The origins of critical psychiatry
Royal College of Psychiatrists AGM
Edinburgh, June 22nd 2005
What is critical psychiatry?
To me ‘critical psychiatry’ means nothing more than the name implies: activities concerned with psychiatry from a critical point of view. It doesn’t refer to a single, homogeneous body of thought to which anybody could claim the copyright. In the 1960’s and 1970’s, critical psychiatry flourished and comprised a wide range of viewpoints. Of course, it had existed in the 19th and early 20th century as well, the most influential example being perhaps Clifford Beers with his book A Mind That Found Itself (1908). Moreover, during the last decade or so another wave seems to have been building up, although it’s hard to say at the moment how much impact this one will have.
The wave which started in the 1960’s gathered momentum at a spectacular rate, but ebbed away just as rapidly in the 1970’s. In 1980 I published a book on it (Ingleby, 1980/1981): unfortunately it took me and authors and publishers so long to get our act together that the movement had all but fizzled out by the time the book appeared. Fortunately, the book was reprinted last year (Ingleby, 2004). In this talk I will try and place the movement in context, describing its origins and the legacy it left behind.
The place of R.D. Laing
It is almost unavoidable to place Laing at the centre of this movement, at any rate as far as Britain is concerned, although to my knowledge he didn’t use the term critical psychiatry himself. (The label ‘anti-psychiatry’ was explicitly rejected by Laing, although many authors persist in using it to describe the movement he was part of. )
Laing’s rapid rise to fame was followed by an equally dramatic fall from grace: he became an alcoholic and was struck off the medical register. The title of a film made about him near the end of his life – Did you used to be R.D. Laing? – sums up his fate. By 1980, Laing’s work had been completely written off by the psychiatric establishment and was not mentioned at all in textbooks. (One is reminded of the way Stalin used to retouch group photos to eliminate colleagues who had displeased him). In the past few years, however, there has been a veritable Laing revival, with a whole spate of books and articles (see, in particular, Crossley, 1998; Mullan, 1999; Miller, 2004; Raschid, 2005). There is even a Society for Laingian Studies, with a highly informative web-site (http://laingsociety.org/) All this attention is well deserved and long overdue.
The importance of Laing for the critical movement was that he had a voracious appetite for ideas and came up with just the right notions at the right moment – or so it seemed at the time. This is not to say he wasn’t original: he simply had a unique gift for communicating his own and other people’s ideas and applying them in novel ways. However, as his fame grew the sources tended to be lost sight of and he was increasingly portrayed, by himself and others, as a solitary pioneer.
The agenda of critical psychiatry in the 1960’s and 1970’s
The main thrust of critical psychiatry at this time was directed against asylum psychiatry, in particular the Kraepelinian variety. The main points of criticism are well-known – to sum up:
The alternatives proposed by Laing and his colleagues are equally well-known:
What was the origin of these notions?
The mental hygiene movement
Although the link may not seem obvious, I think that the main factor which made it possible for these ideas to flourish was the mental hygiene movement. Established at the beginning of the 20th century, this was a reform movement which aimed to remedy the shortcomings of classical asylum psychiatry. It argued for a continuum concept of mental illness (along the lines of Freudian theory) instead of a rigid dichotomy between ‘them’ and ‘us’. Second, it regarded social factors as important in causing illness and breakdown. Third, it held that the mentally ill should be treated humanely and with dignity.
This movement paved the way for critical psychiatry, but it would of course be absurd to equate the two. For the hygienists, mental illness remains illness, not a label aimed at marginalising people. To call it an intelligible reaction to situations would be ‘a bridge too far’. Secondly, social causes were seen as factors, but only as partial ones: individual predispositions were just as important, if not more so.
Nevertheless, the mental hygiene movement was one of the driving forces behind the transformation of mental health care in the 20th century and made a major contribution to the rise of ambulant service provisions (see Abma, 2004). Psychotherapy, rather than medicine, was the model for these interventions. This extension of the paradigm made possible the development of social theories of mental illness and non-medicalising versions of psychoanalysis. These innovations were not fully implemented until after the Second World War, when many new disciplines became involved in the field of mental health. A whole range of new approaches was propagated, including interpretative and sociological ones. In the 1960’s, therefore, classical asylum psychiatry was already being pushed into the background.
Hermeneutics and phenomenology
Since Freud, professionals had been listening to patients and interpreting what they said, but this activity was mostly confined to ‘up-market’ neurotic patients. Laing was trained as an analyst in the somewhat eclectic British tradition, but he soon parted company with this profession. He extended psychoanalytic interpretation to the clientele of asylums: marginalized psychotics. Though Freud had regarded this as a waste of time, the Kleinian approach made it theoretically more viable. (Accordingly to Melanie Klein, viewing things from a ‘paranoid-schizoid’ perspective was a fundamental human disposition.)
A more important source of inspiration for Laing was phenomenology. He read avidly in continental philosophy and discovered Merleau-Ponty, Binswanger and Jaspers. Encouraged by his friend Joe Schorstein, he realised that there was a whole world out there where people talked about ‘human experience’ and ‘intentionality’. Laing nearly went to study with Jaspers in the 1950’s, but his employer (the British Army) put a stop to this plan.
The intellectual culture of the post-war British establishment, especially that of psychiatry, was notoriously insular and philistine. When I read philosophy at Cambridge in the 1960’s, students were taught that continental philosophy was simply mumbo-jumbo which they could safely ignore. In the Netherlands, by contrast, critical psychiatry appealed to professionals because the psychiatric establishment was already partially converted to the cause. Social psychiatry and phenomenological approaches – the ‘soft’ side of German psychiatry – already had a firm foothold within the psychiatric establishment (Abma & Weijers, 2005). This is one reason why critical psychiatry was a much more successful movement in the Netherlands than in Britain (Ingleby, 1998).
Another source of inspiration for critical psychiatry was American sociology. Starting with Talcott Parsons in the 1950’s, American sociologists had discovered the topics of illness, health, and medical power. Most research started from a hermeneutic paradigm, using symbolic interactionism or ethnomethodology. (Erwin Goffman’s work provides a particularly powerful example.) In addition, American family therapists introduced systems theory and a ‘pragmatic’ approach to communication. The roots of all these approaches can be found in elements of the European Geisteswissenschaften which had been transported across the Atlantic to the New World in the 19th century.
General social changes: the ideological climate
The main driving force behind critical psychiatry was not a specific author, but a feeling that was in the air. The 1960’s were a time of profound social change in the West. Traditional, taken-for-granted institutions were challenged, established authorities became targets of scorn and received wisdom was stood on its head. Almost everybody was affected in some way by this climate of social ferment.
Critical psychiatry added its voice to other protest movements, presenting classical psychiatry as a kind of police force which enforced unwritten social rules and administered sanctions without judge or jury. Thus, it saw psychiatry as basically a social control mechanism. The reduction of deviant people’s experience and actions to pathology, their ‘reification’ through the use of the positivist paradigm, served to invalidate and disempower individuals.
A core concept in the 1960’s was ‘liberation’ and critical psychiatry aimed to liberate mental patients by restoring their humanity. It also emphasised the need to liberate ‘normal’ people too – not simply from external oppression, but from a state of internal alienation from their own feelings, thoughts and perceptions.
It is worth noting that the notion of patients’ rights had also been central to the mental hygiene movement and that human-rights arguments were used frequently in the 1960’s to challenge the social exclusion of the mental ill. There was a wave of legal challenges to incarceration, especially in the USA. Perhaps, in the last analysis, this had to do with the fact that mental health care had gone ‘up-market’: asylum psychiatry was developed for social outcasts and the way it treated its clientele was not acceptable to middle-class citizens. (Clifford Beers, after all, was the Yale-educated scion of a wealthy family.)
I have tried to give a thumbnail sketch of the main ideas of critical psychiatry and the influences behind it. At the time, there were a lot of people inside the mental health professions who took these ideas very seriously. Notice that we are talking about ‘mental health’ here and not simply about psychiatry: what was playing itself out was to large extent a power-struggle within the mental health sector. From the 1950’s onwards, ambulant services started their enormous expansion and asylum psychiatry lost its virtual monopoly of mental health service provision. Other disciplines crowded in to get a piece of the action. For the rivals of asylum psychiatry, the devastating critique which critical psychiatry mounted was music to their ears and grist to their mills.
Critical psychiatry was a world-wide phenomenon and in my book I tried to showed the various ways in which it had taken shape in different countries, including Italian ‘democratic psychiatry’; American sociological approaches and ‘radical psychiatry’; and the peculiarly French approach, combining Foucault, Deleuze and Guattari and Lacan. In Britain, the therapeutic community movement had shown that there were other things you could do in a mental hospital besides turning people into zombies.
Decline and fall
As I said, by 1980 critical psychiatry in Britain had more or less fizzled out as a movement. What went wrong?
By the 1970’s, the major figures in the movement had already given up trying to influence mental health policy. When I first met Laing in 1964 I got the impression that he very much wanted to be taken seriously by the British psychiatric establishment. The fact that his ideas were treated with such incomprehension and contempt was, I think, an enormous disappointment to him. After a few years of this, he gave up on his own profession and discovered a different mission. Or rather, the same mission transposed to a global arena – the struggle against alienation from oneself and against the social exclusion of those who dared to be different.
Thus, critical psychiatry adopted increasingly extreme standpoints during the 1970’s and detached itself from the mainstream of progressive opinion within mental health. As Colin Jones (1998) has put it, the movement "constructed a heavily contrastive version of its opponent". This extreme message alienated moderates. Laing and his affiliates were not interested in forming a broad front for mental health reform: the movement split up into hardliners, softliners and mystics. The chance for an alliance was missed. This is in strong contrast to the situation in Italy, where Basaglia’s ‘democratic psychiatry’ created a powerful coalition of doctors, nurses, writers, artists and politicians.
Shortcomings of critical psychiatry
With the benefit of hindsight I think it is possible to see in what respects critical psychiatry in general, and Laing in particular, failed to present an effective analysis of the problems.
Psychiatry instead of mental health
The target of critical psychiatry was a crudely reductionist organic approach and the construction of a rigid barrier between ‘them’ and ‘us’. (Let us not forget that the first psychiatrists were called ‘alienists’.) Methods of diagnosis and treatment were seen as violence. Yet this is the battle which the mental hygiene movement had fought and largely won: asylum psychiatry, as we have seen, was already on the retreat.
Modern mental health is much more that asylum psychiatry and it comprises many sectors, disciplines and paradigms. The ‘continuum’ approach has become the new orthodoxy. This is where the criticism needs to be focussed, for the ‘continuum’ approach has revealed itself to be a Trojan horse. Now that the DSM is no longer tied to theoretical causes of illness, ‘pathology’ can be extended to cover every imaginable sort of human activity. You don’t need to be very crazy to be ‘in need of treatment’. At the moment, a fierce battle rages between ‘expansionists’ and ‘conservatives’ over the inclusion of the so-called ‘mild’ disorders in the next edition of the DSM.
This is not so much social control as social management; ‘violence’ is not the appropriate term any more, because treatment is usually consensual. In his later works, Foucault makes a crucial distinction between ‘repressive’ and ‘productive’ power, and most of the mental health system falls into the latter category. Productive power produces its own reality. A population can avidly internalise psychiatric notions and discipline itself. Criticism of mental health therefore needs a broader focus and new theoretical tools.
An unfortunate habit which critical psychiatrists often took over from classical psychiatry was the monocausal approach. The origins of schizophrenia had to be either biological or social: they could not be both. The result was a sort of social reductionism and far-reaching claims which were all too easy to invalidate.
Focus on schizophrenia
Given the preoccupation with asylum psychiatry, critical psychiatry’s focus on schizophrenia was entirely understandable. Nevertheless, this is hardest condition of all to make intelligible in common-sense terms and to relate to social factors. It is much easier, for example, to show links between depressive and anxiety disorders on the one hand, and factors such as poverty, unemployment, urbanisation and social exclusion on the other.
The new Dark Ages
Social approaches to mental health began to stagnate after the 1970’s. Sociological approaches were everywhere in retreat, and the more extreme claims of critical psychiatry were discredited. In Britain, at least, the movement seemed to have been swept away as if it had never happened. Within mental health services a gradual shift of power back to psychiatry began to occur.
These changes took place against a background of recurrent financial crises. Demand for mental health services increased, but the oil crisis in 1972 plunged Western economies into recession. Mrs. Thatcher introduced ‘Reaganomics’ into Britain and the budget for health and social services was cut drastically.
This ushered in the era of Managed Care – a new bogey for professionals and patients alike. This new alliance of positivism and managerialism created strange bedfellows. Managed Care represents an attack on professional autonomy, whether the professional happens to be a phenomenologist or a brain surgeon.
During the same period, organic psychiatry made a spectacular come-back: once vilified, it now became prestigious – the 1990’s were ‘the decade of the brain’. Psychiatry entered into an alliance with the pharmaceutical industry and discovered an enormous market. David Healy was only slightly exaggerating when he wrote (2001): "Both psychiatry and anti-psychiatry were swept away and replaced by a new corporate psychiatry." This, in combination with managed care, has completely altered the landscape of mental health care – and defined a new agenda for critics.
A glimmer of light on the horizon
However, history shows that movements in mental health are but swings of the pendulum. This one, moreover, would seem to be past its peak, as the following observations would seem to suggest:
Reaction against medicalisation.
The medicalisation of deviance and distress seems to have got completely out of hand. In 2002 an entire issue of the BMJ (13 April) was devoted to this problem. Today, medicalisation does not even require an imputed disease as its basis: anything which is more than a couple of standard deviations from the norm is potentially a candidate for treatment. The backlash against excessive medicalisation is accompanied by a return to what I have called the ‘normalising’ approach. Frank Furedi (2003) is a hardliner in this respect.
The debate about ‘traumatised refugees’ is a case in point. Here, the target of critics is the depoliticisation of organised violence (‘persecution, torture and rape are bad for your health’) and its reduction to an individual level. The work of Derek Summerfield represents a sustained and eloquent challenge to this form of unwarranted medicalisation.
Challenges to pharmaceutical industry
Thanks to the activities in recent years of a few courageous ‘whistle-blowers’, public ignorance about the unethical and anti-social activities of the pharmaceutical industry has been dispelled. Perhaps the most disquieting of these revelations concerns the way in which even the publication of scientific research is manipulated in line with the interests of this immense and powerful industry. Partly as a result of this, the blind faith in chemical answers to human problems seems to be eroding.
Questions about the concept of schizophrenia
The notion that schizophrenia is a brain disease has been, as it were, the flagship of classical psychiatry: that is precisely why Laing chose to attack the notion. However, the search for a biochemical marker with a clear causal role still continues, and meanwhile the unitary nature of the diagnosis is being challenged (e.g. Boyle, 2002; Blom, 2004). The ‘hearing voices’ movement has showed how unclear the dividing-line between normal and abnormal can be.
More power to mental health service users
The more flagrant forms of violence which were the target of anti-psychiatry are much less in evidence today. Indeed, the case for forcible treatment is again having to be argued: to the dismay of governments concerned with public order, psychiatrists have become reluctant to resume the role they previously had as ‘mental police’.
Meanwhile, users of mental health services have acquired other kinds of power. In accordance with the principles of ‘needs-driven care’, they now have a much stronger voice in service provision than thirty years ago. More attention is paid to their satisfaction and their point of view – even if, all too often, this is only to improve their level of ‘compliance’ with treatment. The increased power of the ‘consumer’ of mental health care is one of the few benefits of the market-oriented approaches now in fashion. In spite of all these improvements, however, combating the social exclusion of mental patients remains an urgent priority.
The challenge of multicultural mental health
As I mentioned above, the theories used to regulate behaviour in modern societies have a self-fulfilling character: in Foucault’s terms, they produce their own reality. It is hard to persuade people of the inadequacies of a diagnosis such as ADHD when parents are queuing up to have their children treated and the children themselves use the term in their own playground slang. However, the influx of migrants into Western countries, as well as the export of mental health services to the developing world, bring mental health care into contact with populations that have not already internalised its basic concepts and working methods.
One response to this challenge is simply to try and assimilate the new users to the established system (e.g. by ‘psycho-education’). Another, however, is to revise the basic assumptions of mental health care in such a way as to make them more appropriate and better matched to new populations.
Transcultural mental health care today thus places a strong emphasis on approaches which listen to the voice of users, as opposed to imposing pre-existing categories and concepts on them. These approaches have been largely pioneered within the discipline of medical anthropology. The essential continuity with the otherwise almost defunct tradition of phenomenological psychiatry is shown by the fact that a forthcoming conference* on phenomenology in psychiatry will be addressed by one of the doyens of transcultural psychiatry, Arthur Kleinman.
To sum up: in all these ways, we can see that the themes which critical psychiatry placed on the agenda forty years ago are once again coming to the fore within mental health care today. Perhaps this optimistic note is a good one to end on.
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