub-human machines” who can be mistreated, but as talented and valuable human beings in crisis, and with the potential to flourish. A recent review suggests that psychosocial explanations may indeed reduce stigma (Longdon & Read, 2017).

Although Dąbrowski and Kępiński were held in high regard during their lives, and Kępiński especially is still presented as a model psychiatrist (his works are still read by psychiatry and psychology students in Poland), little in contemporary practice reflects their ideas and attitude. Nevertheless, one example of a systemic solution that invokes this tradition and seems close to postpsychiatry’s ideals is the Integrated and Complex Program of Treatment and Rehabilitation run by the Department of Psychiatry of Jagiellonian University Collegium Medicum in Kraków, which Kępiński headed for many years. The program theoretically draws from social constructionist approaches such as Deissler’s and puts a strong emphasis on the social aspect of recovery. However, in practice, it seems that outpatient units (which are a key part of the initiative) operate within the system that is entrenched in the traditional psychiatric context or doxa—in Bourdieu’s (1990) meaning of the term—and everyday activities and customs do not differ much from those in regular hospital wards (e.g., patients have to ask for permission to leave the building, have to take part in compulsory “therapeutic” activities organized by the staff, cannot refuse to take medication, etc.). In practice, it seems that the only real difference between these outpatient and inpatient units is the fact that patients of the former may go home at the end of the day.

It looks as if core aspects of Kępiński’s, Dąbrowski’s, and Jankowki’s legacies have been forgotten and the biomedical model—even if in the guise of a biopsychosocial model—dominates the Polish psychiatric landscape. Currently, there are plans to increase funding and expand community services in Poland (Sulikowska, 2018); however, these plans, which were first officially announced almost 10 years ago, failed and the situation actually worsened (Najwyższa Izba Kontroli, 2017). It is also dubious whether the situation in Poland will be greatly improved by a system of care that resembles and is based on the same underlying assumptions of the one heavily criticized and evidently failing in terms of outcomes in the West, even if successfully implemented.

As Thomas (2016) recently wrote, 15 years after the original paper presenting postpsychiatry, things continue to worsen despite the pretense of political good faith and the rhetoric and fine words of leaders and opinion makers of professional organizations. He claims that in the context of recent political, societal, and institutional changes, the agenda of postpsychiatry—the centrality of contexts, ethics before technology, rethinking the politics of coercion—seems more important now than ever before, but it is naive to think that only writing critically about the world would change it. This opinion seems to be echoed by Peter Kinderman (2017) in his blog post summarizing his British Psychological Society presidency, and it sounds true also in the Polish context. Though Polish psychiatry and psychotherapy were largely separated from Western discourse for most of the 20th century, they have produced critical approaches similar to postpsychiatry and postmodern psychotherapy and, today, face similar problems.