Psychiatrists are very adept at criticising each other, but do not always realise that their comments are welcome fodder for angry people determined to do the profession down. Middleton & Moncrieff (Reference Middleton and Moncrieff2019, this issue) argue that critical psychiatry is not anti-psychiatry, but it is often interpreted as such. Its adherents indeed serve a useful role in pointing out some of the excesses of therapeutic claims, including those game-changing breakthroughs that turn out in time to be only incremental inches on the road to knowledge. It also helps to correct the view that drug treatments act by adjusting ‘chemical imbalance’ in the brain, to argue that culture is too often ignored in assessing the manifestations of mental illness and our view of what is normal, and that somehow the health technology of psychological treatment can replace the quality of the therapeutic relationship. Their criticisms are also important in correcting the growing belief that mental illnesses are just diseases of the brain and can soon been transferred to neurology. Their arguments against the increased use of coercion in psychiatry carry weight too.
But most of this criticism could be made without the patina of pseudoscience and philosophy that overlays it. Middleton & Moncrieff do not particularly like the link between medicine and psychiatry as the notion that medical knowledge, ‘developed to study the natural world, systematically investigating assumed-to-be immutable truths by measurement and manipulation’, is not appropriate for mental disorders. These should be understood as ‘human reactions rather than as physical diseases’. Say that again: mental disorders are not medical disorders; they are reactions. This is arrant nonsense. If we look at the history of psychiatry it is only when, and only very recently, the discipline has followed the path of medical scientific enquiry, that we have gained knowledge. Neurofibrillary tangles in Alzheimer's disease, lithium for bipolar disorder, cognitive–behavioural therapy for traumatic stress disorders, methylphenidate for attention-deficit hyperactivity disorder, therapeutic communities for personality disorder; the advances here have all been made by following systematic independent evaluation, including personal stories (Seeman Reference Seeman2006), qualitative and observational studies. All NICE guidelines follow the same approach and there is no difference in the form of this evaluation between medical and psychiatric disorders.
Critical psychiatry justifies its criticism by rejecting positivism. Positivism is a philosophy that argues that understanding can only be achieved by logic and scientific verification and that other philosophical systems are therefore of no value. Psychiatrists are trained to be logical and to use scientific data wisely. This makes them all positivists, and the most important message to get over in training is for them to be able to recognise the point when science ends and opinion takes over. This does not mean that hypotheses about matters that are not yet fully known cannot be entertained or decision-making on best available evidence not used.
An illustration of anti-positivist rhetoric
I have recently written a book for the general public on personality disorder, with a foreword by Stephen Fry (Tyrer Reference Tyrer2018). Both Stephen and I have since been assailed by angry accusations mainly beginning with the letter ‘d’ – disgraceful, demonising and disgusting, to name but a few. David Pilgrim, whom I understand to be a supporter of the critical psychiatry movement, has reviewed the content of the book pretty positively, as it ‘summarised the field with optimism’. But then he adds:
‘So why, within weeks of its publication, did he face a storm of protest and hostile reviews from service users? The main answer is that proponents of psychiatric positivism are earnestly committed to discerning what is wrong with people, before “treating” them’ (Pilgrim Reference Pilgrim and Tyrer2018).
This is where critical psychiatry goes completely awry. Good medical practice depends on correct diagnosis; good psychiatric practice and treatment should do the same. So, although we all admit that the diagnosis of personality disorder is far from ideal, even though recent changes may help a little (Mulder Reference Mulder and Tyrer2018), this is no reason for ignoring the term as a heresy against personhood.
Critical psychiatry is generally destructive
A critic's job is to criticise, but good criticism tends to be constructive. There is very little in the article by Middleton & Moncrieff that can be viewed as constructive. They write approvingly about Thomas Szasz, Michel Foucault and Ivan Illich (all authors who are worth reading), but these are like drivers who apply only the brakes, not the accelerators, of knowledge. Yes, we should be hauled up from time to time when we go ahead of ourselves but should not abandon what we have gained in our often plodding scientific enquiries. Instead of copying Ned Ludd and smashing up the knitting frames of psychiatry, critical psychiatry should be fashioning improved ones that make acceptable garments for all.
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