Critical psychiatry

The Critical Psychiatry Network is a group of British psychiatrists who first met in Bradford, England in January 1999. Most people associated with the group are practicing consultant psychiatrists in the United Kingdom National Health Service (NHS). A number of non-consultant grade and trainee psychiatrists are also involved with the network.

The first meeting came about in response to proposals by the British government to amend the 1983 Mental Health Act (MHA). There was concern within and without the profession about the implications of the proposed changes for human rights and the civil liberties of people who use mental health services. Initially known as the Bradford Group it adopted the name Critical Psychiatry Network to reflect views within the group. Since its first meeting, the group has met twice a year - in London in March, and in the North of England (usually Sheffield) in September. It has developed a number of ideas that are fundamental to Critical Psychiatry and the network is open to any sympathetic psychiatrist.

The network is primarily intended for psychiatrists and psychiatric trainees and is not open to other groups. It works closely with service users/survivors, carers, and other professional groups in areas of common concern. CPN also has international links with like-minded psychiatrists in other countries.

Key issues

CPN is concerned with a number of issues, including the problem of coercion and the role of psychiatry in social control, the role of biological science in psychiatry, and the implications of the decontextualisation of experience in psychiatry.

Coercion and social control

CPN recognises that the practice of psychiatry in Britain involves a delicate balance between respecting individual rights and freedoms, and the need to protect other people. The publication of the British Government’s green paper containing proposals to amend the 1983 MHA raised serious concerns within the CPN that the balance would shift too far in the direction of public protection, thus emphasizing the social control function of psychiatry. The green paper contained two proposals that raised particular concern for members of CPN. One involved the introduction of new legislation to enable psychiatrists to detain indefinitely people with so-called dangerously severe personality disorders (DSPD), even though they had not committed or been convicted of an offence.

The other involved the introduction of community treatment orders (CTOs) to make it possible to treat people against their wishes in the community. CPN submitted evidence to the Scoping Group set up by the government under Professor Genevra Richardson.^[1] This set out ethical and practical objections to CTOs, and ethical and human rights objections to the idea of reviewable detention. It was also critical of the concept of personality disorder as a diagnosis in psychiatry. In addition, CPN’s evidence called for the use of advance statements, crisis cards and a statutory right to independent advocacy as ways of helping to sustain autonomy at times of crisis. CPN also responded to government consultation on the proposed amendment,^[2] and the white paper.^[3]

The concern about these proposals caused a number of organizations to come together under the umbrella of the Mental Health Alliance^[4] to campaign in support of the protection of patients’ and carers’ rights, and to minimise coercion. CPN joined the Alliance’s campaign, but resigned in 2005 when it became clear that the Alliance would accept those aspects of the House of Commons Scrutiny Committee’s report that would result in the introduction of CTOs.^[5] Psychiatrists not identified with CPN shared the Network’s concern about the more coercive aspects of the government’s proposals, so CPN carried out a questionnaire survey of over two and a half thousand (2,500) consultant psychiatrists working in England seeking their views of the proposed changes. The responses (a response rate of 46%) indicated widespread concern in the profession about reviewable detention.^[6] and CTOs^[7]

The role of scientific knowledge in psychiatry

There is a general concern in CPN about the dominant role played by biological science in contemporary psychiatry. It is concerned with two aspects of the use of science in psychiatry. One relates to the improper use of scientific evidence by the pharmaceutical industry and those psychiatrists with links to it. The other concerns the limitations of biological science in understanding distress and madness.

There is a strong view by CPN that contemporary psychiatry relies too much on the medical model, and attaches too much importance to a narrow biomedical view of diagnosis.^[8] This can, in part, be understood as the response of an earlier generation of psychiatrists to the challenge of what has been called ‘anti-psychiatry’. Psychiatrists such as David Cooper, R.D Laing and Thomas Szasz (although the latter two rejected the term) were identified as part of a movement against psychiatry in the 1960s and 70s. Stung by these attacks, as well as accusations that in any case psychiatrists could not even agree who was and who was not mentally ill,^[9] academic psychiatrists responded by stressing the biological and scientific basis of psychiatry through strenuous efforts to improve the reliability of psychiatric diagnosis based in a return to the traditions of one of the founding fathers of the profession, Emil Kraepelin.^[10] This signalled the rise of what has been called neo-Kraepelinianism as evident in DSM-III and DSM-IV.

The use of standardized diagnostic criteria and checklists may have improved the reliability of psychiatric diagnosis, but the problem of its validity remains. The investment of huge sums of money in Britain, America and Europe over the last half-century has failed to reveal a single, replicable difference between a person with a diagnosis of schizophrenia and someone who does not have the diagnosis.^[11][12][13] The case for the biological basis of common psychiatric disorders such as depression has also been greatly over-stated.^[14] This has a number of consequences:

First, the aggrandisement of biological research creates a false impression both inside and outside the profession of the credibility of the evidence used to justify drug treatments for disorders such as depression and schizophrenia. Reading clinical practice guidelines for the treatment of depression, for example, such as that produced for the UK National Health Service by the National Institute for Health and Clinical Excellence (NICE), one might be fooled into believing that the evidence for the efficacy of selective serotonin reuptake inhibitors (SSRIs) is established beyond question. In reality this is not the case, as re-examinations of drug trial data in meta-analyses, especially where unpublished data are included (publication bias means that researchers and drug companies do not publish negative findings for obvious commercial reasons), have revealed that most of the benefits seen in active treatment groups are also seen in the placebo groups.^[15][16][17] NICE itself says that the difference between antidepressant medication and placebo is not clinically significant, yet continues to recommend them.

As far as schizophrenia is concerned, neuroleptic drugs may have some short-term effects, but it is not the case that these drugs possess specific ‘anti-psychotic’ properties, and it is impossible to assess whether or not they confer advantages in long-term management of psychoses because of the severe disturbances that occur when people on long-term active treatment are withdrawn to placebos. These disturbances are traditionally interpreted as a ‘relapse’ of schizophrenia when in fact there are several possible interpretations for the phenomenon^[18].

Another consequence of the domination of psychiatry by biological science is that the importance of contexts in understanding distress and madness is played down^[19][20]. This has a number of consequences. First, it obscures the true nature of what in fact are extremely complex problems. For example, if we consider depression to be a biological disorder remediable through the use of antidepressant tablets, then we may be excused from having to delve into the tragic circumstances that so often lie at the heart the experience. This is so in adults and children ^[21]. To disregard the reality of suffering in this way is ethically unacceptable both for critical psychiatrists and many patients, who reject the idea that their experiences are to be explained in terms of psychiatric symptoms, and putative biochemical disturbances.

Meaning and experience in psychiatry

There is a common theme, here, with the work of David Ingleby whose chapter in Critical Psychiatry: The Politics of Mental Health ^[22] sets out a detailed critique of positivism (the view that epistemology, or knowledge about the world is best served by empiricism and the scientific method rather than metaphysics). A common theme running through Laingian antipsychiatry, Ingleby’s critical psychiatry, contemporary critical psychiatry and postpsychiatry is the view that social, political and cultural realities play a vital role in helping us to understand the suffering and experience of madness. Like Laing, Ingleby stressed the importance of hermeneutics and interpretation in inquiries about the meaning of experience in psychiatry, and (like Laing) he drew on psychoanalysis as an interpretative aid, but his work was also heavily influenced by the critical theory of the Frankfurt School ^[23].

Both critical and post psychiatry are concerned with the way in which interest in hermeneutics has waned in late twentieth century psychiatry. There is within critical psychiatry a variety of views about the relevance of psychoanalysis. One strand of thought is that psychoanalysis itself does not possess any special knowledge of the mind; others value the hermeneutic role of psychoanalytic theory, if not practice, as a way of taking social and cultural factors into account in understanding experience. There are many factors responsible for the waning of interest in hermeneutics in mainstream psychiatry, including the ascendancy of clinical neuroscience, the preoccupation with an increasingly narrow, ‘neo-Kraepelinian’ view of diagnosis, and the waning influence of psychodynamic and other forms of insight-orientated psychotherapy. In addition, there is a long-established tradition in clinical psychiatry that sees limits in the extent to which it is possible to understand experience in schizophrenia. In part this may be traced back to the work of the German psychiatrist and philosopher, Karl Jaspers, and his interpretation of Edmund Husserl’s phenomenology.
Jaspers’ work was enormously influential in twentieth century psychiatry. His view of phenomenology is one that dwells on the ‘form’ of experience rather than its content, and thus separates it from the contexts that help to render experience meaningful. Thus it has been argued that the ‘un-understandability’ of some psychotic experiences primarily relates to the way in which psychiatrists, informed by Jaspers, approach experience . If we regard phenomenology as a ‘rigorous science’ of human experience as did Jaspers, and focus on the form of experience, then it will be inevitable that meaning and understandability will be of lesser consequence.

The most forceful critic of this view was R. D. Laing, who famously attacked the approach enshrined by Jaspers’ and Kraepelin’s work in chapter two of The Divided Self ^[24], proposing instead an existential-phenomenological basis for understanding psychosis. Laing always insisted that schizophrenia is more understandable than is commonly supposed. Mainstream psychiatry has never accepted Laing’s ideas, but many in CPN regard The Divided Self as central to twentieth century psychiatry. Laing’s influence continued in America through the work of the late Loren Mosher, who worked at the Tavistock Clinic in the mid 1960s, when he also spent time in Kingsley Hall witnessing Laing’s work. Shortly after his return to the USA, Loren Mosher ^[25] was appointed Director of Schizophrenia Research at the National Institute of Mental Health, and also the founding editor of the journal Schizophrenia Bulletin.

One of his most notable contributions to this area was setting up and evaluating the first Soteria House, an environment modeled on Kingsley Hall in which people experiencing acute psychoses could be helped with minimal drug use and a form of interpersonal phenomenology influenced by Heidegger. He also conducted evaluation studies of the effectiveness of Soteria ^[26]. A recent systematic review of the Soteria model found that it achieved as good, and in some areas, better, clinical outcomes with much lower levels of medication (Soteria House was not anti-medication) than conventional approaches to drug treatment ^[27].

Critical Psychiatry and Postpsychiatry

Peter Campbell first used the word ‘postpsychiatry’ some years ago in the anthology Speaking Our Minds, in an attempt to imagine what would happen in a world after psychiatry.^[28] Independently, Patrick Bracken and Philip Thomas coined the word a year later and used it as the title of a series of articles they wrote for Openmind. This was followed by a key paper in the British Medical Journal , and a book of the same name.^[29] At the same time Bradley Lewis, a psychiatrist based in New York, published Moving Beyond Prozac, DSM, and the New Psychiatry: The Birth of Postpsychiatry.^[30]

One of the most significant developments in the field of mental health over the last thirty years has been the emergence of a vocal and critical service user / survivor movement, and in large part we may understand British postpsychiatry as an attempt to respond to the challenges of service users, survivors, and increasingly carers. (There is an excellent website devoted to the history of the survivor movement in Britain [2], which sets out a very clear time-line for the movement, with many resources.) These groups have not always seen eye-to-eye with psychiatry and in broad terms organizations like Survivors Speak Out, the National Self Harm Network, Mad Pride, Mad Women and the Hearing Voices Network reject the way in which psychiatry identifies, defines and responds to their experiences. At the same time they seek a new, more equal relationship with mental health services. In this they were assisted by the importance attached by the Labour government to democracy and accountability in the NHS on its election in 1997. This created a political environment in which doctors and nurses in all areas of health care were expected to relinquish paternalistic ways of relating to patients and relatives, and to work with them on a more equal footing.

For Bracken and Thomas, postpsychiatry represents an attempt to move beyond the dichotomies that characterised the anti-psychiatry era, and to engage constructively and positively with the concerns of service users and carers. Postpsychiatry identifies the central problem of the mental health field not necessarily in psychiatry, but in the modernist search for technical solutions to life's problems. This modernist impulse drives not only psychiatry, but also many allied disciplines in the field, especially psychology and nursing. It existed before the biological/DSM shift of the 1980s, and has been skillfully manipulated by the pharmaceutical industry subsequently.

Progress in the field of mental health is presented in terms of 'breakthrough drugs', ‘wonders of neuroscience', ‘the Decade of the Brain’ and 'molecular genetics'. These developments suited the interests of a relatively small number of academic psychiatrists, many of whom have interests in the pharmaceutical industry, although so far the promised insights into psychosis and madness have not materialized. Some psychiatrists have turned to another form of technology - CBT. This does at least draw attention to the person’s relationship with their experiences (such as voices or unusual beliefs), and focuses on helping them to find different ways of coping. However, it is based on a particular set of assumptions about the nature of the self, the nature of thought, and how reality is constructed. The pros and cons of this have been explored in some detail in a recent publication.^[31][32]

Framing mental health problems as 'technical' in nature involves prioritising technology and expertise over values, relationships and meanings, the very things that emerge as important for service users, both in their narratives, and in service user-led research.^[33] For many service users these issues are of primary importance. Recent meta-analyses into the effectiveness of antidepressants and cognitive therapy in depression confirm that non-specific, non-technical factors (such as the quality of the therapeutic relationship as seen by the patient, and the placebo effect in medication) are more important than the specific factors.^{[15][34][35][36][37]}

Postpsychiatry tries to move beyond the view that we can only help people through technologies and expertise. Instead, it prioritises values, meanings and relationships and sees progress in terms of engaging creatively with the service user movement, and communities. This is especially important given the considerable evidence that in Britain, Black and Minority Ethnic (BME) communities are particularly poorly served by mental health services. For this reason an important practical aspect of postpsychiatry is the use of community development in order to engage with these communities.^[38] The community development project Sharing Voices Bradford is an excellent example of such an approach.^[39]

There are many commonalities between critical psychiatry and postpsychiatry, but it is probably fair to say that whereas postpsychiatry would broadly endorse most aspects of the work of critical psychiatry, the obverse does not necessarily hold. In identifying the modernist privileging of technical responses to madness and distress as a primary problem, postpsychiatry has looked to postmodernist thought for insights. Its conceptual critique of traditional psychiatry draws on ideas from philosophers such as Heidegger,^[40] Merleau-Ponty,^[41][42] Foucault^[43] and Wittgenstein.^[44]

Postpsychiatry is not anti-science, but is critical of the dualisms implicit in Cartesianism, body-mind, mind-society, and body-society, and thus the failure of medical science to engage fully with the embodied and encultured reality of human experience in disease and illness. The Critical Psychiatry Network or movement on the other hand encompasses a range of philosophical positions and is not conceptually wedded to postmodernism. Members of the Network are particularly concerned with the political and ethical basis of the clinical practice of psychiatry, and countering the influence of the pharmaceutical industry on the psychiatric profession and mental health care in general. At root, there is a conceptual issue about the nature of mental illness. Critical psychiatry and postpsychiatry maintain that psychiatry can be practiced without postulating brain pathology as the basis for functional mental illness.

Anti-psychiatry and Critical Psychiatry

The word anti-psychiatry is associated with the South African psychiatrist David Cooper, who used it to refer to the ending of the ‘game’ the psychiatrist plays with his or her victim (patient) ^[45]. It has been widely used to refer to the writings and activities of a small group of psychiatrists, most notably R.D. Laing, Aaron Esterson, Cooper, and Thomas Szasz (although he rejects the use of the label in relation to his own work, as did Laing and Esterson), and sociologists (Thomas Scheff). Szasz discards even more what he calls the quackery of ‘antipsychiatry’ than the quackery of psychiatry ^[46].

Anti-psychiatry can best be understood against the counter-cultural context in which it arose. The decade of the 1960s was a potent mix of student rebellion, anti-establishment sentiment and anti-war (Vietnam) demonstrations. It saw the rise to prominence of feminism and the Civil Rights movement in the USA and Northern Ireland. Across the world, formerly colonised peoples were throwing off the shackles of colonialism. Some of these themes emerged in the Dialectics of Liberation, a conference organized by Laing and others in the Round House in London in 1968 ^[47]. As far as psychiatry is concerned, we have already seen how, in The Divided Self, Laing argued for an existential (or hermeneutic) phenomenology as the basis for understanding and helping people with schizophrenia, an influence that can be seen in the work of Loren Mosher and Soteria in America. Recent years have seen the emergence of a Soteria Network in Britain to promote the development of minimum drug therapeutic environments for people experiencing psychosis, an initiative supported by some involved with CPN.

Critical Psychiatry Network - Activities

CPN is involved in four main areas of work, writing and the publication of academic and other papers, organizing and participating in conferences, activism and support. A glance at the members’ publication page on the CPN website [Critical Psychiatry Network ] reveals in excess of a hundred papers, books and other articles published by people associated with the network over the last twelve years or so. These cover a wide range of topics, from child psychiatry, psychotherapy, the role of diagnosis in psychiatry, critical psychiatry, philosophy and postpsychiatry, to globalization and psychiatry. CPN has also organized a number of conferences in the past, and continues to do so in collaboration with other groups and bodies. It has formal links with the Hearing Voices Network. It also supports service user and survivor activists who campaign against the role of the pharmaceutical industry in psychiatry, and the campaign for the abolition of the schizophrenia label. The CPN has published a statement in support The Case against Schizophrenia

One of the most important aspects of CPN’s work has been that of mutual support. In recent years it has become increasingly difficult to practise psychiatry flexibly, in ways that recognize the limitations of the scientific evidence that underpins a great deal of contemporary psychiatry. There are many reasons for this, including the rise of evidence-based medicine and the risk-averse culture in which we live. Consequently anyone whose practice is seen to diverge even modestly from clinical practice guidelines is likely to attract unwelcome attention, criticism from peers and managers, or worse. It has thus become increasingly difficult to hold views that differ from what is claimed to be mainstream opinion, even though there are legitimate grounds for doing so based in carefully argued critiques of existing evidence. For example, many critical psychiatrists are highly sceptical about the effectiveness of antidepressant drugs and other forms of physical treatments, the use of diagnoses such as schizophrenia, or the use of the Mental Health Act in social control. CPN thus has a vital role in justifying and supporting those who espouse a critical position in relation to psychiatric theory and practice, and in recent years has supported a number of colleagues who have fallen foul of their peers because their work is wrongly seen not to follow clinical practice guidelines. This is one of the main reasons why membership is restricted to psychiatrists.

Comparison of Anti-psychiatry, Early Critical Psychiatry, Critical Psychiatry and Postpsychiatry

	Anti-psychiatry	Early Critical Psychiatry	Critical Psychiatry	Postpsychiatry
Practitioners / advocates	Psychiatrists, sociologists	Sociologists and psychologists	Psychiatrists	Psychiatrists
Site of practice	NHS (Villa 21) Outside NHS (Kingsley Hall)	n/a	NHS	NHS and NGO (community)
Service user engagement	No	No	Yes	Yes
Role of diagnosis	Generally opposed	n/a	Yes, but highly sceptical about neo-Kraepelinian DSM and ICD	Yes, but highly sceptical about neo-Kraepelinian DSM and ICD
Role of medication	Opposed to its use	Opposed	Has a role, but EBM overstates the case	Has a role, but EBM overstates the case
Role of psychoanalysis	Yes, modified form of object-relations theory	Yes, as a hermeneutic tool (Marcuse)	No, but sees a role for psychotherapies and talking therapies	No, and broadly critical of some talking therapies as technology
Role of biological science	Critical, and largely opposed	Critical, and largely opposed	Critical (e.g. Pharma influence), but of value in some areas	Critical (e.g. Pharma influence, & dualism), but of value in some areas
Philosophy	Existentialism – Sartre, Heidegger, Wittgenstein	Frankfurt School (Habermas)	Various	Heidegger, Merleau-Ponty, Foucault, Wittgenstein

References

1. ^ to Scoping Group
2. ^ Response
3. ^ Mental Health Bill
4. ^ Mental Health Alliance web site
5. ^ resignation
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25. ^ http://www.moshersoteria.com/
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27. ^ Calton, T., Ferriter, M., Husband, N. & Spandler, H. (2008) A Systematic Review of the Soteria Paradigm for the Treatment of People Diagnosed With Schizophrenia. Schizophrenia Bulletin 2008 34:181-192
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46. ^ Szasz T (2010) Antipsychiatry: Quackery squared. Syracuse University Press
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