A Critical Look at Critical Psychiatry

Critical Psychiatry Network is a group of British psychiatrists who are developing and promoting concepts that question and criticize the assumptions that underlie present-day psychiatric practice, not only in Britain, but also in the US and other developed countries.

Critical Psychiatry challenges the notion that the various DSM “diagnoses” are biologically-based illnesses, and adduces a great deal of evidence to the contrary.  They stress the cultural/social aspect of psychiatric diagnosing.  For instance, they point out that a “diagnosis” of ADHD is a cultural construct which provides schools and parents with a socially acceptable method of dealing with difficult children (rather than an identification of an illness).

Critical Psychiatry draws attention to the fact that spurious biological explanations of human problems obscure the role of contextual factors such as poverty, and effectively encourage people to see themselves as powerless to improve their lot.

Critical Psychiatry also discusses the role that the pharmaceutical industry has played in the proliferation of “diagnoses” and in the export of western “solutions” to developing countries.

All of this sounds great, and resonates positively with material published on this website over the past four years.  In fact, I have mentioned Critical Psychiatry a number of times, and have recommended some of their articles and books, including Joanna Moncrieff’s book The Myth of the Chemical Cure (2008).

This book, which incidentally I still consider a must-read, contains two main themes.  Firstly, psychiatric “diagnoses” are not real illnesses, and psychiatric drugs do not correct chemical imbalances.  Dr. Moncrieff’s treatment of this topic is scholarly and probably the best to be found.

The second theme of the book (a drug-centered model of treatment) is more problematic.  Dr. Moncrieff’s notion here is that psychiatric drugs produce abnormal mental states.  Many of these states are potentially harmful, but might have some usefulness for some people in certain circumstances.  Just as a small quantity of alcohol might help a shy young man ask a girl to dance, so a mild sedative might help a person through a particularly difficult life crisis.

In the book, this theme is developed at considerable length, and although I think I have accurately outlined the gist of the matter, I encourage readers to read the original.

Dr. Moncrieff proposes a new model of psychiatric treatment in which practitioner and client collaborate, in what she calls a democratic fashion, discussing the client’s presenting problems and how drugs might or might not help.  No attempt is made to uncover a diagnosable illness, and the client is considered an equal partner.  The psychiatrist is the expert on the drugs; the client is the expert on the client.

When I first read The Myth of the Chemical Cure, I was delighted with the treatment of the first theme, and cautiously positive about the second.  It has always been my contention that what people ingest is nobody’s business but their own [see my post Drugs and Alcohol (Part 2)], and the idea of a psychiatrist sympathetically helping people with these kinds of decisions wasn’t too much of a reach for me.  It also seemed very honest, and was light-years ahead of the standard psychiatric lie – “these are medicines, just like insulin for a diabetic.”

The drug-centered model wasn’t my vision for the future, but I could see how it might have appeal, and anyway, it seemed to me that it was a relatively minor part of Critical Psychiatry’s overall agenda.

Fast-forward to the present.  In December 2012, the members of Critical Psychiatry published an article in the British Journal of Psychiatry called “Psychiatry beyond the current paradigm.”  I drew attention to the piece in a recent post.  The article attacks the assumptions of modern psychiatry, especially the notion that these “diagnoses” are illnesses, and that drugs correct chemical imbalances.  The authors stressed the need to focus on contexts, relationships, and the promotion of dignity, respect, meaning, and engagement.  Again, all good stuff.  Amazingly, however, the authors’ primary conclusion was that:  “Psychiatry has the potential to offer leadership in this area.”

In my post at the time, I expressed some skepticism in this regard, but basically wrote it off as turf-protecting rhetoric.  Economics makes cowards of us all, and even the members of Critical Psychiatry, alongside their commendable ideals, must presumably also entertain concerns in the area of personal finance.  In addition, I didn’t take the leadership thing seriously because it seemed clear to me that if their primary theme prevailed, psychiatrists would simply become unemployed, and pharmaceutical companies would find other outlets for their products.

Last week, however, I was checking Duncan Double’s website Critical Psychiatry (Dr. Double is a member of Critical Psychiatry).  On the blog I found an agenda for a Critical Psychiatry workshop scheduled for April 15 in Nottingham, England.  The first item on the agenda is a presentation by Hugh Middleton – “What is it we are critical of?”  The second item is: “Rethinking Psychiatric Drugs” by Joanna Moncrieff.

Now maybe all this means is that Dr. Moncrieff, being a member of Critical Psychiatry, has been asked to present her views.  Or maybe it means that this drug-centered model is the consensus stance of the group.

These are complicated issues.  I will continue to express support for Critical Psychiatry and mention their publications on this website.  But I do have some concerns about the drug-centered model.  In particular, my main question is:  Would it ultimately look much different from what we have today?  I haven’t met any members of Critical Psychiatry, but my guess is that they are not run-of-the-mill psychiatrists.  Their publications indicate a high level of intellectual and ethical integrity coupled with empathy for human suffering and a recognition of the role that contextual factors play in the genesis of human problems.  In a word, they are a far cry from the “you’ve-got-the-illness-I’ve-got-the-pill” practitioners that, in my experience, constitute the majority of the psychiatric profession.

It may well be that the members of Critical Psychiatry could implement Dr. Moncrieff’s drug-centered model, and deliver excellent service.  I’m not sure that the same could be said of most psychiatrists.  I find it hard to believe that the latter group will ever conceptualize these issues in anything but strictly medical terms and will interpret a drug-centered model as even more license to carry on with business-as-usual.  At the very least, their performance over the last five or six decades must be considered grounds for skepticism.

But the central issue is this.  Given that the members of Critical Psychiatry envisage psychiatrists retaining the leadership role in a revamped, demedicalized helping organization, are they basing this claim to leadership on Dr. Moncrieff’s drug-centered model?  In my view, the kind of drug-dispensing activity that Dr. Moncrieff described in her book would be very peripheral in the business of helping people improve their social and problem-solving skills, find meaning and purpose in their daily activities, and generally move their lives in more positive directions.

I can’t see a logical reason for assigning the leadership role to a peripheral player, but I can see many disadvantages.

So – a complicated and thorny issue.  I would be very interested in views.

  • Sweet63

    I’m currently reading Anatomy of an Epidemic by Whittaker..it’s got me shaking my head, that psychiatrists and other practitioners can continue to prescribe meds with such poor long-term outcomes. Personally I worry about a grandkid who has been slapped with the bipolar label and mustered out of the National Guard. They probably have him on something, but I don’t dare interfere. And my best friend is cycling in and out of depression after 20+ years on lithium, Risperdal and what have you. It’s too late for her.

    Meanwhile I threw away my new bottle of alprazolam. I don’t take a lot but I’ve been taking it a long time and recognize some of the symptoms that Whittaker details…I don’t trust any meds anymore. Looking at you, omeprazole!

  • Phil_Hickey

    Sweet63,

    Thanks for coming back. The medicalization of all human problems is one of the great tragedies of our time. People are being disempowered and lives are decaying. But perhaps we’re beginning to see a glimmer of hope.

    With regards to the alprazolam, I’m sure you’re aware that there can be problems with abrupt discontinuation, and these problems can be
    serious. Possible withdrawal symptoms include depression, insomnia, abdominal and muscle cramps, vomiting, sweating, tremors, and convulsions. The risks of a serious adverse reaction are very real. Alprazolam is generally one of the most difficult drugs to withdraw from. Gradual tapering under medical supervision is strongly recommended.

    Best wishes.

  • Sweet63

    I’m fine, actually I quit my occasional use last October, but tried to use it again to sleep through some shoulder pain. But it’s useless to me now. I think all these psychic drugs alter something in your brain chemistry that renders it useless over time.

    And I think it’s crazy for anyone to take a drug like that daily. I’ve never done that with alprazolam and never did it with Ambien or Halcion. How can you not build up a tolerance and a habit if you’re taking it every day? How can you not become addicted?

  • Phil_Hickey

    Sweet63,

    Glad to hear you’re doing ok. You’ve hit the nail on the head. The body adapts to these products, so a person needs more to achieve the same effect; and so, to addiction. It’s just another example of psychiatric disempowerment. The message to the client is: you are damaged; you can’t cope; you need these pills just to get by.

    I knew a psychiatrist one time who said that the difference between Xanax and true love is that Xanax is forever. “You don’t take people off Xanax,” he explained. So people become clients for life. Lots of these individuals end up in chemical dependency units.

    Best wishes.

  • I have dificulty accepting the notion of ‘critical psychiatry’. In my view this is akin to Darwinists calling themselves ‘critical creationists’. Of course, in a video I watched on youtube, Thomas Szasz was critical of Duncan Double who has also been very disparaging of Szasz in return. Much as I applaud the aims of this group I cannot help but think they want a foot in both camps. Sometimes the middle ground is an impossible position to take.

  • Phil_Hickey

    Nick,

    Thanks for coming in. You make an interesting point.

    Certainly within the current paradigm of psychiatry, the Critical Psychiatry group is an anomaly. They realize that psychiatry for the past 50 years or so has been based on unscientific nonsense and blatant deception. So they’re trying to re-write the script from within. But like all middle grounders, they’re trying to respond to the anti-psychiatry groundswell on the one hand, while retaining membership of the psychiatry community on the other. My prediction is that as the groundswell gains momentum (which right now looks almost certain), we will see increasing numbers of psychiatrists dancing some version of this vacillation.

    I am reminded of Daniel Carlat, a psychiatrist who saw clearly the spurious and venal nature of his chosen profession, wrote an exposé
    (Unhinged: The Trouble with Psychiatry), and got out. I believe he took a job in Washington D.C., reviewing conflict of interest recommendations, with information to be disseminated to medical schools and teaching hospitals throughout the United States.

    I have recently heard of Adrian Preda, a California psychiatrist who is maintaining that at least some of psychiatry’s current woes are attributable – not to the stupidity and greed of psychiatrists – but to the biased media and the uninformed general public who distort the message of the well-informed scientific psychiatrists. I kid you not. I plan to write this up in one of my next posts – coming soon!

    Once again, thanks for coming in. Keep writing and speaking out.

  • Oh. My last comment does not appear to have escaped the moderators censorship. Any reason why?

  • Phil_Hickey

    Nick,

    It needed approval because of the hyperlink, but there seems to be an additional issue. So my Webmaster is working on it. Meanwhile, I will watch the video.

  • Phil_Hickey

    Nick,

    Thanks for coming back. We finally “captured” the video, and I’ve watched the segment you’ve mentioned. Dr. Szasz did succeed in elucidating the contradictions inherent in Critical Psychiatry Network’s position. Of course – as I think everybody recognizes – Dr. Double is not the most lucid of writers, and I’m not always confident that I’ve understood his material.

    But I think the general point here is that if we engage in anti-psychiatry, we inevitably find ourselves with strange bedfellows. For instance, I agree with CPN’s position that mental illness is a spurious concept, though I do not endorse their proposed drug-centered remedies. I can appreciate Iowa Senator Chuck Grassley’s stand against conflicts of interest in this field, though on political ideology we would probably not see eye to eye. I recently did a post against the proposed mandatory mental health screenings for Connecticut children. The bill is also being opposed by extreme right wing anti-government activists, with whom I would not normally be in agreement.

    Incidentally, like yourself, I also admire Thomas Szasz’s work, and I think it is particularly sad that he died just as the anti-psychiatry movement was gaining some serious momentum.

    Getting back to Double vs. Szasz. As I’ve stressed often, mental illness as an explanatory concept is circular nonsense. Szasz obviously saw this clearly. I believe that the brighter members of the psychiatric community saw this also. But from a purely logical point of view, the “diagnoses” are saved from the trash pile if they refer to brain illnesses.

    For the past forty years or so, psychiatric leaders have pushed the brain illness stuff, but – for obvious reasons – have baulked at including it in the DSM. Rank and file psychiatrists have played along, and the public bought it. Big Pharma, of course, was a prime mover. In my view, the brain illness notion was elevated to the status of a religious doctrine, i.e. it was believed without evidence. I also think that they hoped that one day the brain illness notion would be proven. They were like a person who keeps borrowing money in the hope that some day he will strike it rich and get out of debt. But eventually the house of cards collapses, which in my view is what’s happening to psychiatry today.

    I have particularly appreciated Thomas Szasz’s stand against involuntary committals. Many years ago I was debating this with a psychiatrist whom I had accused of committing people too readily. The discussion went back and forth, and finally he said: “Look, psychiatry is an arm of law enforcement. If the police call us – we send the person to the state hospital.” Enough said!

    Once again, thanks for coming in.

  • I do support the CPN. The question is whether psychiatry can be changed from within. The group I have been trying to persuade is the scientific ‘skeptical’ movement who have coined the term ‘mental illness deniers’ for all those that are critical of the current psychiatric biological medical paradigm. Steven Novella is a key figure here who ridicules Szasz.

    http://theness.com/neurologicablog/index.php/mental-illness-denial-part-i/

    http://theness.com/neurologicablog/index.php/responding-to-a-szaszian/

    http://theness.com/neurologicablog/index.php/dsm-v-mental-illness-vs-normal-behavior/

    http://theness.com/neurologicablog/index.php/how-electroconvulsive-therapy-works/

    Dr. Novella has his own influential blog, contributes to sciencebasedmedicine.com, is a director of JREF forums and promotes skepticism against quacks. Although I would agree with most of his views, his support of pyschiatry and opposition to Szasz (just a scientologist!!) has influenced too many young people in what has become a religious crusade. I have failed in my attempts to even question current Pharma/psychiatry views.

  • Phil_Hickey

    Nick,

    Thanks for coming back, and for sending me the links to Steven Novella’s articles. He writes well and is persuasive, but in my view there are logical flaws.

    In “Mental Illness Denial-Part 1”, he writes:

    “The brain must malfunction also, and in fact each brain function should have a disorder associated with its malfunction, including cognition, mood, and behavior.”

    This argument is entirely beside the point. Nobody is denying the existence of neurological illnesses. And nobody is denying that neurological illness/damage can adversely affect behavior. The issue, for me at any rate, is that dysfunctional/counterproductive behavior can and does occur in the absence of any neurological illness or malfunction.

    A complication here (which Dr. Novella exploits) is that dysfunctional behavior can and does adversely affect anatomy and physiology. For instance, if a person never uses his legs, the muscles will atrophy. A medical examiner looking at this person years later might conclude that his failure to walk stemmed from his atrophied muscles, when in fact the opposite was the case. To understand why the person didn’t walk in the first place one needs to explore the behavioral dynamics in his life at that time.

    Dr. Novella applies this concept to the act of paying attention.

    “… if part of the brain allows us to pay attention, in some people that part of the brain must function poorly causing a deficit of attention.”

    The behaviorist position is that paying attention to appropriate stimuli is an operant. It will occur if reinforced and otherwise not. Failure to attend to appropriate stimuli can and does occur in the absence of any neural pathology. The critical issue here is that the individual is always paying attention to something, so the notion that his attention-paying machinery is broken is untenable.

    An over-riding issue here is that if the so-called mental illnesses are really brain illnesses, why don’t we simply diagnose them with neurological tests. Assuming a neurological illness on the basis of aberrant behavior is unsafe and logically fallacious.

    [Incidentally, there is a distinct ad hominem flavour to Dr. Novella’s lumping all of us “deniers” into two or three insultingly simplistic categories. Even the term “denier” has connotations of stupidity, and to my mind devalues his general stance.]

    “How ECT Works”

    For me, this is simply a moot point. ECT doesn’t work, and does a great deal of damage to boot. When real ECT results are compared with “sham” ECT, no significant differences are found. (Sham ECT involves putting the subject through all the procedures including anesthesia, but then not giving him the ECT. It’s kind of like a placebo.) Current research on this is summarized in CPN’s article in the BJP.

    “Responding to a Szaszian”

    Dr. Novella’s opening statement, “I have a strict “do not feed the trolls” policy on this blog” suggests a high level of animosity towards “deniers.”

    He also states:

    “Those who wish to maintain their premise that psychiatry is pseudoscience respond to all counterexamples by saying that, well then that disease or disorder is not psychiatric, is neurological. They therefore define psychiatry as encompassing any mental disorder that they do not believe is legitimate, and not including any demonstrably legitimate diagnoses.”

    This statement in my view is logically flawed. The notion that all of us who describe psychiatry as a pseudoscience rely on essentially the same argument is simply false, and is a rhetorical device used to score points – put words in your opponent’s mouth and then argue against that position.

    “Mental Illness vs. Normal Behavior”

    He writes:

    “This is a healthy debate to have, as the concepts involved are tricky and there are real implications for societal perception, insurance coverage, and treatment strategies. I do not, however, share Dr. Kinderman’s position, which in my experience is fairly typical for a clinical psychologist. He is essentially saying that his profession’s approach to the question of mental illness is superior to the psychiatric profession. While the debate is legitimate and important, I can’t help feeling that there is a major component of a turf battle here also.”

    Here again, Dr. Novella resorts to “ad hominem” tactics. He attacks Dr. Kinderman’s position – not on its merits – but rather as part of a “turf battle.”

    His final statement is interesting:

    “But when you get past the turf-war posturing and semantic arguments, I find there is actually widespread agreement on the important issues. Human mood, thought, and behavior are complex, there is a wide range of variation in what constitutes human mental states, and any thoughtful approach must consider circumstances, environment, culture, and biological considerations, including their complex interactions. Further, therapeutic approaches should consider the full range of potential interventions and should ultimately be evidence-based.”

    This sounds very good, but in practice I have never encountered – or even heard about – a psychiatrist who takes this approach. In my experience, the profession ignores circumstances, environment, and culture, and goes straight to biology. I have never encountered a psychiatrist who appeared to have even a rudimentary appreciation of the fact that abnormal behavior can be acquired in the same way as normal. And – again in my experience – psychiatry as practiced is not particularly evidence-based. For instance, it’s been known for decades that anti-depressants are no better than placebos, yet they continue to be widely employed.

    So – interesting stuff. Dr. Novella is brighter than most of the people who defend psychiatry, but his enthusiasm has, I think, blinded him to some of the logical flaws in the standard theory. For instance, the APA’s definition of a mental disorder can be accurately paraphrased as: any significant human problem. They then examine a specific human problem (poor school performance, for instance), and “discover” that this is a mental disorder! This is logic 101.

    Secondly, the “diagnoses” are positivistic rather than essential. In other words, the only evidence for the “diagnosis” is the very behavior it purports to explain. The “diagnosis” has no explanatory value, and if it has no explanatory value – then what’s the point. Dr. Novella skirts this by talking about convenient “clusters” of problems. But I’ve only ever met one psychiatrist who acknowledged this. All the others I’ve met proclaim boldly that these “diagnoses” are real illnesses, which the pharmaceutical products corrected.

    Incidentally, Elliot Valenstein’s book Blaming the Brain counters a good deal of Dr. Novella’s material.

    If Dr. Novella is representative of the skeptical movement, I don’t think you’ll have much success persuading them.

    Can psychiatry change from within? One of the fundamental tenets of behaviorism is that learning continues until death. So if we concede that psychiatrists are alive, then of course they can change. People generally make fundamental changes in their behavior, however, only in response to fundamental changes in their circumstances. At the present time most psychiatrists are making a good living dishing out pills to willing consumers, and there’s very little incentive to change. Their trade association provides a theoretical framework to “validate” their work, and all’s right with the world.

    There are cracks in the sand-castle, however, and as these widen, well, we’ll see. I don’t think it’s likely that we will see much reduction in the demand for drugs in the near future.

    Once again, thanks for coming in with such interesting material. I will try to keep up with Dr. Novella’s stuff.

  • The Right Hon. Cledwyn B’Stard

    I’ve come to the conclusion that the reason so many critics take an intermediate position on this issue is because in many cases, they clearly don’t want to piss off their coleagues or people they are quite cosy with in the mental health movement, and who they’ve perhaps come to identify with through too close proximity to them.

    This is why I tend to avoid people who work within the system like the plague; one shouldn’t get too close to oppressors; you might come to like them, and even think like them, through a process of osmosis. It can create a conflict of loyalty. Ergo, tis advised to give such people a wide berth, lest you compromise yourself, and thereby do their victims a disservice. It will also lead inevitably to a desire to absolve of blame the person you are in sympathy with, which in turn often leads to the wholesale absolution of all such people, but you render a disservice to a victim when you absolve his/her victimizer of blame, thereby becoming an accomplice in his crimes.

    Commonly heard amongst such people is that the majority of mental health professionals simply mean well, which is in part born of the democratic delusion that most people are compassionate humanitarians. This shibboleth does nothing to advance our understanding of what is really going on here. They paint a picture of the average mental health professional as particularly empathic, desperate to help. Truth is, as I see it, is that empathy is in short supply in society, and it goes without saying that psychiatry doesn’t operate in a societal and cultural vacuum. The ongoing sacrifice of patients, by those who work against them, to this Moloch, this sacrificial institution architecturally and rhetorically concealed, furnishes sufficient evidence that empathy is precisely what is lacking in psychiatry.

    Most of them just don’t care, and are too busy indulging their power fantasies and feathering their own nests to frankly give a toss.

    There is another reason though. Empathy establishes a conduit between ourselves and the emotional and experiential world of others, allowing us to experience it vicariously, and the world of the mental patient is often a thoroughly unpleasant place to reside, characterized by immense suffering and unpleasantness, therefore true empathy for suffering humanity inevitably involves an element of self-sacrifice, which many stake a claim to, but few truly partake of.

    The great french writer Ferdinand Celine (and Nazi sympathizer!) was right when he said that humans are pleasure junkies, which I believe partially explains the tremendous isolation, and also the abuse (because of a lack of empathy strategically maintained to guard against vicarious suffering, a lack of empathy being at the root of much abuse), of the “mental patient”, who is an obstacle to the maintenance and pursuit of pleasure, an emotional and cognitve contaminant, who must be confined and ostracized, and condemned to loneliness so that people can pursue their greed for pleasure without hindrance, amongst other things, of course.

    This is borne out by the fact that old people, people with terrible diseases, the homeless, “mental patients” etc., live in such isolation, existing on the periphery of society and collective consciousness, though in the case of the latter this is attributed to their supposed disease.

    On top of that, empathy might interfere with the proper discharge of duties, and give the relevant mental health professionals ideas above their remit, which of course they could never hope to put into practice in such a oppressive environment where thought and practice is so meticulously circumscribed.

    Nevertheless these kind of claims are often made by critics whose allegiance is split, but as I say, the history and contemporary record constitutes sufficient evidence that psychiatry is distinctly lacking empathy.

    Their position inevitably compromises their criticism, no matter how much they would wish to be respected as impartial observers.

  • Anonymous

    British Critical Psychiatry is useful for one thing. But I’m not going to talk strategy publicly, for that you should email me. As for the people of British Critical Psychiatry, I say to hell with them, until the day they stop using the “Mental Health Act” to rape the brains of strangers. As far as I know, they are all fence sitters, the worst kind, the kind that now infect various other nameless places, that oppose community commitment, but support “inpatient” brain rape forced drugging because they seem to think raping the biology of distressed human beings is acceptable even though they admit there is nothing demonstrably wrong with anybody’s biology. Such people should have their violence against their “patients” exposed. Writing a book or an article slightly critical of psychiatry doesn’t erase the grave moral wrongs these people have perpetrated. We know more than most, how many devastated, decimated people these violent syringe wielders leave in their wake, it’s an injustice, it’s genuine oppression not Social Justice Warrior oppression, and it must stop.