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BJB 44 6 Articles 54 108 233..238 EDITORIAL Critical psychiatry: an embarrassing hangover from the 1970s? Duncan B. Double BJPsych Bulletin (2020) 44, 233–236, doi:10.1192/bjb.2020.5 Trinity College Cambridge, University of Summary Critical psychiatry is associated with anti-psychiatry and may therefore Cambridge, UK seem to be an embarrassing hangover from the 1970s. However, its essential Correspondence to Dr Duncan Double position that functional mental illness should not be reduced to brain disease ([email protected]) overlaps with historical debates in psychiatry more than is commonly appreciated. First received 13 Dec 2019, final revision Three examples of non-reductive approaches, like critical psychiatry, in the history of 5 Jan 2020, accepted 15 Jan 2020 psychiatry are considered. © The Author 2020. This is an Open Access article, distributed under the terms Declaration of interest D.B.D. is a founding member of the Critical Psychiatry of the Creative Commons Attribution Network. licence (http://creativecommons.org/ licenses/by/4.0/), which permits Keywords Aetiology; philosophy; history of psychiatry; critical psychiatry; unrestricted re-use, distribution, and anti-psychiatry. reproduction in any medium, provided the original work is properly cited. The Critical Psychiatry Network has promoted critical psychiatry, by encouraging eclecticism in practice that psychiatry for the past 20 years.1 It is a small group of psy- includes psychosocial as well as biological factors.6 The chal- chiatrists and although psychiatrists in general may be aware lenge to a narrowly biomedical model, which was of such con- of its critique, it remains a minority perspective. In this cern for anti-psychiatry, was thereby averted. sense, critical psychiatry still seems marginal to mainstream Mainstream psychiatry now tends to regard anti- practice. This may be because of its association with psychiatry as a ‘straw man’ argument. It was sustained by so-called anti-psychiatry. Although the first modern use of the counter-culture of the 1960s and without this support ‘anti-psychiatry’ was probably by David Cooper in his book it has waned away. Social cultural critiques, with which Psychiatry and Anti-Psychiatry,2 the term has generally anti-psychiatry was aligned, are no longer academically been applied by mainstream psychiatry to denote criticism respectable. Critical psychiatry, by apparently resurrecting that it does not accept. For example, Martin Roth, when anti-psychiatry ideas, may therefore seem like an embarras- he was the first president of the Royal College of sing hangover from the 1970s. Psychiatrists, identified an international movement against psychiatry that he regarded as ‘anti-medical, anti-thera- peutic, anti-institutional and anti-scientific’.3 Historical foundations of critical psychiatry The history of psychiatry can be understood as a conflict Psychiatry’s response to anti-psychiatry between two factions of somatic and psychic approaches rather than a simple chronological development. Critical Anti-psychiatry, perhaps most associated with the names psychiatry is part of this debate. The essential position of of Thomas Szasz and Ronald Laing, now tends to be critical psychiatry is that functional mental illness should seen as a passing phase in the history of psychiatry.4 In not be reduced to brain disease. Its challenge to reduction- this sense it was an aberration, a discontinuity with the ism and positivism, including mechanistic psychological proper course of psychiatry. However, it is difficult to approaches, creates a framework that focuses on the person accept that there was no value in the approach and what and has ethical, therapeutic and political implications for may be more beneficial is to look for the continuities, clinical practice. This editorial focuses on conceptual issues, rather than discontinuities, with orthodox psychiatry. In as the more practical aspects of critical psychiatry could be fact, anti-psychiatry is not a single perspective; for said to follow from its theoretical position. This is not example, Szasz equally rejected both mainstream psych- meant to detract from these central practical concerns of iatry and Laing’s views.5 critical psychiatry, such as the political and socioeconomic Part of how psychiatry was able to move on from anti- origins of mental illness. psychiatry was by trying to make psychiatric diagnoses more The argument of critical psychiatry is that psychiatry reliable; for example, through the American Psychiatric can be practiced without taking the step of faith of believing Association’s publication of the DSM-III. Another way was that functional mental illness is owing to brain pathology. by avoiding ideological disputes engendered by anti- This anti-reductionism is primarily explanatory rather 233 Downloaded from https://www.cambridge.org/core. 28 Sep 2021 at 07:08:08, subject to the Cambridge Core terms of use. EDITORIAL Double Critical psychiatry than ontological and does not undermine the importance of mechanical natural science, although he remained aware of organic factors. Functional psychiatry could be said to be the gap between this ideal and reality. Nonetheless he set doomed to a kind of descriptivism rather than being able the trend for this positivist biomedical understanding that to become a mechanical natural science. Historically critical has dominated psychiatry since the middle of the 19th cen- psychiatry may actually be more integrated with mainstream tury. His aphorism that ‘mental diseases are brain diseases’ psychiatry than is commonly appreciated. could be seen as the origin of modern biomedical psychiatry Modern psychiatry has its origins in the Enlightenment with its wish to find a physicalist basis for mental illness. of the 18th century.7 The problem of knowledge began to Such a positivist reduction of mental illness to brain disease shift away from philosophy toward science. Critical engage- is what causes such concern for critical psychiatry. ment of reason with itself created a descriptive approach to This historical narrative is necessarily selective and madness. Psychiatrists were originally called alienists, iden- schematic. It is more of a genealogy, attempting to make tifying mental alienation. the origins of critical psychiatry intelligible. Psychiatry and Descartes had separated the soul from the body, and, its critical version had their origins at the same time in med- reacting against this Cartesianism, anthropology established ical psychology. Incorporating the anatomoclinical way of itself as an independent discipline, concerned with the study understanding disease into psychiatry, particularly following of man as a psychophysical unity. In this context, medical Griesinger, has eclipsed a more critical understanding of psychology had its origin with two major variants of mental illness. There have, nonetheless, been non-reductive anthropological thinking.8 A medically orientated anthropol- approaches in modern psychiatry that amount to a critical ogy represented by Ernst Platner, among others, was one position. For reasons of space, this editorial will consider version, and can be seen as the root of biomedical psychiatry. just three examples: Ernst von Feuchtersleben, Adolf Meyer Physiological knowledge of humans seemed to create the and George Engel. possibility of a natural scientific psychology. The other ver- sion was Immanuel Kant’s pragmatic anthropology, which may be seen as the origin of critical psychiatry. Kant The forgotten psychiatrist Ernst von believed that a natural science psychology was impossible Feuchtersleben to realise in practice. Applying a physico-chemical mechan- In the same year, 1845, that saw the publication in German of istic approach to life cannot accommodate the purposiveness the book that gave Wilhelm Griesinger his reputation in psych- of living beings. Organisms, unlike machines, are self- iatry, Ernst von Feuchtersleben produced his psychiatric text- organising and self-reproducing systems. Kant was clear book9 based on his lectures. Following Kant, he recognised that it is futile to expect to be able to understand and explain that the mind–brain problem is an enigma, which can never life in terms of merely mechanical principles of nature. be solved. He was aware of the somatic bias in medicine and Building on this proto-psychiatry, the first half of the one of the aims of his lectures was to encourage young physi- 19th century saw the development of anatomoclinical under- cians to study its psychical element. As far as he was con- standing. Relating symptoms and signs to their underlying cerned, all physicians should have a clear understanding of physical pathology was a major advance for medicine and the relationship between mind and body. still underlies our modern understanding of disease. Feuchtersleben took a holistic approach to medical Pathology emerged as a distinct discipline with autopsy find- psychology. Materialism, in the sense of reducing mind to ings of lesions in organs and tissues being related to clinical body, as far as he was concerned, explains nothing because examination at the bedside. Histological studies established such reductionism leads to the loss of meaning of human cellular abnormalities for disease. action. Mental illness is deduced rather from the relation- Applying this anatomoclinical method to psychiatry was ship of mind and body without necessarily being able to not as successful because it was not always easy to relate men- explain this relationship. There is a limit to the natural sci-
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