The definition of critical psychiatry

I mentioned before my interview with Awais Aftab (see previous post), which has now been published as a chapter in his edited book Conversations in critical psychiatry. Awais has added an introductory chapter to the interviews he has collected in the book. In that chapter he quotes my comment that “critical psychiatry may be difficult to define precisely” and suggests that the most specific use of the term is merely to make reference to psychiatrists, such as myself, associated with the Critical Psychiatry Network (CPN) (see eg. previous post). This suggestion fails to take account of my further comment that CPN takes an ideological position that primary mental illness cannot be reduced to brain disease. There is a range of views within CPN, true, but it coalesces round a systematic collection of ideas (see eg. previous post) and seeks to move on from the reductionism and positivism of much of modern psychiatry. 

Awais tries to be open to critical perspectives in psychiatry (eg. see previous post), but he is not as explicitly ideological in his position as CPN. The trouble is that he is inclined to see what he calls the integrative tradition as continuous with the critical. He wants to see integrative and critical pluralism as a variant of critical psychiatry. I’m very much in favour of an integrative and pluralistic perspective in psychiatry but this is based on CPN’s ideological position about the nature of psychiatry and the uncertainty in the field, rather than wanting to hold on to the possibility of biomedical perspectives, as does Awais.

As Robin Murray says in his foreword to the book, Awais suggests critical and integrative pluralism as a corrective to what he calls the lack of self-criticism of critical psychiatry. I’m not so convinced that critical psychiatry is lacking in self-criticism. It's more Awais saying he can't accept at least part of its critique. True, there are those within the critical psychiatry movement that want to abolish psychiatry but actually, as Awais acknowledges, members of CPN are psychiatrists themselves. As he says, “They fundamentally see critical psychiatry as a form of psychiatry”. They are open to different perspectives and take a reflexive position in their critique.

Awais is correct that “The folk judgements of 'something has gone wrong’ [in mental illness] might or might not be indicative of failure of a psychological or neurobiological mechanism to perform its ‘natural’ function”. But Awais suggests critical psychiatry creates “various binaries that sort psychiatric conditions into diseases versus problems of living, biologically caused vs representing self-directed behaviours, and illnesses vs understandable reactions to circumstances”. I agree with him that there is a form of critical psychiatry that does that. But it need not, nor do I, as a member of the Critical Psychiatry Network, so therefore representing 'critical psychiatry', at least part of it, in his sense. Those that do, as Awais notes, can be called neo-Szaszian critical psychiatrists.  Critical psychiatry does not need to be neo-Szaszian. I have always emphasised how it needs to be integrated with the mainstream (see eg. previous post). Awais should take on board, as I say in my interview, that "most presentations to psychiatrists do not have an underlying physical cause, even if that is presumed still to be discovered". Psychiatry came out of its previous phase of brain mythology in the 19th century by recognising the structural/functional distinction of mental illness at the beginning of the 20th century (see eg. previous post). Over recent years this distinction has been fudged, if not obliterated (see eg. another previous post). The point is though that psychiatry must stop reducing people to their brains (see eg. yet another previous post).

Awais is clear that he thinks it is plausible that psychiatric medications “act on mechanisms that produce, sustain, and modify symptoms”. I agree with his emphasis on outcome-based prescribing (see eg. previous post). But he is not sufficiently critical of the notion of whether medication “works” (see eg. previous post). He speculates that it “is likely that psychiatric medications act on symptom mechanisms while also producing global psychoactive effects”. He doesn’t want to consider that any effect of psychiatric medication may be primarily due to the placebo effect (see eg. previous post). 

In the same way that Anthony Clare did for a previous generation by emphasising psychiatry's eclecticism (see eg. previous post), mainstream psychiatry seems to be defending itself against the message of critical/relational psychiatry by promoting integrative and critical pluralism. The publication of Awais' book is welcome. The trouble is that although it engages with the critique of psychiatry, it does not properly take its message on board because psychiatry does not want to change. However difficult it may be to hear the critique of critical/relational psychiatry, it does need to be stated boldly in the interests of patients (see eg. another previous post). Otherwise, psychiatry will merely continue to defend and maintain its biologism.