Over the last twenty years there has emerged a body of work that questions the assumptions that lie beneath psychiatric knowledge and practice. This work, appearing as academic papers, magazine articles, books, and chapters in books, hasn’t been written by academics, sociologists or cultural theorists. It has emerged from the pens and practice of a group of British psychiatrists.
This is not antipsychiatry. There are important differences between the antipsychiatry of the 1960s and present-day critical psychiatry; there are also important points of convergence, but the two nonetheless are quite different. Some of these similarities and differences will become clear as this series of blogs, written to complement the narrative blogs I’ll occasionally be posting, evolve over time.
In this series of postings, to appear under the ‘Critical Psychiatry’ tag, I want to present an overview of some of this work. This is because interest in critical psychiatry is growing, especially in the USA. There will be presentations by British critical psychiatrists at the APA annual meeting in San Francisco, and the Institute on Psychiatric Services in Philadelphia, both this year. This series of blogs about critical psychiatry is also by way of a sneak preview of a book I’m writing about British critical psychiatry, to be published by PCCS Books – http://www.pccs-books.co.uk – in the near future; watch this space!
So what exactly is critical psychiatry? The bulk of this work has been written by a small group of psychiatrists, all of whom are, or were, practicing psychiatrists in the NHS in England. All are associated with the Critical Psychiatry Network – http://www.criticalpsychiatry.co.uk – which first met in Bradford, England in 1999. The most active members of this group have between them written ten single or dual author books, ten edited books with forty-two chapters, and one hundred and thirty seven papers mostly in peer-reviewed journals. A survey of this work reveals that it covers five themes:
- The problems of diagnosis in psychiatry
- The problems of evidence based medicine in psychiatry, and related to this, the relationship between the pharmaceutical industry and psychiatry.
- The central role of contexts and meanings in the theory and practice of psychiatry, and the role of the contexts in which psychiatrists work.
- The problems of coercion in psychiatry.
- The historical and philosophical basis of psychiatric knowledge and the practice of psychiatry.
These themes are not mutually exclusive, for example, there is a close relationship between some aspects of the problems of diagnosis, particularly the problem of validity, and the problems of evidence-based medicine. In addition, the problems of diagnosis in psychiatry may also be seen in terms of another set of issues, that of the application of the methods of scientific inquiry to human subjects. This in turn relates to a third, that of the neglect of contexts and meanings in contemporary psychiatric practice. And, at a conceptual level, these problems can be understood in terms of three key philosophical issues, the nature of knowledge and different ways of knowing about the world (epistemology), the nature of the body-mind relationship, and the relationship between mind and the world, especially the social world.
These three issues are of fundamental importance in understanding the limitations of scientific psychiatry. Most important of all, however, is a focus on the moral and ethical implications of the use of scientific knowledge (whether biological, psychological, sociological) in relation to madness and distress. Ultimately, critical philosophical thought has a great deal to offer when it comes to understanding how these different problems of psychiatric knowledge and practice are related. In this blog I will focus on the first of these themes. Subsequent blogs in the coming months will deal with the others.
The problems of diagnosis in psychiatry
The writings of critical psychiatrists see the problems of diagnosis in psychiatry in two areas: problems with the scientific basis of psychiatric diagnoses, and the moral problems that can arise from the use of psychiatric diagnosis.
The scientific basis of diagnosis in psychiatry
Joanna Moncrieff (1997) points out that despite extensive scientific research, there is no convincing evidence that specific biological causes account for either depression or schizophrenia. Research councils and other funding bodies have invested huge sums of money over the years in the quest for the biological basis of the condition called schizophrenia, but without success. Researchers in molecular genetics, neuroimaging and other neuroscientific fields persistently overstate the significance of their findings. Duncan Double (2000) also questions the evidence to support a biological basis for psychiatric diagnoses. He points out that a low level of agreement over the diagnosis of schizophrenia between psychiatrists in different countries has hampered psychiatric research.
Until the 1970s, American psychiatrists had a much broader conception of schizophrenia than their British colleagues, who used the diagnosis much less frequently. He also points out that the monoamine theory of depression and the dopamine theory of schizophrenia developed after the introduction of drugs that were claimed to ‘cure’ these conditions. Prior to this there was little interest in neurotransmitters like dopamine and the monoamines. This emerged when laboratory research drew attention to the effects of these drugs on neurotransmitters. Only then did these theories emerge. In contrast, the discovery of drugs to treat neurological conditions like Parkinson’s disease resulted from extensive laboratory research into the role of dopamine as a neurotransmitter.
The biological basis of schizophrenia remains elusive and unsubstantiated (Thomas, 2011). One reason for this as Duncan Double (2002) points out that is the poor level of agreement between psychiatrists over the diagnosis. This was one of the factors responsible for the move towards a more scientific psychiatry heralded by DSM-III. The first edition of the DSM published in 1952 gave definitions and criteria for 106 categories of psychiatric disorders, but the publication of the fourth edition in 1994 saw this number swell to 354. The third edition ‘…encouraged the reification of psychological conditions. Social phobia, post-traumatic stress disorder, for example, were first included in international classifications in DSM-III.’ (Double, 2002:902). The third edition, he suggests, coincided with the growing influence of scientific psychiatry, and a return to the values expounded by the German psychiatrist Emil Kraepelin a hundred years earlier.
Sami Timimi (2004) argues that the diagnosis of attention deficit hyperactivity disorder (ADHD) is a cultural construct. He points out that there are no specific biological or psychological markers for the condition, and as a result of disagreements and uncertainties over the definition there are wide variations in the prevalence of the condition. One thing that is clear from epidemiological studies is the condition has become much more common over time. In order to understand this we have to adopt a cultural perspective, and in particular recent changes in Western culture.
The expansion of diagnosis has also been a feature of child psychiatry. Until relatively recently the emphasis here was on child development, the family, and psychodynamic and social understandings of childhood. Sami Timimi (2004a) points out that before the introduction of DSM-III, depression was an uncommon diagnosis in childhood. It was also considered to be different from depression in adults, and not to respond to antidepressant drugs. This changed when an influential group of academic child psychiatrists claimed that childhood depression was more common than most people thought, and that it responded to physical treatments. Sami Timimi argues that current psychiatric diagnostic criteria in depression are so broad as to be useless. Most children can be identified as suffering from some form of psychiatric disorder. In addition there are low levels of agreement between the diagnosis of depression and the psychosocial problems that are usually associated with it. This raises serious doubts about the value of constructs like childhood depression.
The moral problems of diagnosis
In Britain this is seen most tragically in the problematic encounter between psychiatry and people from Black and Minority Ethnic (BME) communities. Suman Fernando (1991) argues that belief in the neutrality of psychiatric knowledge and practice has helped to conceal the racist assumptions in which the two are based. This problem operates nationally and globally. In Britain a huge body of evidence has accumulated over the last fifty years that the incidence of schizophrenia is much higher in people from African-Caribbean communities, especially young men. This fact, allied with what is a widely held but racist perception that young Black men are dangerous, is linked to the higher rates of compulsion and coercion they experience in mental health services. Young black men are also more likely to receive physical treatments and higher doses of drugs in hospital than other groups.
But the problem doesn’t end there. Psychiatric theories resort to racist explanations for the raised incidence of schizophrenia in black people, based either in supposed biological or genetic differences between black people and the white majority, or in the family structures and life styles (especially cannabis use) that are said to characterise the African-Caribbean cultures. Psychiatry consistently locates the origins of the problem of schizophrenia in the biology or culture of these young men, and not in the experiences of racism and discrimination that feature prominently in their lives. This is a serious moral failure.
Racism is a difficult issue for health professionals to have to face up to. Kwame McKenzie (2003) argues that the experiences of racism have adverse effects upon the health of those affected. This can be seen in the raised incidence of high blood pressure, respiratory illnesses, anxiety, depression and psychosis in black people. Writing in the context of the Macpherson Report into the failure of the Metropolitan Police to bring about a prosecution in the racist murder of black teenager Stephen Lawrence, he (McKenzie, 1999) points out that like the police, doctors take offence to accusations of racism. This is where the idea of institutional racism is helpful, because it considers how the values and structures of mental health services inadvertently discriminate against minority groups.
More generally, as Duncan Double (2002) argues, the use of diagnosis based in biological explanations of experience eliminates the possible significance of the meaning of distress, and obscures its social and psychological origins. This encourages people to see themselves as powerless to do anything about their problems. This has important implications for recovery.
The use of diagnosis has become an important tool in the pharmaceutical industry’s attempts to extend its global commercial interests, and Suman Fernando (1991) points out that this has harmful consequences on local understandings of distress and madness and the systems of support that are based in this, especially in non-Western countries. Western scientific understandings of distress originate in historical and philosophical assumptions about the self that are a feature of Western civilization. International agencies like the World Health Organisation (WHO) place additional pressures on non-Western countries to adopt Western ‘solutions’ to the problem of madness, indirectly endorsing the pharmaceutical industry’s agenda and further weakening local support systems. Support for this view comes from a paper that Pat Bracken & I wrote (Bracken & Thomas, 2001), which argues that scientific accounts of distress exemplified by the DSM are rooted in the view that human suffering would ultimately yield to scientific progress.
The notion of progress through rational scientific thought originated in the European Enlightenment. One of the important outcomes of this period of thought and history was the replacement of religious belief and superstition by science and rationality in our attempts to understand our lives and our relationship to the world. The scientific approach, which reached its apogee in the Decade of the Brain, replaced a wide variety of non-scientific ways of understanding madness and distress, first in Europe, but increasingly through the second half of the twentieth century, across the globe.
If it is the case that psychiatric diagnoses have no firm scientific basis, and that they are little more than consensus statements produced by committees of experts, then it should come as no surprise to discover that political factors play an important part in their creation and abolition. Forty years ago the British and American psychiatric establishments rightly attacked the former Soviet Union for its use of the diagnosis “sluggish schizophrenia” as a means of silencing dissidents. At the same time gay activists in the USA campaigned politically to have homosexuality removed as a diagnosis from the DSM, and in 1973 it was replaced by the category “sexual orientation disturbance.” Derek Summerfield draws attention to the political nature of psychiatric diagnosis, and the moral problems that arise from this. He argues that the origin of the diagnosis of post-traumatic stress disorder (PTSD) was a political, not scientific, achievement.
Following the Vietnam War the U.S. anti-war movement persuaded military psychiatry to provide help and support for veterans. As a result the diagnosis of PTSD replaced earlier conceptions of battle fatigue and war neurosis, and drew attention to the traumatogenic nature of war. In doing so the diagnosis also transformed Vietnam veterans from perpetrators of war atrocities to victims of trauma; the category “…legitimized the “victimhood,” gave moral exculpation…” (Summerfield, 2001:95). The diagnosis of PTSD has less to do with science and natural categories than it has to do with internal political struggles to salve a nation’s conscience after a terrible conflict.
Western concepts of trauma and the psychiatric diagnosis of PTSD attempt to redefine the moral consequences of conflict. In another paper Derek Summerfield points out that surveys of the residents of war zones tend to interpret feelings of revenge as an indicator of poor mental health (Summerfield, 2002). For example in Croatia, a foreign-led project told Croatian children affected by the war that not hating Serbs would help them to recover from trauma. In South Africa, studies of the victims of apartheid found that PTSD was significantly more common in those who were unforgiving (as measured by their score on a ‘forgiveness’ scale).
These, and similar, studies give weight to the view that forgiveness is necessary for recovery. Thus the emotional responses of those affected by war, ‘traumatisation’ or ‘brutalisation’ are held to be harmful and in need of modification. This belief, he argues, provides the basis for large scale counselling interventions by Western aid agencies. He challenges this view, by asking: is anger and the need for revenge necessarily a bad thing? They draw attention to the moral aspects of injustice that lead to suffering in the first place, and the importance of social cohesiveness and solidarity as a social and cultural response to the injustices of war.
Bracken, P. & Thomas. P. (2001) Postpsychiatry: a new direction for mental health. British Medical Journal, 322, 724 – 727.
Double, D. (2000) Critical Psychiatry. CPD Bulletin Psychiatry, 2, 33 – 36.
Double, D. (2002) The Limits of Psychiatry. British Medical Journal, 324, 900-904.
Fernando, S. (1991) Mental Health, Race and Culture. Macmillan / Mind Publications, London. (1st edition).
McKenzie, K. (1999) Something borrowed from the blues? British Medical Journal, 318, 616 – 617.
McKenzie, K. (2003) Racism and Health. British Medical Journal, 326, 66.
Moncrieff, J. (1997) The medicalisation of modern living. Soundings, 6, 63 – 72.
Summerfield, D. (2001) The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. British Medical Journal 322, 95 – 98.
Summerfield, D. (2002) Effects of war: Moral knowledge, revenge, reconciliation, and medicalised concepts of recovery. British Medical Journal, 325, 1105-1107.
Thomas, P. (2011) Biological explanations for and responses to madness. Chapter Fourteen in (eds. D. Pilgrim, A. Rogers and B. Pescosolido) The SAGE Handbook of Mental Helath and Illness. London, Sage. (pp 291 – 312).
Timimi, S. (2004) In Debate: ADHD is best understood as a cultural construct – For. British Journal of Psychiatry (In Debate) 184, 8-9.
Timimi, S. (2004a) Rethinking childhood depression. British Medical Journal, 329, 1394-1397.