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.