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"Critical psychiatry" is the name given to a body of ideas which, while critical of the conceptual foundations of psychiatry and its claim to authority in matters of madness, nevertheless sees a place for the continued existence of something like psychiatry, albeit very different in its approach. The Critical Psychiatry Network in the UK serves as a focus for debate, discussion, lobbying and publication. The editor of this volume, Duncan Double, is a psychiatrist whose name is synonymous with critical psychiatry. Members of the critical psychiatry network have published numerous conceptual analyses, as well as papers critical of the practices of psychiatry, and on public policy issues related to mental health. To my knowledge this is the first book specifically on critical psychiatry, although one of the contributors published a book by that name over two decades ago. There is also Bracken and Thomas's 2005 Postpsychiatry. Mental health in a postmodern world.
Since the height of the "anti-psychiatry" movement in the 1960s and 70s, psychiatry has retrenched into a new biological reductionism armed, if not with a new array of biological investigative tests, at least with a new language with which to claim its place in the pantheon of medical specialisms. It is not too much of a stretch to characterize the biological psychiatry of the early 21st century as a new discourse, a system of practices that, in Foucault's terms, "constructs the objects of which it speaks". But if critical psychiatry is still psychiatry, what are its values, its theoretical commitments, its philosophy and its practices? These are questions that Duncan Double attempts to answer in this collection of twelve readings, many from familiar figures in the critical psychiatry literature.
The book begins with an historical overview by Double. From the coining of the term "antipsychiatry" by David Cooper in 1967, this movement was defined more by its critics than by theorists working on a coherent project. Double reviews the work of Laing and Szasz, pointing out that both rejected the term "antipsychiatry", that the two were entrenched critics of each other's ideas, and that they shared a view, arrived at by different reasoning, of the invalidity of psychopathaology. Double points out that "antipsychiatry" remains a term of disparagement; a convenient label for inconvenient views. Cooper is described as a zealous fanatic, and the description is hard to resist given Double's characterization of Cooper's thought.
Much is made in literature critical of psychiatry, of the failure of psychiatry to produce a definitive "test" for disorders such schizophrenia. This is one of Thomas Szasz's foundational arguments. Such criticism misses the point in a number of respects. Firstly, such a test would not resolve the fundamental problem of meaning posed by madness any more than a biological marker of poetry writing would explain the meaning of poetry. Secondly, this argument suggests that the idea of a definitive test is itself coherent. In response to biologist ideologues, critics would be better to adopt the position of opponents of "string theory": "not even wrong". As Double states in relation to Szasz, criticisms that point to the absence of a definitive test are themselves immersed in the same positivist paradigm as those they argue against: for them it is at least plausible that the answer to the question of madness is ultimately biological.
With the historical foundations of critical psychiatry in place, John Heaton provides a philosophical analysis in chapter three. He identifies a methodological link between sceptical philosophers such as Socrates, Kant and Wittgenstein, and critical psychiatry, and introduces important arguments about positive and negative freedom. Heaton discusses the "two natures" of human beings; the natural and the meaning-making. Confusing one with the other has led to a positivist psychiatry, one which subjugates personhood to biochemical processes. Arguing against Freud, Heaton draws on Wittgenstein, especially the Tractatus, to advocate a psychology of persons, not the disembodied constructs of psychoanalysis. Cognitive therapy, currently the darling of mental health services, is also critiqued for its commitments to causal processes rather than meaning. These views place Heaton in conflict with others within the critical psychiatry tradition, who advocate the use of psychological and psychoanalytical interventions. Heaton also draws on Nietzsche's concept of genealogy to show how the culturally embedded nature of psychiatry is at odds with much of its objectivist thinking. He characterizes of psychiatrists and psychoanlaysts as speaking in a private language, of constructs incapable of verification, leaving little room for theory. Heaton advocates for philosophically based intervention, although it is not immediately clear that such intervention would necessarily avoid the hubris of practitioners, unequal power relationships, or exploitation of clients. It is not even clear that the approach Heaton advocates is, as he claims, atheoretical.
David Ingleby's chapter takes up the challenge of beginning to articulate what critical psychiatry is. This is an engaging chapter which follows Ingleby's career and its intersections with the waxing and waning of critical ideas in mental health. It takes some time for Ingleby to come to the point of the chapter: transcultural psychiatry, but his description of the rise in the 60s and 70s of social criticism, followed by its decline under the New Right, and its impact on his own work, is compelling. Ingleby was himself an immigrant, almost an exile, having moved from England to Holland in 1982 after being professionally ostracized by the psychiatric establishment for his unorthodox views. As he describes it, Ingleby was also a refugee from the neo conservativism of Thatcher's Britain. Exploring the nature of critical psychiatry, Ingleby provides a classical contrast between positivist and interpretive practices, aptly illustrated in his account of Littlemore Hospital. He describes two wards, imaginatively named 'A' and 'B', side by side, one practicing neo-Kraepelinian diagnostic psychiatry, the other Maxwell Jones' therapeutic community principles. These wards may have been poles apart, but for Ingleby, critical psychiatry is not a matter of choosing between positivist and interpretive paradigms:
Critical psychiatry, therefore, does not regard mental illness as a 'myth'; rather, it insists that an emphasis on biological determinants must never blind us to the possible human sense of people's behaviour and experience" (p. 67).
Ingleby discusses transcultural mental health care in the context of colonization and globalization, pointing out the proliferation of mental health services offered to individuals. This effectively individualizes societal and community problems.
I found Lucy Johnstone's chapter on the limits of biomedical models of distress a little disappointing. Johnstone draws on a number of different sources to show how the uncritical biological theorising that underpins much of the public discussion about mental illness. There are powerful arguments that can be mounted against a narrow biomedical model, although as noted above, Ingleby makes some allowance for "biological determinants". But some of Johnstone's arguments seem scientifically naïve. For example:
"Neurotransmitters are in a constant state of flux and change as the body seeks to regulate its functions (a process known as homeostasis); they do not get knocked out of balance at some arbitrary level….a perfect state of balance would be death" (p.87-8).
Just how that statement is intended to argue against biochemical causation is not at all clear. This is not to argue for biochemical causation, it is only to point out that not every argument against it is successful. Also, it is not correct to imply that homeostatic mechanisms cannot be "knocked out of balance". That is precisely what happens in dehydration, heat stroke, shock and neuroleptic malignant syndrome and the like. Johnstone is quite correct to state that complex processes resulting from trauma or detrimental early experiences can influence brain functioning. It would be surprising if they did not. But it is not clear how these influences are different in kind to neurotransmitters getting "knocked out of balance". Influences on brain functioning are not limited to those that support a particular worldview.
The comparison of mental illness with physical illness has been discussed previously in this review, but another comment is in order here. Johnstone makes the point that the concept of mental illnesses is fundamentally flawed, and so can never give rise to a valid set of categories, let alone a valid science. In making this argument, and it is one frequently made in critiques of psychiatry, Johnstone invokes a model of medicine which is at odds with how medicine is practised. Doctors are not scientists, they are health practitioners. They do not treat diseases, they treat people. Even in cases where diseases can clearly be demonstrated the doctor does not act as a scientist, but as a health practitioner responding to an expressed need, not simply to a disease state. There are plenty of cases, especially in primary care, where no pathology can be demonstrated, but doctors still feel an obligation to treat. Sometimes (but not always) they would be better not to, but that is another matter. The social construction of diseases is shown in the naming of new diseases (obesity, hyperlipidaemia) which are a response to social and political influences as much as scientific ones. If medicine is best understood as a practical human science rather than a pure science, much of this sort of critique of psychiatry is defused. Johnstone is on firmer ground in her discussion of how narrow biological explanations have supplanted alternatives in much mainstream psychiatric discourse. But conceding that there might be more conceptual similarity between psychiatry and the rest of medicine than Johnstone's analysis allows need not place us on the slippery slope to biological reductionism.
Terry Lynch writes about the increasing tendency of doctors, both specialist psychiatrists and general practitioners, to prescribe antidepressants. Most western countries now have "depression initiatives", and a core component of these initiatives is medical treatment with drugs. The World Health Organisation talks of a "global burden of disease" arising from the increasing prevalence of depression. It is no coincidence that this increasing prevalence occurs at the same time as an increasing prevalence of prevalence surveys. While I found myself in sympathy with Lynch's concern at this increasing medicalization of ordinary life, I found his analysis overwrought. Yes, there are those, perhaps many, doctors and other health professionals who describe low mood and depression using a fairly thoughtless analaogy with diseases like diabetes. But given the speciousness of such an argument it can be dealt with quickly; it doesn't need pages of discussion. It's rather like heaping more straw on the straw man to make sure it will burn. This chapter lacked a focus on its title of "Understanding Psychiatry's Resistance to Change". I was hoping to read, perhaps, of the marketing strategies of pharmaceutical companies, of the educational practices of medical schools, or the role of specialty colleges in maintaining biomedical hegemony. The best parts of this chapter were Lynch's descriptions of working with people carrying the diagnostic labels of psychiatry, helping them come off psychotropic medications, and helping them develop a more coherent and meaningful narrative about their experiences.
Joanna Moncrieff's contribution on the politics of psychiatric drug treatment is both sober and sobering. Despite the increasing number of national depression initiatives, the evidence for effectiveness of common pharmacological treatments is modest at best. Moncrieff, who has published numerous studies on this topic marshalls an impressive array of evidence in support of her contention that social influences have contributed to the increasing popularity of psychotropic medications, antidepressants in particular. Moncrieff locates this development within a general shift towards the redefinition of social problems as technical, especially medical problems. This, she argues, extends to proposed extensions of compulsory powers into the community.
Shulamit Ramon's contribution is an interesting case study of how the psychosocial orientation of social workers has been appropriated by organised psychiatry, and to some extent by social workers' own aspirations for professional status. The establishment of the "Approved Social Worker" role in the 1983 UK mental health legislation gave social workers a role in mediating psychiatric decision making in civil commitment, and in advocating a psychosocial perspective in this aspect of mental health care. Judging from Ramon's account, this legal status has proved to be something of poisoned chalice, meeting the professional aspirations of the discipline, but at the expense of the independence to fully engage in psychosocial initiatives. Changes to the English legislation will see social workers lose their exclusive advocacy role in civil commitment. Ramon has concerns about whether other disciplines, such as nursing, are adequately prepared to assume this role. More positively, freed from their legislative role, social workers may have an opportunity to refocus on psychosocial care.
The next two chapters return to the historical roots of modern psychiatry. Pat Bracken and Philip Thomas offer a model of "postpsychiatry", underpinned by postmodern concepts of democracy and citizenship. Postpsychiatry proposes a more overtly political agenda than critical psychiatry, although this is really a matter of emphasis rather than philosophical difference. Context is primary in postpsychiatry. Individualistic frameworks and medicalization are rejected. Bracken and Thomas argue for a separation of issues of care and treatment from the process of coercion. Many of their arguments are covered by Double and other contributors, but the issue of coercion deserves mention because, along with the conceptual challenges presented by Szasz's critique, legal coercion remains a fundamental problem for psychiatry.
Bracken and Thomas offer a limited analysis of this difficult issue. There is an acceptance that there are instances when "society" can justifiably "remove a person's liberty on account of mental disorder". The problem is that "society" cannot do that: it must authorize agents to act on its behalf. As an alternative to medical control of legal coercion Bracken and Thomas offer the alternative that doctors and others should be able to apply for detention, but not make the final decision. There are many examples where this model is institutionalized in law, but they have not resolved the problematic association of medical care with coercion. As Paul Appelbaum has showed in the United States, initial legal restraint on clinical decision making gave way to medical paternalism as courts were persuaded to accept medical testimony over legal arguments based on autonomy. The recent (2003) Scottish legislation on community treatment orders appears to be something of a model in terms of the protections provided. In addition to a set of guiding principles, the legislation contains a test of competence, judicial rather than clinical decision making, and the notion of reciprocity. Time will tell whether the Scottish ideals are achieved in practice.
Critical psychiatry's concern about legal coercion has been fuelled by the initial extremes of the proposed changes to legislation in England and Wales. The idea of preventative psychiatric detention of people with "severe personality disorder" has been dropped, but reservations arising from the overt political agenda of social control have remained. Duncan Double tells us in this book that the Critical Psychiatry network withdrew from the Mental Health Alliance in order to reserve its position on the new legislation. Much of the international debate about community treatment orders overlooks the current practice of "supervised discharge", a legal regime with most of the features of community treatment orders. It is rather a moot point whether a community treatment order is necessarily more coercive. Early indications from Scotland are that patients under the newly introduced community orders feel that the mandatory protections of the regime provide greater transparency and a greater sense of fairness than was the case in the previous leave of absence provisions. Critical psychiatry may not be reassured by such findings, but they seem to provide something of a way forward, given Bracken and Thomas's qualified support for some process of detention on grounds of mental disorder.
Critical psychiatry is clearly in need of an explanatory theory if it is to move beyond criticism to a positive model of madness. For this task Duncan Double turns not to the postmodernity advocated by Bracken and Thomas, but to the ideas of Adolph Meyer. Double's review of "the Meyerian legacy" is a timely reminder of a time when a psychiatrist could still respectably talk about psychological explanations of mental disorder, and not simply as an "alternative" to biology. Like many psychiatrists of his time, Meyer was a neurologist, and understood that neurological processes played a part in the manifestations of mental disorder. Yet Meyer was not a reductionist, like some of the modern day proponents of biological explanations. He was opposed to Kraepelin's bright line distinctions between mental disorders, and although he accepted psychoanalytical concepts, he was skeptical of Freud's overdetermined views of mental phenomena. Meyer was something of an eclectic theorist, ready to explore ideas he fundamentally disagreed with. His own "biopsychology" was less an attempt to provide a unifying theory, than an expression of his commitment to multiple explanations. Such an approach has obvious attraction to critical psychiatry. Double is well aware of Meyer's personal foibles, most notably his failure to respond to the blind biologism and unethical practice of his protégée Henry Cotton. This shameful affair has been incisively exposed by Andrew Scull, and Double acknowledges the palpable shortcomings of Meyer's handling of Cotton.
The growth of child psychiatry is discussed by Sami Timimi who, while following the critical pathway established by Double and others, introduces a more explicit analysis of the role of culture in constructing ideas of mental disorder, especially as they relate to children. Much of this chapter is given to a social history of childhood in Britain, with Timimi concluding that western children are at risk of exploitation while their parents are badgered by professionals to measure up to official standards of parenting. Children manifesting the stress from these twin pressures are diagnosed with mental disorder: the individual bearers of dual social tension. Timimi's is a wide ranging analysis which explores the expansion of pharmaceuticals in childhood problems, and questions the validity of the much diagnosed ADHD and more recently "childhood depression". In part this chapter critiques western child psychiatry and western views of childhood by comparing with non-western understandings of childhood; it is also and internal critique of western psychiatry on its own terms.
By this stage of the book I was still wondering, what is critical psychiatry? It is not that the book to this point did not address critical psychiatry; the themes of skepticism, contextualization and resistance to biological reductionism run through all of the chapters. But does this all come together in something approaching a theory? The answer seems to be "not yet." Double starts to answer this question by giving three meanings to the word "critical". They are: critical thinking, the careful application of reasoning to problems, which Double links to Dewey's ideas on reflective practice, "critical theory", which in a brief treatment includes theorists (such Foucault) whose ideas are critical of psychiatry as well as those such as Marcuse whose work is associated with the schools of critical theory; and finally the social practice of the Critical Psychiatry Network.
When it comes to outlining the key issues for critical psychiatry, I suspect that there is little here that a careful, reflective, socially conscious practitioner would take issues with, at least in principle. There are two key issues. One is that neurobiology is too narrow to account for mental disorder, the other is the importance accorded to ethical awareness in clinical practice.
Following this discussion Double returns to his most familiar territory, critique of biological psychiatry. He cites three examples of psychiatrists with differing degrees of commitment to the biological model. E Fuller Torrey will need little introduction to readers of this review. A number of his books have been reviewed on this site. Among advocates of the neurobiological model of mental illness, Torrey holds perhaps the most doctrinaire view of all. The other examples are Anthony Clare, and Julian Leff. Double's criticisms of Leff are interesting, given that (as Double acknowledges) Leff has undertaken considerable research on social issues in mental illness and has most recently published (with Richard Warner) a book on social inclusion for people with mental illness. Double criticises Leff's views on the neurobiology of mental illness, but allows that Leff "has more interest in the social perspective than most psychiatrists". That's really something of an understatement, and illustrates a problem for critical psychiatry. If critical psychiatry is going to change the way mental health services are provided, it will need to work with practitioners such as Leff, while agreeing to disagree about some fundamental views. No doubt Double and others of the critical psychiatry network are cautious of this approach, remembering Adolph Meyer's end of career doubts about whether he had been assertive enough about his psychobiological theory.
Currently, it seems that critical psychiatry is negatively defined; that is, by its critical stance towards the dominant biomedical psychiatric enterprise. Given the political dominance of biomedical psychiatry this is not surprising; it is probably necessary, meaning that critical psychiatry is a social movement, rather than a theoretical model.
A common response to such a critical work is to concede that some valid points have been made and, if nothing else, at least the book makes the reader think. Critical Psychiatry. The Limits of Madness does more than that. It begins the difficult process of deconstructing a social and political enterprise, and of rebuilding an alternative. There is a certain amount of repetition as a number of authors rehearse the arguments against biological understandings of mental distress. The book might have more appropriately been subtitled Limits to Medical Psychiatry, as chapter after chapter explores the shortcomings of the current medical model. Something I found a little puzzling was the use by more than one author of the descriptor "schizophrenic". This was at odds with the otherwise person centered tenor of the book. A future edition could also include a contribution from service users.
It seems churlish to criticize a book which overall does a fine job of critiquing the dominant model of psychiatry, both conceptually and empirically, but I would like to have seen more focus on alternatives. Terry Lynch's chapter perhaps suggested some of the possibilities of psychiatry devolving from a medical specialty to part of primary care practice. The UK has seen a number of mental health in primary care initiatives, although they have had mixed success. But if the medicalization of human distress is to be rolled back, primary care practitioners are going to play an important part in that.
Reviewing this book is made easier by the omission of any contribution from my own discipline, mental health nursing. Many of the criticisms of psychiatry can equally be directed at the discipline of nursing, with the exception, perhaps, of administrative dominance. This is not to say that nurses have been silent on the issues raised by critical psychiatry. Phil Barker, for example, has been a vocal critic of biological psychiatry, and of the institutional practices of mental health services. Barker's ideas are difficult to summarize theoretically, and in some respects he is conceptually, if not philosophically close to Szasz. He has developed an alternative, narrative based, model of the practice of nursing, which reflects many of the concerns articulated by critical psychiatry. In addition, a number of other nurses have provided critique of the medicalization of human problems. If critical psychiatry is to become a force in mental health care in the United Kingdom it will need to develop its alliance with nurses, and there seem to be plenty sympathetic to its ideals.
For critical psychiatry to avoid the excesses of antipsychiatry, it will need to occupy a position between antipsychiatry's total rejection of the notion of mental illness, and the currently dominant medical model. This book makes it clear that Double and others are well aware of the need to stake out this middle ground. Critical psychiatry cannot be disinterested; it is clearly founded on a positive commitments to humanistic, liberal ideals, as well opposition to conceptually flawed theories and oppressive practices. Association with coercion will not go away, but neither can it be accepted as inevitable. In any area of health care or social practice there is a balancing of interests, at the individual, social and political levels. If there is anything to be learned from the narrowly medical model that currently dominates societal response to madness it is that certainty in psychiatry is bought at the price of oversimplifying complex human problems.
© 2007 Tony O'Brien
Tony O'Brien RN, MPhil, Senior Lecturer, Mental Health Nursing, University of Auckland, a.ob[email protected]
Duncan Double sent the following response to Tony O'Brien's review, published May 31, 2007.
I am grateful for Tony O'Brien's attentive interest to my edited book and his appreciation that it is more than a critique of the biomedical model of psychiatry. I think it is important to be cautious about potentially undermining a critique by suggesting it does not provide enough of an alternative, in case this argument is used to buttress what is being critiqued. For example, it is commonly suggested that there is no alternative to justify prescribing psychotropic medication. Of course, part of the reason that the biomedical model has so much support is because it at least gives the semblance of "doing something". I agree, however, that more needs to be done politically to deconstruct the dominance of biomedical psychiatry. Perhaps Tony O'Brien and others can help us do this.
© 2007 Duncan Double