A brief history of critical psychiatry

This article will focus on the distinctive subculture of critical psychiatry within UK psychiatry. A culture can be regarded as a group of people with a shared set of values. Values are action-guiding beliefs that also shape our interpretation of experience. ^{Reference Sadler1} Individuals within a culture will vary in how strongly they adhere to these values. Traditional psychiatry has a set of values and beliefs, such as a commitment to empiricism and that the typical medical model is usefully applied to help what are called mental health problems. ^{Reference Sadler1,Reference Huda2} One important point is that critical thinking is part of mainstream psychiatric thinking, including awareness of bias and other weaknesses in sources of information (such as critical analysis of papers), and of one’s own biases when interpreting information – for example, in the diagnostic process or trying to be accurate when using concepts. The term ‘critical psychiatry’ does not therefore mean that mainstream psychiatry is not ‘critical’.

Critical psychiatry arose in the 1960s at a time when patients were often kept for many years in authoritarian asylums and the discovery of effective medications a decade previously was leading to a new period of biological dominance in psychiatry. There was an ideological split between Szasz in the USA and Europeans such as the Glaswegian Laing and Italian Basaglia. ^{Reference Morgan3} European critical psychiatrists accepted the reality of mental illness such as psychosis and wanted to replace authoritarian, asylum-based psychiatry with better psychiatric care, including a more democratic relationship between patients and doctors. Szasz rejected the concept of mental illness and wanted psychiatric care replaced with people voluntarily paying for therapy to help with ‘problems in living’. ^{Reference Szasz4} Another contrast was that European critical psychiatrists were more compassionate towards their patients and insightful towards their experiences than Szasz. Laing wrote a valuable description of schizoid-type personality structures. ^{Reference Laing5} Basaglia contributed towards reforms such as Law 180 in Italy, and helped set up the world-leading Trieste community mental health service. European critical psychiatrists tended to have more progressive political stances whereas Szasz belonged to a right-wing libertarian tradition. Szasz went on to tarnish his legacy by accepting money from Scientology to set up an anti-psychiatry organisation.

Like-minded psychiatrists in the UK, concerned about increasingly coercive proposals for the Mental Health Act, formed the Critical Psychiatry Network in 1999. ^{Reference Double6} Aspects of contemporary mainstream psychiatry also probably contributed: domination of biological research but without much improvement in aetiological knowledge or beneficial treatments, and widespread pharmaceutical industry influence in medicine – all those drug lunches, sponsorship of training and paid attendance at conferences, including overseas junkets.

The values and beliefs of UK critical psychiatry

Critical psychiatrists have a diverse set of values and beliefs that set them apart from mainstream psychiatry, ^{Reference Double6} and not all belong to the Critical Psychiatry Network, having more of a questioning attitude to psychiatric orthodoxy rather being part of a movement. Publications by the most influential members of the Critical Psychiatry Network suggest positions that many, but not all, will cohere around. Many mainstream psychiatrists have critical psychiatrists as colleagues; their own personal views may vary quite markedly from those expressed by the Critical Psychiatry Network and their clinical practice may resemble those of other psychiatrists. ^{Reference Double6}

Some of these values and beliefs are placed in opposition to what are asserted as beliefs and assumptions held by mainstream psychiatry.

Mainstream psychiatrists are said to use a reductionist biomedical model and to assume that mental illness is a brain disease, but critical psychiatrists believe that functional mental illness should not be reduced to brain disease. ^{Reference Double6}

Mainstream psychiatrists are claimed to assume that psychiatric medication is beneficial and corrects underlying biological mechanisms (‘disease-centred’ practice). Critical psychiatrists presume that psychiatric medication is harmful but that it’s psychoactive effects, although harmful, may be regarded as potentially useful in certain circumstances (‘drug-centred’ practice). ^{Reference Yeomans, Moncrieff and Huws7}

This assumption of harmfulness means that critical psychiatrists are sensitive to the detection of adverse effects of medication, such as discontinuation/withdrawal syndromes from medication. ^{Reference Double6} Critical psychiatrists listen carefully to patients’ accounts of adverse effects, and then subsequently study these adverse effects and bring awareness to the rest of the profession and public about them.

Whereas some critical psychiatrists distance themselves from Szasz, ^{Reference Double6} others are more approving of his claim that illness relies on the presence of a biological lesion, and that the absence of this in most mental health conditions means that we should not talk of ‘mental illness’. ^{Reference Middleton and Moncrieff8}

There is a preference to focus instead on socioeconomic, political, interpersonal and cultural factors as causes for what are labelled as mental health conditions rather than biological factors. ^{Reference Middleton and Moncrieff8} Suman Fernando is known for his work on the effects of racism and cultural bias on psychiatric and psychological ideology and practice. ^{Reference Fernando9}

Some critical psychiatrists appear to endorse strong social, constructivist, debunking views of what are called ‘mental disorder’, i.e. these states are labelled as medical conditions purely for social reasons such as to serve political goals or other interests of the powerful, ^{Reference Middleton and Moncrieff8} rather than to identify states to alleviate suffering associated with them.

Part of this shift away from diagnosis, biological aetiological models and interventions is due to scepticism about the psychiatric evidence base. Critical psychiatrists express concerns that differences between people diagnosed with mental health conditions and controls are confounded by various other potential explanatory factors, including social differences (such as class or life experiences) or the effects of medication. ^{Reference Middleton and Moncrieff8} Some critical psychiatrists doubt that natural science research methods (such as nomothetic research based on diagnosis, or randomised controlled trials (RCTs) of medication) can be used in psychiatry because these cannot explain the whole reason for all aspects of behaviour or experience in the specific contexts of people’s lives. ^{Reference Middleton and Moncrieff8} They may prefer idiographic alternatives such as hermeneutics to explain behaviour or experience in the context of patients’ lives. ^{Reference Middleton and Moncrieff8}

Critical psychiatrists have concerns, to varying degrees, about the medical role in what are called mental health conditions. ^{Reference Double6} Some are wary of ‘over-medicalisation’ of what may better be regarded as social problems requiring social solutions, and the harmful effects of the ‘sick role’ for people categorised as mental health patients. ^{Reference Middleton and Moncrieff8} Critical psychiatrists vary in their views, from thinking that so-called mental health conditions are no place for typical medical involvement to accepting that the medical approach can have an important role, but not to the same extent as do mainstream psychiatrists. ^{Reference Double6}

There is extensive criticism of the role of the pharmaceutical industry’s influence on psychiatry, such as creating misleading information on the risk–benefit balance of treatment and creating demand for their products by over-medicalising problems that should, instead, be helped in a non-medication way. ^{Reference Middleton and Moncrieff8} In response to this, critical psychiatrists instead focus on addressing the social causes of the patient’s predicament and using the therapeutic benefits of supportive and accepting relationships between clinician and patient. ^{Reference Middleton and Moncrieff8}

A feature of critical psychiatry is awareness of psychiatry’s history of oppression in the service of enforcing societal norms. ^{Reference Middleton and Moncrieff8} Szasz was against the use of coercion in public but in private, according to those who met him, he said that he would agree to coercion if his children were suicidal. Many critical psychiatrists will use Mental Health Act legislation if they feel that the risks justify it, but will use their powers within a human rights-based framework to avoid abuse of these powers. ^{Reference Double6} Critical psychiatrists are aware of power dynamics between doctors and their patients and, to counteract this, adopt collaborative approaches to help patients be in the driving seat about the decisions concerning their medical care, such as prescribing medication. ^{Reference Yeomans, Moncrieff and Huws7,Reference Middleton and Moncrieff8}

Medical decision-making principles are often taught using aphorisms or rules-of-thumb that can be diverse or even oppositional. ^{Reference Montgomery10} Trainees will be taught that ‘common things occur commonly’, but also not to miss rare conditions that can have serious complications. A psychiatric example is Jasper’s dictum that psychiatrists should choose between scientific explanation and psychological understanding as to which is more useful in describing how aspects of an individual’s psychopathology arose. ^{Reference Jaspers11} Clinical judgement lies in choosing which of the aphorisms to use in a particular case. Critical psychiatry values and beliefs are often useful as part of a range of values and beliefs that can be used to guide clinical care. As a sole set of values and beliefs they can prove limited in their usefulness (see following section), and therefore it is better to integrate them with mainstream psychiatric values and beliefs to improve clinical care. ^{Reference Aftab12}

Validity of the values and beliefs of critical psychiatry

Whereas some critical psychiatrists distance themselves from Szasz, ^{Reference Double6} others are more enthusiastic about his views. ^{Reference Middleton and Moncrieff8} This is problematic, due to concerns over some of his actions. Szasz is praised for defending his views throughout his life, ^{Reference Middleton and Moncrieff8} but in reality he was fairly quickly defeated in debates and mainstream psychiatry developed answers that provided satisfactory responses rebutting his claims. ^{Reference Clare13} Szasz compromised his credibility by the alliances he made in order to gain influence and change psychiatric practice, such as accepting Scientology funding. Szasz was associated with right-wing libertarian political views rather than progressive politics. ^{Reference Morgan3} Unfortunately, UK critical psychiatry has tended to follow this path of conceptual rigidity, not changing its mind with the evidence, making unfortunate alliances to gain influence and being associated with right-wing political views (even if their personal politics are different).

Many of the claims by critical psychiatry, such as psychiatric conditions being wholly different from other medical conditions (the ‘comparativist’ critique ^{Reference Chapman14} ) and psychiatric treatments not being effective, have been rebutted using more accurate descriptions of concepts and the empirical evidence. ^{Reference Huda2} A brief review of the evidence rebutting critical psychiatrists claims now follows.

It is false to claim that general medical diagnostic constructs always name causes or pathological mechanisms, unlike psychiatric diagnostic constructs. ^{Reference Huda2} Nor can we state as true that general medical diagnostic constructs always identify valid conditions based on identified value-free lesions (Szasz’s claim) but that psychiatric diagnostic constructs never do; and so forth. ^{Reference Huda2} Another problem with the comparativist critique is that, by placing general medicine on a pedestal compared with psychiatry, it ignores the oppressive values and implicit norms within medicine as a whole. ^{Reference Chapman14}

Psychiatric treatments overlap in effectiveness for achieving clinical goals with general medical treatments (although people differ more in how much they value clinical goals in psychiatry compared with general medicine). ^{Reference Huda2,Reference Leucht, Hierl, Kissling, Dold and Davis15} Many general medical treatments do directly address the underlying causes of the condition. Nevertheless, several commonly prescribed general medical medications resemble psychiatric treatments in achieving clinical benefit without directly targeting the cause, or even having unknown mechanisms of action. ^{Reference Huda2}

Contradictory to the claim that psychiatrists mostly prescribe medication believing they are reversing the cause of the condition (disease-centred prescribing), ^{Reference Yeomans, Moncrieff and Huws7} in one survey most psychiatrists prescribed medication because of research evidence of effectiveness and not because they thought they were reversing disease (‘outcome-centred’ prescribing). ^{Reference Huda2}

Antidepressants’ small effect size averaged over groups of active treatment participants, compared with participants given placebo, ^{Reference Huda2} does not represent an ineffective treatment, but that those treated with antidepressants are more likely to have a clinically significant improvement than those given placebo (number needed to treat, 7), but the majority in each group have non-specific responses leading to the small effect size advantage on group analysis. ^{Reference Stone, Yaseen, Miller, Richardville, Kalaria and Kirsch16} This last study included Kirsch as an author, who was a prominent advocate of antidepressants having an insignificant benefit. Claims that the advantages of antidepressants compared with placebo are almost completely due to factors other than effectiveness, such as unblinding of participants in RCTs, is not supported by the evidence. ^{Reference Huda2}

Increasing sophistication of techniques and accounting for potential confounding factors by researchers are demonstrating that biological factors are associated with increased risk for developing psychiatric conditions. For example, the increase in striatal presynaptic dopamine function associated with psychosis is also found in participants who have never been given antipsychotic medication, ^{Reference Laruelle and Abi-Dargham17} demonstrating that this biological risk factor is not simply an after-effect of treatment with antipsychotics. In any case, social factors said to be the confounding factors for biological changes ^{Reference Middleton and Moncrieff8} may be distal vulnerability risk factors causing brain changes in vulnerable individuals as a more proximal risk factor for the condition. There is no simple binary between the biological and social for causation of conditions, but a complex interplay. ^{Reference Aftab, Huda and Meechan18}

The biopsychosocial model – not the reductionist biomedical model – has been the dominant model used in psychiatric clinical practice for decades. This is despite criticism of it not being explanatory for how biology interacts with psychology and social factors, ^{Reference Savulescu, Roache, Davies and Loebel19,Reference Bolton and Gillett20} although there has been theoretical work looking at the role of information as the nexus factor. ^{Reference Bolton and Gillett20} The philosophy of health distinguishes between illness and disease, and that both in psychiatry and general medicine illness can occur in the absence of identified disease. ^{Reference Huda2} When trainee psychiatrists were surveyed, they tended to weight different models (such as biological, cognitive, behavioural, psychodynamic or social) depending on the nature of the condition and, even when a biological model was favoured for schizophrenia, other factors such as cognitive models were still considered important. ^{Reference Harland, Antonova, Owen, Broome, Landau and Deeley21} This contradicts the claim that traditional psychiatry is based on all mental illness being caused by disease. ^{Reference Double6} Critical psychiatry ignores the fact that, even in biomedical tradition, there is a strong element of humanism – such as Osler advocating for holistic care (e.g. the aphorism attributed to him: ‘It is much more important to know what sort of a patient has a disease than what sort of a disease the patient has’).

The strong social constructivist debunking theory of what are called mental disorders is unlikely to be true for many cases, but social construction theory is still an important tool in explaining many factors such as clinical presentation and changing incidence (see Levy chapter in ref. ^{Reference Savulescu, Roache, Davies and Loebel19} ). Social factors are the largest determinants of health status for both general medical and psychiatric conditions. ^{Reference Huda2} It has long been recognised in medicine that it is up to politicians, and not clinicians, to change society to improve the health of the population. ^{Reference Ashton22} Psychiatrists are aware of the problems of over-medicalisation, and try to determine whether the problems presenting to them are better thought of as purely social problems rather than medical ones. ^{Reference Borelle23}

The critique of the use of natural science techniques in mental health, that they cannot provide a total explanation for human behaviour and motivations, ^{Reference Middleton and Moncrieff8} has two counterpoints. First, science also has a descriptive function that is not simply explanatory, and this allows description of the probability of outcomes of the condition (prognosis) and outcomes of treatment (efficacy). Second, science does not have to explain totally a participant’s behaviour or motivation; all it has to do is to explain enough of it to be useful for the purposes of the research. Jaspers pointed out that psychiatrists should be flexible in choosing between scientific explanation and psychological understanding as is appropriate for the case, not to discard either method entirely. ^{Reference Jaspers11}

Critical psychiatrists wish to change psychiatric practice for the better, ^{Reference Double6} and their frustration with mainstream psychiatry has led them to make alliances with other professionals opposed to aspects of mainstream psychiatry such as diagnosis, medication or even that medical doctors have a role in mental health services. Research carried out by critical psychiatrists – sometimes in conjunction with other professionals opposed to aspects of psychiatry – can often seem weak in quality. This can include technical errors in application of research techniques, biased choices in analysis to skew results, highly selective inclusion and exclusion of data, misleading interpretations of concepts and invalid inferences from empirical findings. ^{Reference Huda2,Reference Jauhar, Arnone, Baldwin, Bloomfield, Browning and Cleare24,Reference Ghaemi25}

Research from the USA has shown that psychiatry is in the bottom third of medical specialties for percentage of physicians receiving payments from industry (such as pharmaceutical companies and surgical appliance manufacturers), and for those receiving more than US$10 000 in industry payments. ^{Reference Tringale, Marshall, Mackey, Connor, Murphy and Hattangadi-Gluth26} This suggests that contemporary psychiatry is not particularly under the influence of the pharmaceutical industry as compared with other specialties. Some critical psychiatrists do not declare their conflict of interests, including financial conflicts, in their papers or books.

Critical psychiatry concerns about over-medicalisation and the harms of the sick role have been amplified in the media, contributing to a political climate of trying to reduce access to support and benefits for those with mental illness. This is more in keeping with the right-wing libertarianism of Szasz than with more progressive European critical psychiatrists. ^{Reference Morgan3,Reference Chapman14}

Summary

Critical psychiatry has a range of values and beliefs that can be usefully included when thinking about clinical practice while integrated with other more mainstream psychiatric values and beliefs. ^{Reference Aftab12} Many of the assertions and claims by critical psychiatry have been contradicted by developments in understanding of concepts and empirical evidence. ^{Reference Huda2} In science, including medicine, when someone’s views have been shown to be contradicted by the evidence the response is not usually an explicit statement admitting they got it wrong. Often what happens is that people quietly drop the disproven views from future discourse, but other views still compatible with the evidence may be promulgated instead. Nevertheless, some critical psychiatrists still persist with disproven views as if they are still tenable. This, along with other faults, may be due to following the example of Szasz when his legacy is problematic in so many ways, instead of that of Laing or Basaglia. Critical psychiatry would be better looking to Glasgow and Italy, not the USA.

Critical psychiatry should evolve its thinking instead of persisting with ideas contradicted by the evidence and developments in conceptual understanding. This would benefit itself as an intellectual tradition, and mainstream psychiatry as innovative challenge will stimulate fresh thinking and research ideas in response. Critical psychiatry is also useful in highlighting problematic areas in psychiatric practice such as neglected adverse effects of treatment. Perhaps a new generation of critical psychiatrists can raise the standard dropped by its current leadership.