An Effort To Distance Critical Psychiatry From Antipsychiatry

I read the paper “Critical psychiatry: a brief overview” by Middleton and Moncrieff. This paper was the basis for the commentary by Peter Tyrer in the previous post on this blog. The authors try to make an argument to differentiate critical psychiatry from antipsychiatry. They claim that critical psychiatry offers constructive criticism of the field whereas antipsychiatry seeks to abolish the field. Constructive criticism needs to be valid criticism I hope to point out why critical psychiatry does not meet that threshold.

One of the interests for me in reading this paper was to see if critical psychiatry in fact could be distinguished from typical antipsychiatry rhetoric. That might be the easiest way to illustrate a significant difference. An associated strategy might be to show that critical psychiatry had origins that were clearly independent of antipsychiatry.   The authors suggest multiple common origins.  They both have the same heroes - Szasz and Foucault. They both draw heavily on the defective ideas of Szasz and Foucault. These ideas have no scientific basis and are not logically derived.

Social control is one concept that ties in what the authors claim is “controversy” about the institution of 19^th century psychiatry and the ideas of Szasz and Foucault. By the authors own definition Szasz trivializes serious mental illness as a social disorder and socially deviant behavior rather than a potentially lethal illness. In order to consider a mental illness to be a true disease, Szasz believed it would have to be a “neurological” illness.  That does not recognize that a significant number of these disorders have no known pathophysiological mechanism.  Szasz and the authors paint themselves into a corner with this construct given the clear medical, neurological, and substance induced disorders listed in any diagnostic manual for psychiatry. They also seem to not realize that these distinctions are all arbitrary definitions by Szasz. Most medical professionals and lay people do not believe that a specific pathophysiological mechanism is the basis for disease, illness, or treatment in most cases. For the antipsychiatry and critical psychiatry adherents of Szasz this is one of their most predictable arguments.

On the issue of social control, the antipsychiatry arguments are as weak. The authors explain Foucault’s position as:

“Thus, the birthplace of institutional psychiatry can be considered arrangements for managing unproductive behaviour in a system of wage labour and industrial production. The growth of psychiatry in the 19th century legitimated this system by presenting it as a medical and therapeutic endeavor.”

I really doubt that Foucault was accurate in his historical observations.  German psychiatry at the time was clearly focused on persons with significant psychopathology and who could eventually be discharged as well as the biological basis of psychopathology. Have psychiatrists ever had the influence to run governments and dictate government policy? What ever spin Foucault could put on old history we all know what is happening now. Psychiatry is nearly completely marginalized.  Despite the antipsychiatry movement there is widespread agreement that there are too few psychiatrists and that people do not have enough time with them.  That process also highlights the true agents of social control.  Federal and state governments have supervised rationing bed resources to the point where they are extremely low.  At the same time there has been a huge increase in the mentally ill who are incarcerated, making county jails the largest psychiatric institutions in the country. Los Angeles County jail is building a new facility that is designed to hold a population with mental illness. They are calling it the Mental Health Treatment Center.  Foucault's speculation has not stood the test of time. There should be no doubt that the true agents of social control are federal and state governments, law enforcement, and businesses that profit from their relationships with government officials and not a marginalized medical specialty.  

The authors also march out the old Foucault quote “psychiatry is a moral practice, overlaid by the myths of positivism”.  Philosophers have the annoying practice of coming to a conclusion that is not backed up by any data or proof. That may be why Foucault also has to discredit positivism. He is basically in his own little parallel universe.  Let’s forget about the fact that no psychiatrist I have ever met was trained to exert social control and manage “unproductive behavior” by putting the poor and disabled into almshouses. Present day psychiatrists in the US are most commonly battling with insurance companies to get minimally adequate care for their patients.  That insurance company rationing has also resulted in the bed crunch that leads to incarceration, chronicity, and associated medical problems. Foucault’s proclamations about psychiatry have not withstood the test of time and in the modern world are wrong. 

  

An offshoot of the social control speculation is the authors comments about the sick role:

“Psychiatry’s institutional functions are legitimated by the designation of its clients or patients as ill or ‘sick’.”

They speculate that when the designation occurs the person is relieved from their social responsibilities as long as they play ball and remain in a passive sick role following the advice of their psychiatrist. Unfortunately for the authors they seem to have no real-world experience in what happens to people with psychiatric disabilities. They live in poverty. In the US, they may have to spend a much larger portion of their income on medical expenses. They have significant medical morbidity and have less access to care.  Substandard living conditions exposes them to more violent crime than the average person. They are at higher risk for incarceration. If they receive assistance from the state or federal government, these stipends can be reduced or stopped at any point resulting in homelessness – another significant risk in this population.  All of these factors combine to illustrate that there is no contract with society.  American society has shown time and time again – persons with mental illness are the first people thrown under the bus. So much for another critical psychiatry theory.

The final section is a recap about social control and they have an interesting paragraph where they blame psychiatry for both homosexuality as an illness and drapetomania as an illness.  No mention of the fact that Spitzer changed that designation about homosexuality in 1973, decades before the rest of the world caught on (some still have not).  Blaming psychiatry for drapetomania is standard antipsychiatry rhetoric. Anyone reading that word should realize this. It was a term coined in 1851 by Samuel Cartwright, an American physician to suggest that when slaves ran away it was a sign of mental illness. Antipsychiatrists have locked onto to this term since Whitaker put it in his provocative book Mad In America (p 171) as something else to blame psychiatrists for. The only problem is that Cartwright was not a psychiatrist and his off the wall theories were widely discredited at the time. The term has nothing to do with psychiatry or any psychiatric diagnostic system. Anyone using either homosexuality or drapetomania as examples of a powerful group (implicitly psychiatry) defining socially repudiated behavior as a mental illness to eradicate or control it (the authors words) – is by definition an antipsychiatrist.

The authors proceed to discuss treatment and how it differs if provided by critical psychiatrists.  This discussion contains very little that is remarkable.  They suggest that psychotherapeutic outcomes are broadly similar and discuss very broad definitions of psychotherapy. Anyone familiar with psychotherapy would not agree with these broad generalizations. They provide no real evidence for their conclusion that there are obstacles in place that discourage the relationship dimensions of therapists and encourage “paternalizing and instrumental approaches”.  It sounds to me like they are not approving of research based psychotherapies.   

On the medical side of things, I have serious questions about whether they do anything at all that is medical.  They suggest that psychiatry needs to be affiliated with medicine in order to get professional legitimacy. They have apparently never picked up a copy of Lishman’s Organic Psychiatry, Lipowski’s Delirium: Acute Confusional States, or Principles and Practice of Sleep Medicine by Kryger, Roth, and Dement.  Professional legitimacy is a two way street and psychiatry gives as much as it gets.  They can also find those biomarkers they are looking for in any sleep medicine text.

The section on “drug treatment” explains the critical psychiatry theory of a “drug centered” model.  In this model, there are no specific mechanisms of action – only alterations in normal mental processes, emotion, and behavior.  They include a table showing that the effects of most modern psychiatric medications depend on producing sedation, cognitive impairment, dysphoria, and loss of libido.  When I read this section I had three thoughts.  The first is that this table contains list of side effects.  I had to look again to confirm that the authors are calling them psychoactive effects.  The second is that none of the critical psychiatrists treats anyone with severe psychiatric disorders or monitors side effects very well.  The most striking feature of treating people with severe illnesses is when their acute symptoms of hallucinations, delusions, mania, or severe depression go away. The associated goal is when their side effects are managed so that they have none.  Not noticing either of these effects may be because you are just not treating very ill people. My third thought was that the authors just don’t know very much about pharmacology.  We are currently talking about decades of study of some of these systems where the behavioral pharmacology and imaging studies have been done. If you don’t know that stimulants can cause hallucinations and delusions, that non stimulant dopamine receptor agonists can do the same thing and that dopamine receptor antagonists can reverse these effects – you have just not been paying very much attention. This is basic pharmacology that every psychiatric resident should know.

The authors conclude that “critical psychiatry is not antipsychiatry” but the problem is they have not offered any compelling arguments to back that statement. If anything, the bulk of their discussion illustrates that their philosophical origins and rhetoric against clinical aspects of modern psychiatry is right out of the antipsychiatry playbook.  They claim to be not be anti-science and have clearly rejected modern pharmacology and brain science in favor of a meaningless theory of drug effects.  The closing paragraphs on the existence of social problems and the importance of the therapeutic relationship is nothing new to the practice of psychiatry - everybody does it.

The only logical conclusion is that critical psychiatry is antipsychiatry.  Just like Szasz and Laing they eschew the term, but there is just no getting around it.  I want to end with a quick note about the practical implications of critical psychiatry coming out into the light. The first is that clinicians doing the work every day should not be surprised to see this rhetoric surface time and time again. There is nothing innovative about critical psychiatry - how could there be? Nothing will deter them from making these arguments in the foreseeable future.  My concern is the potential impact on patients. I have certainly seen patients affected by antipsychiatry cults. I have concerns about the effects in large health care organizations. Is it just money that caused psychiatric resources to be cut to the bone and our patients incarcerated or is there somebody making these decisions who embraces critical psychiatry or antipsychiatry?

At the academic level, the best way to deal with these biases against psychiatry is to leave the people perpetuating these biases back in the mid-19th and 20th centuries. Psychiatry has given many of these authors plenty of space in journals and debates.  They thrive on freedom of speech and expression. I think there is a problem with academic or clinical departments allowing the expression of information that in many cases reflects poor scholarship, is largely rhetorical, and in some cases is patently false. No other medical departments do this. 

The question is where and when that line should be drawn and as readers may have guessed - my threshold is lower than most.      

George Dawson, MD, DFAPA



Supplemental:

In their Szaszian efforts to act like psychiatric disorders are not illnesses, diseases, or diagnoses, antipsychiatrists typically refer to them using the pejorative term "labels".  The following philosophical cartoon illustrates why a psychiatric diagnosis is no more a label than a hot dog is a sandwich.  Cartoon here. 

Ref:

Middleton H, Moncrieff J.  Critical psychiatry: a brief overview. BJPsych Advances (2019), vol 25, 45-54.    

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.

Radicals and Reformers for Managed Care

I was struck by a post on the Critical Psychiatry blog this AM.  Duncan Double discusses his experience at a meeting of the radical caucus at the APA on Sunday.  His main argument was the need to abolish psychiatric diagnostic systems - specifically the DSM, but he mentions that you can apparently provide psychiatric services without an ICD diagnosis in the UK.  But then he makes this astonishing comment: " The American psychiatric system has become very dependent on DSM for billing purposes, but I'm sure the insurance companies could develop an alternative system unrelated to DSM. "


I am positive that the American insurance industry would like nothing better than to establish their own "alternative system unrelated to the DSM'.  In fact, they are doing it already with a host of measures that they can use to basically deny care or dismantle systems of care.  The managed care industry in the US has selectively discriminated against psychiatric services for the past 20 years to the point that most states have little service availability.  The motivation for managed care is clear - shift hundreds of billions of dollars away from providing care to persons with mental health and chemical dependency problems and into the pockets of the insurance industry.  We are talking about an industry where the CEOs can make an annual salary of millions of dollars and in a famous case the CEO received a $1 billion dollar bonus.


Stated in another way, the "American psychiatric system" is no system at all.  There is hardly any availability of psychotherapy services.  Most people are restricted to a handful or less of 15 minute visits with a psychiatrist every year.  The length of stay in hospitals is appallingly short by UK or European standards and people are asked to leave if they are no longer "suicidal".  It is psychiatrists on the one hand being severely restricted in attempting to provide care and a predatory insurance industry trying to make disproportionately more money off policy holders with mental health problems on the other.   The government is not a passive player in this effort with most state governments abdicating their role in caring for the indigent and the uninsured often by using managed care tactics.  All of this happens independent of any DSM or ICD diagnosis.  At the national level, there is a long list of interests who favor the same tactics in order to maintain leverage over doctors and the clinical care advocated by doctors.


Critical psychiatry would rather "Occupy American Psychiatric Association" rather than "Occupy Wall Street" .    I guess we can add them to the managed care  list.  That is exactly the type of reform that the politicians want.