Critical Psychiatry or Antipsychiatry?

Peter Tyrer wrote a commentary on Critical Psychiatry in a recent edition of British Journal of Psychiatry Advances.  It was in response to a paper by Middleton and Moncrieff that focuses primarily on distancing critical psychiatry from antipsychiatry. Dr. Tyrer is very clear about the fatal flaws of critical psychiatry. He takes on Middleton and Moncrieff’s false dichotomy between medicine psychiatry and characterizes it as "arrant nonsense". He cites a few of the many lines of evidence that psychiatry developed as a medical discipline and that great majority of us are still on that pathway.

He also takes on the pseudoscience and philosophical aspects of critical psychiatry most notably the lack of positivism. His definition 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”. That makes psychiatrists in the training program of psychiatrists positivist in nature. This is a significant difference since much of critical psychiatry does not depend on logic or science.   That is an unappreciated difference for many people who use philosophy to criticize psychiatry. I have an excellent example on this blog of a philosopher who decided that the DSM-5 was really a recommended blueprint for living by psychiatrists. It was clear from his position that he had no knowledge of the DSM-5, had not discussed it with a psychiatrist, and did not know how it was applied. Even those limitations did not prevent him from giving a philosophical opinion on what was wrong with the DSM-5. That is a clear example of criticism that has no value.

Dr. Tyrer’s second major point has to do with the critical psychiatrists criticism of the diagnostic process. He had co-authored a book on personality disorders for the general public and apparently got a “storm of protest and hostile reviews from service users”. The critical psychiatrist writing the review suggests that this was due to the standard medical sequence of diagnosis and then treatment. Apparently the critical psychiatry thinking is that people can be “treated” or not without making a diagnosis. One of the distinguishing characteristics of critical psychiatry is vagueness. In reading the writings of critical psychiatrists how they actually practice psychiatry is unclear. Why people see critical psychiatrists is really not clear. The outcomes of critical psychiatry practice is even less clear. The associated issue illustrated here is that critical psychiatry is a social media magnet for people who are self proclaimed experts who find it easy to embrace rhetoric rather than study science.

Dr. Tyrer’s commentary starts out in a charitable way where he suggests that critical psychiatry may have a useful role in pointing out there is frequently exuberance about a particular new therapy that never pans out. In my experience, noncritical psychiatrists and average clinical psychiatrists provide the best criticism and feedback in that area. He incorrectly cites “chemical imbalance” theories as legitimate criticism by critical psychiatrists. In my library I have 40 years of psychopharmacology texts and not a single one of them refers to “chemical imbalance”. To me chemical imbalance is a red herring marker of both anti-psychiatrists and critical psychiatrists. He points out the importance of culture and suggest that this is another area where critical psychiatrists may have a role. The role of culture has been discussed in the DSM, many departments of psychiatry have cross-cultural departments with interpreters, and in the past 20 years I’ve attended numerous conferences where cross-cultural psychiatry was either the main component or one of the significant lectures. I doubt that critical psychiatry as had anywhere near the impact of regular psychiatrists who go to work every day and practice cross-cultural psychiatry. He cites “coercion” in psychiatry is another area where critical psychiatry may have some legitimacy. In fact, every state in the United States as safeguards written into their statutes that describe the circumstances where involuntary treatment may be ordered by a court. Critical psychiatry and anti-psychiatry continue to confuse the legal system, psychiatry, and involuntary treatment of mental illness whenever it is convenient.

Dr. Tyrer also suggests that critical psychiatry has a role in “correcting the growing belief that mental illnesses are just diseases of the brain and can soon be transferred to neurology”. It is no longer the early 20^th century. The neuroscientific study of the brain and mind is growing exponentially. As we appreciate that complexity it should be apparent to everyone in the field that no single practitioner or scientist will be able to master all of that information. Psychiatrists are not neurologists even though many of us share the same personality characteristics. Psychiatrists are still trained in the importance of the interpersonal relationship and its meaning whether or not the underlying biology of the process is completely known or not. This is an ongoing scientific endeavor also occurs at the clinical level and I think it is unlikely that the hundreds of newly identified clinical entities will ultimately be classified as neurological conditions.

I agree completely with Dr. Tyrer’s main points but as noted above don’t think he went far enough.  Critical psychiatry really is not an exercise in scientific criticism - it is an exercise in rhetoric. Speaking to his metaphor critical psychiatry is not "becoming Luddite" - it has always been.  He does not give the field of psychiatry enough credit in the area criticizing itself. He also gives critical psychiatry too much credit for constructive criticism while pointing out that they have created “increasingly destructive commentaries”.  He points out that critical psychiatry is adding little knowledge to the field and serving a brake on progress but does not comment on significant conflict of interest that exists with much of this criticism.

There is also a question of how much harm is caused by these destructive commentaries and anti-psychiatry websites and anonymous posters suggesting to readers that the treatments working for them are toxic and that psychiatrists are inherently bad people. As physicians we need to be very explicit about that problem.

I plan to read the Middleton and Moncrieff paper and post a critique here the end of the weekend.  I have already done much of that work on this blog. It will hopefully be useful to see what their positions really are.

George Dawson, MD, DFAPA

Reference:

1.  Tyrer P.  Critical psychiatry is becoming Luddite. BrJPsych Advances 2019, vol 25: 55-58.

Some Psychiatrists Continue to Obsess - Time for Action

In an editorial in this month’s British Journal of Psychiatry, Peter Tyrer contemplates the future of the profession.  It seems that pieces like this happen every 6 months or so in psychiatry and never in other medical specialties.  Tyrer discusses a recent conference in Belgrade where one of the speakers predicted that psychiatry would vanish and be absorbed into neurology.  That is after he develops the theme that neurology is so different from psychiatry that he could not possible entertain the idea of being a neurologist.    He would not have gone into psychiatry if it was a branch of neurology.  I think the problem for psychiatry and psychiatrists is really encapsulated in a single sentence in this editorial and it is also one of the main reasons I keep writing this blog:

"We live in turbulent economic times and may have a right to be gloomy, but I was quite disturbed to hear speaker after speaker predicting the demise of our profession or its absorption into neurology or some other discipline, as the funding for mental illness and respect for psychiatrists gets progressively less."

There is probably no better recipe for the demise of a profession than continuing to obsess about the future.  Pick a direction, any direction and the critics be damned.  It seems that the personality of most psychiatrists does not allow for that action.  We can dissect how psychiatrists as a group may be different from other specialists but I think the problem is that introspection and the need to understand motivations and emotions has translated into a lack of action and a really very annoying tendency to never take a stand.  I have also observed and equally annoying trait of uncritically accepting any criticism that comes down the pike as though it is generally legitimate.  All of the maladies in Dr. Tyrer’s piece including stigma, decreased funding, and a lack of respect for psychiatry come from those places.  Tyrer goes on to say that he sees no connection between stigmatization and discrimination and psychiatry’s lack of direction.

Let me suggest that at many levels this is the perception of a lack of direction.  The psychiatrists I know are trained to high levels of competency, technically skilled and care about what happens to their patients.  They successfully treat mental illness, save lives, correct misdiagnoses, and improve the lives of millions of people.  What they do every day differs considerably from what is written in the American press.  The sensational and inaccurate headlines can only be countered by aggressive political activity against all of the distortion that is typically being passed about psychiatrists.  For a moment, I was going to write that this is an American phenomenon, but then I recalled the work of Claire Bithell in the UK,  showing that coverage of psychiatry was less often than other specialties and when it did happen it was four times as likely to be negatively framed.

How about at least getting the word out that this trend exists and it biases people at all levels including the people who are responsible for funding treatment?  Here in the US, an unrealistically negative press feeds into a health care system that is set up to exploit patients with mental illness and the mental health professionals trying to treat them by providing disproportionately less funding.  It was so blatant that a parity law had to be passed to attempt to counter that discrimination.  But even as I type this note, large health insurance companies are trying to figure out a way to avoid paying for specific treatment settings, therapies, and drugs recommended by psychiatrists.   Nothing helps their cause more than propaganda against psychiatrists. 

  

So let’s break the deadlock of continuing to obsess about the future of a specialty when the current practitioners know what they are doing and treat people as successfully as they get treated by any other specialists.  This is not about the difference between psychotherapy or medications or treatment philosophies.  This is about the difference between a stroke and a psychiatric disorder.  I have had to educate many practitioners about that difference over the years, always when they were misdiagnosed with a mental illness.  Some of those practitioners were neurologists.  That is proof of an unique skill set that nobody else in medicine seems to have and for psychiatry that is just the tip of the skill set iceberg.

George Dawson, MD, DFAPA