What is Critical Psychiatry?

Philip Thomas, MD
January 21, 2013
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, hasnt 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 Ill 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
Im 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:
1. The problems of diagnosis in psychiatry
2. The problems of evidence based medicine in psychiatry, and related to this, the relationship between the
pharmaceutical industry and psychiatry.
3. The central role of contexts and meanings in the theory and practice of psychiatry, andthe role of the contexts in
which psychiatrists work.
4. The problems of coercion in psychiatry.
5. 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 Parkinsons 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 there 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 doesnt 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 industrys 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 industrys 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 nations 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.

References
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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. (1
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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.

Philip Thomas, MD
English Madness: The founder and co-chair of the Critical Psychiatry Network, psychiatrist Philip Thomas writes of madness,
meaning and culture.