Psychiatric practice exists at the nexus between medicine, psychology and society. As such it will always be open to criticisms from within and from without. This is healthy and, as Professor Aftab makes clear, we should always have some humility about how little we really know about the nature of mental disorder. This is even to the extent that the terminology of disease, condition etc. is in itself suspect. The main substance of this book consists of 25 interviews with scholars offering critiques, such as Allen Frances, Anne Harrington, Joanna Moncrieff, Sanneke de Haan and Kenneth Kendler. In conducting these Aftab discovered many new and interesting ideas that profoundly influenced his understanding of his own practice, while not necessarily agreeing with all their arguments.

His exemplary introduction, in which he condenses an understanding of psychiatry that everyone working in the field would benefit from, is perhaps the most significant chapter. He emphasises that both critics and ourselves should continue to be self-critical. He considers that, throughout its history, psychiatry has been bedevilled by a ‘zealous devotion to unidimensional frameworks’, and we should extend our perspective beyond the purely medical, an opinion echoed by Professor Sir Robin Murray in the foreword. His own perspective is philosophical, but he also argues for understanding the social nature of patients’ lives and problems. He offers an integrative critical psychiatry perspective that emphasises pragmatism and eschews biological–social dichotomies while recognising that mental health conditions arise within and are influenced by the social environment. Although there are significant difficulties in classification there are scientific facts that inform and constrain nosology. As he states, the ‘resulting picture is one of conceptual, explanatory, and methodological pluralism’ within which we must operate with circumspection. He is at pains to emphasise that we need to be aware of and tackle political cooption, injustice of psychiatric institutions and the marginalisation of those experiencing mental disorder.

Aftab’s stance is not uncontroversial. In criticising a purely drug-centred model of medication action, he argues for the use of drugs without ‘messy assumptions about disease processes’ which impose ‘restrictions on our understanding of psychopharmacology that we are better off discarding’. We recognise the benefits and phenomenological effects of medication in many cases, but poorly understand how they actually work. He is also critical of how the DSM ‘has acquired influence and power well beyond what is warranted’. He calls for a ‘dialogue with madness’, taking the voices of those with whom we are working seriously, understanding the issues arising from lived experience and acknowledging diversity from cultural norms. This stretches beyond the clinic to the nature of coercion of those seen as damaging to themselves and others.

It is difficult in a short review to characterise the range of interviews that Aftab has carried out. Two that impressed me were those with Nev Jones and Jonathan Shedler. The former experienced a psychotic episode as a student of philosophy and this has coloured her sceptical view of diagnostic practice ever since in her work as a psychiatrist. For her, too much emphasis is laid on key symptoms, neglecting the profoundly variable phenomenology that affects each person. In so doing we fail to gain the trust of those we are working with and thus they perceive our interventions in terms of an unequal power relationship. It takes time to listen to our patients and Shedler argues that psychotherapy allows us to insert such ‘spaces for reflection’, enabling us to understand the meanings that patients give to their experiences, validating their perceptions and opening up ways to re-evaluate how they might live with their burdens. These two contributors, as with most of the others, do not condemn present day psychiatric practice outright, but wish us to acknowledge the relevance, and value, of the profound multiplicity of causation and experience of each person undergoing these conditions.

In her brief contribution Sandra Steingard congratulates Aftab on his elegant and nuanced understanding, but expresses concern about how it can be translated into practice, given the increasing emphasis on productivity. I concur with both observations.