Presentation at a retreat of New York Group for the Association for the Advancement of Philosophy and Psychiatry (AAPP) (http://alien.dowling.edu/~cperring/nycaappretreat2004.html)
Critical psychiatry: A neo-Meyerian perspective
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Most of you, I imagine, will not be aware of critical psychiatry. I am a member of the Critical Psychiatry Network (CPN), which first met in Bradford, UK, in January 1999. It is a small group of psychiatrists that forms a network to develop a critique of the contemporary psychiatric system.
The first meetings of the group coincided with publication of the UK government's intention to undertake a root and branch review of the Mental Health Act 1983. The initial phase of this review involved a scoping exercise, undertaken by a small expert group, to which CPN submitted evidence. CPN has also responded at each stage of the subsequent consultation process leading to the recently published draft Mental Health Bill 2004.
CPN's position statement in October 1999 made clear its opposition to compulsory treatment in the community, and preventive detention for people who are considered to have ‘personality disorders’. A new response to the conflict between care and coercion was proposed that recognised the way values inform medical decisions. This ethical perspective resists attempts to make psychiatry more coercive.
Critical psychiatry is partly academic and partly practical. Theoretically it is influenced by critical philosophical and political theories. Three main elements have been identified: (1) a challenge to the dominance of clinical neuroscience in psychiatry (although this is not excluded); (2) a strong ethical perspective on psychiatric knowledge and practice; and (3) the politicisation of mental health issues.
Over recent years, it has become popular to regard critical thinking as something that can be taught. Critical thinking involves getting into the habit of reflecting on our inherent and accustomed ways of thinking and leads to action in every dimension of our lives. Similarly, critical psychiatry wants to promote critical reflection on practice and research in psychiatry.
More generally, critical psychiatry is supported by critical theory, which is a term that tends to be used quite loosely to refer to a range of theories that take a critical view of society. Critical theorists include such people as Roland Barthes, Michel Foucault, Jacques Derrida, Julia Kristeva, and Judith Butler, who do not necessarily fit easily into any one discipline. In particular, perhaps, critical theory seeks to understand how systems of collective beliefs legitimate various power structures. In relation to psychiatry, this can be applied to appreciating why people are so ready to adopt the biomedical model in psychiatry. Critical theory has also distinguished itself through its critique of science as positivism. In other words, there is a tendency to believe that natural science is the only valid mode of knowledge and that progress continues to be made in uncovering facts through science. However, critical theory recognises that verifiable knowledge about the mind is as essential as natural scientific facts.
The sceptical attitude of CPN to the use of psychotropic medication has influenced contributions as a stakeholder to various guidelines produced by the National Institute for Clinical Excellence (NICE), which produces recommendation for treatment in the UK National Health Service (NHS) The scientific limits of the possibilities of randomised controlled trials are acknowledged, as is the general bias in the interpretation of the data.
CPN's campaigning on the reform of the Mental Health Act has emphasised the importance of rights to advocacy and advance statements. It is also currently campaigning against pharmaceutical company sponsorship of psychiatric conferences and educational activities. CPN has also organised and participated in various conferences, where papers have been presented which develop the notions on which critical psychiatry is based. Some of these papers have been published on its website (www.criticalpsychiatry.co.uk), as have the other documents prepared by the group.
The Critical Psychiatry Network has never hidden its historical link with so-called "anti-psychiatry". However, the label anti-psychiatry needs to be understood for what it is. The terminology was disowned by both RD Laing and Thomas Szasz, two people who are probably most closely and consistently identified with the anti-psychiatry movement. The general view is that anti-psychiatry was a passing phase in the history of psychiatry and that it is no longer of any influence.
In a way, the spectre of "anti-psychiatry" has functioned as a means of identifying and thereby marginalising psychiatry's critics. There is an orthodoxy about current psychiatric practice that feels threatened by any challenge to its foundation. Identifying psychiatry's critics as its opponents, therefore, allows them to be confronted and undermined.
Not all psychiatrists have seen the issue of anti-psychiatry in this way. For example, Kees Trimbos, one of the founders of Dutch social psychiatry, in his book on anti-psychiatry in 1975 warned against supposing that it was just a fad. To quote from him, "After all, anti-psychiatry is also psychiatry!" The Critical Psychiatry Network also wishes to avoid the polarisation created by the antagonism between psychiatry and anti-psychiatry. Being open to the uncertainties of psychiatric practice needs to be encouraged.
Anti-psychiatry had a popular, even romantic, appeal as an attack on psychiatrists' use of psychiatric diagnosis, drug and ECT treatment and involuntary hospitalisation. The apparently anti-authoritarian nature of anti-psychiatry obscures how much the ideas that amounted to anti-psychiatry predated its emergence.
This is the issue I wish to examine in this presentation. In particular, I wish to highlight the extent to which a biopsychological model of mental illness has been promulgated within mainstream psychiatry, and to see this model as essential to anti-psychiatry and critical psychiatry. Although the somatic hypothesis has always been the dominant model of mental illness, the view that mental illnesses have primarily psychological and social causes is not new.
In retrospect, this view may merely have held sway during a brief interlude in the psychiatry. Freud first spoke publicly on psychoanalysis in an American university in 1909. In the 1950s, post-Freudian views dominated American psychiatry with biological psychiatrists in a minority. During the 1960s and certainly by 1970 in the USA, the biological model of mental illness reasserted its dominance, as the power and attractiveness of Freudian psychology declined.
Besides psychoanalysis, the first half of the 20th century also witnessed the formulation of Psychobiology, a term used for the work of Adolf Meyer. Meyer was an immigrant to the United States from Switzerland. He had an important role in American psychiatry and was arguably the foremost American psychiatrist in the first half of the twentieth century. His theoretical approach has not always been well articulated. Although he lived in the United States for many years, he had a rather convoluted style of communication in english. His ideas never really took hold as a systematic theory of psychiatry. Few references are now made to his writings in the literature. His collected works have been published, but are little read.
Essentially Meyer saw his views as an advance over the mechanistic notions of mental illness of the 19th century. He regarded the person as the focus for theory and practice in psychiatry. Psychiatric assessment should concentrate on understanding the patient as a person.
Such a biopsychological perspective can be contrasted with the biomedical approach of Emil Kraepelin. For example, Kraepelin viewed the origin of schizophrenia (or dementia praecox, as it was then called), like manic-depressive illness, as a single morbid process. Meyer questioned the biological basis of Kraepelin's concepts and had a psychogenic understanding. He believed that such psychological understanding should apply to dementia praecox as much as for any other psychiatric disorder. The reasons why people become psychotic are not understood by suggesting that such a process happens because of a condition behind the symptoms called dementia praecox.
Typically, Meyer called speculation about the biological basis of mental illness 'neurologising tautology'. The infamous psychiatrist, Thomas Szasz has been criticised for suggesting that mental illness is a 'myth'. Although Meyer would not have agreed with Szasz that the notion of mental illness is meaningless, he did concur with Szasz's contention that belief in mental illness as a disease of the brain is a negation of the distinction between persons as social beings and bodies as physical objects. To quote from Meyer, "Very often the supposed disease back of it all is a myth and merely a self-protective term for an insufficient knowledge of the conditions of reaction."
Meyer's views are important because of the increasing hegemony of the biomedical model over the last 40 or more years. In fact, the drive to create a systematic biological perspective over recent years was at least partially driven by the wish to replace the perceived vagueness about psychiatric diagnosis blamed on the Meyerian perspective. Other factors were of course also important in encouraging the biomedical somatic hypothesis, such as the increasing development and marketing of psychotropic medication, related to biochemical theories of mental disorder.
I do not want to overestimate the differences in psychiatry 40 years ago compared with the present. The dominant model of mental illness has always been biomedical. The natural assumption has been to presuppose that mental illness is a physical disease and that the "answer" will be found in biological discoveries. However, I do want to highlight the relative pluralism of the psychiatry of the past. Modern psychiatry has become so governed by biological psychiatry that we need to be reminded that biopsychological perspectives are not new.
In mid-twentieth century, there was little in the way of psychotropic medication. Although there was a certain enthusiasm for physical treatments such as electroconvulsive therapy (ECT) and insulin coma therapy, there was much interest in psychoanalysis and psychotherapy. A disparity existed between the relatively pessimistic situation regarding therapeutic options for serious psychiatric illness and increasing investment in outpatient work with neurotic and people with personality disorders. In the USA in particular, the highest calling was to go into psychoanalytic training. At the Maudsley hospital in London, the centre of postgraduate psychiatry in Britain in the early 1950s, and one of the best in the world, half of the trainees were in analysis. There were Freudian, Kleinian and Jungian trainees, all vociferously defending their schools.
Meyer ultimately rejected psychoanalysis but still encouraged a psychological understanding in terms of the patient's life history. More generally, psychoanalytic theories were re-evaluated by focusing on environmental factors and the critical nature of disturbances in human relationships.
Others taking this kind of approach included William Alanson White. During the first third of the 20th century, he was one of America's leading psychiatrists and played a major role in the introduction of psychoanalysis in the United States. He was also mentor to Harry Stack Sullivan. The interpersonal approach of Sullivan focused on relationships and the effects of the individual's social and cultural environment on inner life.
In the immediate post-war years, Karl Menninger's The Vital Balance represented a broadly conceived psychosocial theory of psychopathology. As Menninger himself says, "As a result of Meyer's efforts and those of William Alanson White, American psychiatrists began to ask, not "What is the name of this affliction?" but rather, "How is this man reacting and to what?"" American psychiatry came to have a distinctively pragmatic, instrumental and pluralistic approach.
Contrast this pluralism with the current dominant emphasis on natural scientific causation, rather than psychologically meaningful experiences. This trend has been reinforced by factors like the therapeutic advances in psychopharmacology since the introduction of chlorpromazine and the development of brain imaging. These biological perspectives tend to lack the whole-person viewpoint of a biopsychological approach.
The attempt to make psychiatric diagnosis more reliable, combined with a return to a biomedical model of mental illness, has been called the "neo-Kraepelinian" approach. I want to look at the neo-Kraepelinian perspective as the modern representative of the biomedical model in psychiatry. I then want to move on to compare the neo-Kraepelinian position with the views of Adolf Meyer, and to relate Meyer's views to critical psychiatry.
The modern explicit and intentional concern with psychiatric diagnosis contrasts with earlier views, such as Meyer's, de-emphasising diagnosis in favour of understanding the life story of the individual patient. Psychiatric diagnosis became increasingly codified following the original paper by Feighner et al and the introduction of the Research Diagnostic Criteria, through editions of the latter revisions of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-III, DSM-IIIR and DSM-IV). Symptom checklists and formal decision-making rules for psychiatric diagnoses were produced. This operationalisation of diagnostic criteria was developed specifically to respond to criticisms of the basis of psychiatric classification.
Neo-Kraepelinianism regards psychiatry as a scientific, medical speciality that qualitatively differentiates mentally ill patients, who require treatment, from normal people. Scientific psychiatry's task is to investigate the causes, diagnosis and treatment of different mental illnesses, which are seen as discrete from each other. Biological aspects of mental illness are regarded as psychiatry's central concern. Diagnosis and classification are intentionally viewed as important. Belittling of the value of psychiatric diagnosis is discouraged. Mental illness certainly should not be seen as a myth. Instead diagnostic criteria should be codified and research should attempt to validate these criteria, using statistical techniques to improve reliability and validity.
The most visible product of the neo-Kraepelinian movement was the third edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-III). The change in diagnostic classificatory systems between DSM-II and DSM-III was dramatic. This can be seen if only from the size of the manual. The chapter related to psychiatric disorders in DSM-II is a thin pamphlet. In contrast, DSM-III it is a large textbook.
Robert Spitzer chaired the task force that produced DSM-III. Spitzer was so panicked that psychiatric diagnoses may be unreliable, because of attacks from labeling theory and anti-psychiatry in general, that he made every effort to ensure that they were clearly defined. The inherent vagueness in category definitions, which could be linked to Meyerian views and other pragmatic perspectives, was blamed. Although careful analysis of the evidence presented in reliability studies of psychiatric diagnosis may not be as negative as is commonly assumed, the commitment to increase diagnostic reliability became a goal in itself. Transparent rules were laid down for making each psychiatric diagnosis in DSM-III.
In retrospect, what could be seen to have happened is that the response to the attack on psychiatric diagnosis, to which DSM-III responded, also served to undermine the Meyerian perspective. The neo-Kraepelinian approach provided an argument for mainstream psychiatry to re-establish the reality of mental illness, seen as under threat from anti-psychiatry.
Meyerian ideas, if they are restated, now appear tainted with the unorthodoxy of anti-psychiatry. It is almost as though they are held responsible for allowing the threat of anti-psychiatry to be taken so seriously. The underlying assumption seems to be that if psychiatry had not allowed itself to become so imbued with the vague and woolly ideas of Meyer about diagnosis, anti-psychiatry would not have been able to take such hold and to have had such credence. The biomedical model, reinforced in its neo-Kraepelinian form by the operationalisation of diagnostic criteria, has again become dominant in current psychiatric practice.
Meyer, of course, did not fail to recognise the neurobiological substrate of mental states and behaviour. His emphasis on the person, however, meant that mental illness was understood as a maladaptation in terms of the patient's life experiences Although he maintained an interest in neuropathology, biological considerations hardly ever arose in dealing with everyday psychiatric problems. In contrast, modern psychiatric practice tends to focus on biomedical matters.
Meyer was concerned about a positivistic view of science, in the sense that he did not believe that what we need is simply more scientific ‘findings’. For example, at the time he was practising, he regarded the advent of insulin shock therapy as a resurgence of medical emphasis where humane psychological interest should have prevailed. Biological psychiatry has continually perpetuated the illusion that just round the corner lies some vital new discovery that will settle the arguments once and for all. For Meyer, there is already a wide range of facts, usually left to untrained common-sense. The job of the psychiatrist is to organise this information as a collection of methods of study and therapeutic procedures. For biomedical psychiatry, such a view is too unscientific. To quote from Roth & Kroll's book The reality of mental illness: "Such a closure of the model at the level of vague statements that all factors are important and must be taken into account threatens to interfere seriously with the continued progress of medicine".
Psychiatry is a form of hermeneutical science in that it recognises the importance of interpretation in establishing objective facts. It is part of the human sciences, not natural sciences. Biomedical psychiatrists to buttress their case should not abrogate the authority of science. There is a perceived certainty about the biological viewpoint, which is highly valued and gives an apparent justification to the biomedical hypothesis. As there are difficulties in deciding a priori between the legitimacy of the biomedical and biopsychological models of mental illness, factors like this do sway heavily.
In summary, Meyer and the neo-Kraepelinian approach find different ways of accommodating to two main conceptual issues (i) the mind-body problem and (ii) the application of scientific method to the study of human nature. Meyer sought an integration of mind and body, whereas biomedical psychiatry postulates an underlying physical lesion as the cause of mental illness. The neo-Kraepelinian approach encourages a positivistic view of mental science, whereas Meyer recognised the interpretative nature of human knowledge.
Critical psychiatry is a new approach that emphasises the significance of social, political, and cultural contexts for the understanding of mental illness. In a way, it could be seen as the restatement of a biopsychological approach in a post anti-psychiatric age.
My colleagues, Pat Bracken & Phil Thomas have called their new direction for mental health practice "post-psychiatry". This approach does recognise the importance of empirical knowledge, and it gives priority to interpretation and to meaningful experiences. It argues that mental health practice does not need to be based on an individualistic framework centred on medical diagnosis and treatment. It is about creating a space in which a new debate about mental health, which is open, genuine and democratic, can take place.
Bracken & Thomas suggest that post-psychiatry is the post-modern deconstruction of modernist psychiatry. Following the Enlightenment, the concept of psychiatry developed as a separate area of medical endeavour. For example, Foucault views the associated emergence of institutions in which mad people were housed as the 'The Great Confinement'. Post-psychiatry sees the modernist agenda as no longer tenable because of various post-modern challenges to its basis. These include the questioning of simple notions of progress and scientific expertise. The rise of the user movement, with its challenging of the biomedical model of mental illness, is seen as being of particular importance. Recent government policy emphases, at least in the UK, on social exclusion and partnership in health are viewed as an opportunity for a new deal between professionals and service users.
Post-psychiatry takes its philosophical foundations from 'hermeneutical' philosophers such as Wittgenstein and Heidegger and the Russian psychologist Vygotsky. Such approaches give priority to meaning and interpretation rather than causal explanation.
Post-psychiatry also emphasises the importance of values rather than causes in research and practice. This theme chimes with the so-called "new philosophy of psychiatry", a term used by Bill Fulford.
Post-psychiatry, therefore, is probably the best-articulated form of critical psychiatry. However, critical psychiatry covers a broad span of approaches. Personally, I do not see there is a need to use the discourse of post-modernism. There may be advantages in not doing so, for example, the avoidance of philosophical critiques of post-modernism, such as that it tends to retreat into the irrational.
What I prefer is to point to the more general link to what I have been calling the pluralistic emphasis in psychiatry of the past. In many ways, post-psychiatry is not a new direction. What is crucial is that psychiatric practice is not taken for granted. It needs to be self-conscious, self-critical and non-objectifying. Its world-view, collective beliefs and attitudes need to be examined. This is why I prefer the term critical psychiatry. I am using the term 'critical' in the sense of "characterised by careful, exact evaluation and judgement" and "of the greatest importance to the way things might happen", and not just "inclined to find fault, or to judge with severity."
When Gerald Klerman enunciated the neo-Kraepelinian perspective, he expected a neo-Meyerian response. It seems to have been slow to be constituted. What I am suggesting is that this may be because the neo-Kraepelinian movement conflated opposition to Meyerian principles of diagnosis and the perceived threat of anti-psychiatry. In my view, the Meyerian approach, to remove the taint of the unorthodoxy of anti-psychiatry, needs shamelessly to acknowledge its affinity with anti-psychiatry.
The problem is that anti-psychiatry itself is not always well defined and understood. In particular, there is a failure to appreciate the differences between RD Laing and Thomas Szsaz. Both are regarded as anti-psychiatrists, but they were in fact both very rude about each other. Essentially, Szsaz rejects the notion of mental illness as a logically coherent concept, because "illness" must be physical. By contrast, Laing is concerned with understanding mental disorder, which is not a disease in the medical sense, but a reaction to unbearable life stresses.
Certainly, there were many excesses in what was identified as 'anti-psychiatry'. For example, David Cooper saw the dawning of a non-psychiatry, a society without madness or psychiatry, which could only be reached in a transformed, genuinely socialist society. In essence, many anti-psychiatrists were more interested in personal growth, rather than changing psychiatry.
However, there are links between anti-psychiatry and Meyerian psychobiology. For example, this affinity was recognised by Boyers & Orrill when they chose to interview Theodore Lidz for their edited collection of what they considered at the time it was published in 1972 to be most of the serious writing that had been addressed to the work of R.D. Laing. Lidz was professor and chief of clinical services in psychiatry at Yale, having taken his residency in psychiatry at John Hopkins University, where he studied with Adolf Meyer. In the interview, Lidz identified various excesses in the work of Laing, but he made clear that he did not consider schizophrenia to be an organic disease and instead viewed it as a developmental reaction related to personality organisation.
Lidz complained that when Laing discussed mystification in the family that he did not make reference to his and his colleagues' work that covered similar ground dealing with irrational patterns of communication in the family. Lidz pointed out that Adolf Meyer had advocated taking experience as a fact in itself, which is close to Laing's perspective and that very little of what Laing proposed was new.
Laing did acknowledge the influence of similar biopsychological ideas, such as the interpersonal psychiatry of Harry Stack Sullivan. He also recognised the significance of the William Alanson White Foundation, where there was a tradition of analogous views, albeit modified from psychoanalysis.
Both Laing and Meyer recognised that the term mental illness is used metaphorically. Both Laing and Meyer recognised the psychological aetiology of mental illness. Both Laing and Meyer did not take a deterministic view of the science of human nature.
In other words, Laing essentially had a biopsychological understanding of mental illness. He quoted favourably from such psychologically minded psychiatrists as Manfred Bleuler. I am not disputing that there is a sense in which Laing wished to go a step further and to "abandon the metaphor of pathology" altogether. However, essentially Laing had the same basis of understanding of mental illness as Adolf Meyer.
Critical psychiatry seeks to move beyond the polarisation created by the opposition of psychiatry and anti-psychiatry. To my mind, this means re-establishing its origins in the biopsychological approach of Adolf Meyer. This is not easy when the current biomedical consensus is so dominant. However, there is as much of a consensus for the interpretative, biopsychological perspective. It is just struggling to be re-stated after the turmoil caused by anti-psychiatry. Critical psychiatry is my proposed synthesis.