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Home , Anatomy of an Epidemic, Joanna Moncrieff, The Gene Illusion, Thomas Szasz

BJPsych Advances (2019), vol. 25, 47–54 doi: 10.1192/bja.2018.38

† Critical : a brief overview ARTICLE Hugh Middleton &

psychiatry and of the aims and organisation of Hugh Middleton MA, MB, BChir, SUMMARY services. Important concerns are the MD, MRCP, FRCPsych is an honorary Associate Professor in the School of Critical psychiatry has often been confused with implications of the medical or biological model of what is widely known as ‘anti-psychiatry’. In this Sociology and Social Policy at the , harmful effects of the sick role, article the distinction is clarified and the particular University of Nottingham and a overuse and misunderstanding of psychopharma- retired consultant . From contribution critical psychiatry makes is outlined. ceuticals, recognition of the central part relationship 1994 until 2016 he was a general That contribution is constructive criticism: of the adult psychiatrist with relationship between and mental health plays in psychological therapies, tensions between Nottinghamshire Healthcare NHS practice, of the way drug and psychotherapeutic social control functions and patients’ best interests, Foundation Trust and a senior lec- treatments for mental health difficulties might be and socio-political influences on psychological turer, then Associate Professor at the better understood. These have implications for well-being. Many in the critical psychiatry move- University of Nottingham. His earlier everyday clinical practice and there is much to research was in ment are practising keen to grapple and psychophysiology, and subse- be gained by openly embracing the controversies with the intellectual and practical challenges that quently included social as critical psychiatry highlights. confront them, and thus develop better ways of applied to mental health difficulties. working with people suffering mental health Joanna Moncrieff BMedSci, LEARNING OBJECTIVES MBBS, MRCPsych, MD is a Reader in problems. • Understand the origins of critical psychiatry and Critical and Social Psychiatry in the The Critical Psychiatry Network (CPN) started in recognise some of the difficulties that arise from Division of Psychiatry, University College London, and an honorary identifying psychiatry with medicine the UK but now extends globally. It accommodates a wide range of opinions rather than claiming to speak consultant psychiatrist with North • Appreciate the differences between disease- East London Foundation Trust. Her centred and drug-centred approaches to pre- with a single voice, and it acts as a lobbying, cam- research includes theories of drug scribing paigning and mutually supportive body. This con- action, the subjective experience of • Become aware of implications that arise from tribution to BJPsych Advances is intended to air taking prescribed medication, deci- sion-making, the history of drug psychotherapeutic outcomes research controversies experienced by many and widely dis- treatment and the history, philosophy cussed by members of the CPN. It is presented in and social theory of psychiatry more DECLARATION OF INTERESTS two sections: the relationship between medicine generally. H. M. and J. M. are co-chairs of the UK Critical and psychiatry, and alternative approaches to Correspondence Professor Hugh Psychiatry Network. Middleton, School of Sociology and understanding the principal forms of treatment Social Policy, Law and Social KEYWORDS psychiatry offers. Building, University of Critical psychiatry; anti-psychiatry; philosophy; Nottingham, University Park, Nottingham NG7 2RD, UK. Email: medical treatment; psychotherapy. [email protected] Medicine and psychiatry Copyright and usage Traditional psychiatry presents itself as a medical © The Royal College of Psychiatrists specialty addressing ‘mental illness’: ‘Differences 2018 What is critical psychiatry? between mental and physical illnesses, striking

The institution of psychiatry has attracted contro- though some of them are, are quantitative rather † For a commentary on this article, see versy since its 19th century origins, initially from than qualitative, differences of emphasis rather pp. 55–56, this issue. public campaigners with experience of asylum life. than fundamental differences’ (Kendell 2004: These centred on wrongful detainment and poor pp. 41–42). conditions. During the mid-20th century certain The idea that psychiatric conditions are equiva- scholars (Box 1) began to articulate an intellectual lent to medical diseases suggests that psychiatric critique which became known as ‘anti-psychiatry’. practice is straightforward and uncontroversial. This focused on the suitability and implications of Illnesses should be eradicated wherever possible, considering mental disorders as medical conditions. and coercion is sometimes justified because mental Other perspectives that challenge the hegemony of illness can disrupt insight. Disturbances of thought the now dominant biological view of mental disorder and behaviour are sufficiently understood as include social psychiatry, psychotherapy and psy- medical conditions, underpinning much of how choanalysis. Critical psychiatry is indebted to this mental health difficulties are viewed and responded background. Unlike anti-psychiatry, which often to, and who has authority over them. Unfortunately, called for the abolition of psychiatry on what have this position glosses over a number of conceptual been perceived as ideological grounds, critical difficulties, which critical psychiatry considers psychiatry offers constructive criticism of clinical important.

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are some subtle group differences between people BOX 1 Leading ‘anti-psychiatrists’ with some diagnoses and ‘normal controls’ in aspects of brain structure or function does not dem- (1920–2012) An American psychiatrist who challenged the idea of mental onstrate the presence of a neurological disease. None illness, and argued that what is considered as mental illness is better understood as socially of the findings are sufficiently specific or capable of deviant behaviour.a differentiating between a person who is thought to R. D. Laing (1927–1989) A Scottish psychiatrist, whose work was influenced by existential have a particular mental disorder and one who is philosophy. He analysed the meaning of mental illness ‘symptoms’ in relation to the familial and not. Diagnosis is still made on the basis of behav- social environment. He founded Kingsley Hall, a for people with .a iour, thoughts and feelings that are reported by the individual or those around them and that depend, (1926–1984) A French philosopher whose first major work considered varying of course, on judgements about what is ‘normal’ understandings of madness through different historical epochs and social responses to it. and what is not. Moreover, the variations in brain David Cooper (1931–1986) A South African psychiatrist, who worked in Britain. He set up a structure or function that are detected, are most therapeutic community (known as Villa 21) within an existing asylum. He was a Marxist likely attributable to other differences between ideologue and he coined the term ‘anti-psychiatry’. people who are labelled with psychiatric disorders (1922–1982) An American sociologist whose book Asylums described the and those who are identified as ‘controls’: differences impoverishing effects of ‘total institutions’, including asylums, on people’s behaviour. in life experiences, social class, IQ and the use of psy- ‘ ’ a. Szasz did not consider himself an anti-psychiatrist , a term he disliked and considered to be chiatric medication (Ho 2011; Kendler 2015). associated with the ideas of R. D. Laing. Laing, in his turn, also eschewed the term. Szasz lived long enough to defend his thesis in person for more than half a century. Criticisms of it include the view that, although mental illness is not adequately understood in biological terms, a dis- ‘ ’ The myth of mental illness? tinction between mental and physical illness is too The assumption that mental disorders are medical categorical. Some critical psychiatrists have conditions is challenged by Thomas Szasz’s expressed this view: that the assignation of all famous assertion that ‘mental illness is a myth’ illness and disease reflects a negative evaluation, (Szasz 1960). Szasz insisted that ‘disease’ and and mental and physical suffering cannot be illness are the consequence of a bodily biological wholly disentangled (Bracken 2007). Others dysfunction: ‘pathology’. From this position it is suggest that Szasz was right to highlight how con- misleading to extend the use of ‘illness’ to situations cepts of disease and illness are fundamentally bio- that are characterised by patterns of personal logical and are different from the situations we conduct rather than by evidence of physical path- regard as constituting mental disorder (Moncrieff ology. He argued that ‘mental illnesses’ are proper- 2017). Yet others argue that use of terms such as ties of human beings, not of biological systems. It ‘pathology’, ‘disease’ and ‘illness’ is at root a seman- is whole human beings who think, speak and act, tic choice reflecting common usage. Their use by and as humans are social creatures, behavioural psychiatrists is determined by wider social forces abnormalities considered evidence of mental illness which favour the identification of mental disorders are identified by reference to social norms. with medical problems in order to facilitate a Furthermore, defining unwelcome behaviour as a number of otherwise difficult social or political pro- ‘mental illness’ amounts to a social interaction, not blems (Scheff 1999; Middleton 2015). something wholly explained by reference to a Although Szasz’s ideas have not been widely single individual. embraced by psychiatry and are variously inter- Much has been invested in a search for biological preted, they do open debate about the consequences evidence that would allow mental disorders to be of viewing mental health difficulties through the considered ‘true’ diseases by this logic. Szasz’s same conceptual and institutional lens as physical response was always that, were this to be successful, illness. Viewing conditions as illnesses or diseases the result would be a category shift whereby the con- sets them in a particular social context, where dition would cease to be considered a ‘mental illness’ certain professions have jurisdiction and certain and become a ‘neurological’ one instead. Despite arrangements (in this case the sick role and its enti- decades of intensive research, there is still no conclu- tlements) automatically apply. It also facilitates sive evidence that enables any of the major categor- mental health legislation, though not necessarily in ies of mental disorder, including , the most fair or transparent manner (see below). depression, anxiety and attention-deficit hyperactiv- ity disorder (ADHD), to be considered a neuro- ’ logical condition in this way (Joseph 2003; Psychiatry s knowledge base Sullivan 2003; Moncrieff 2008; Leo 2009; The link between psychiatry and medicine confers Moncrieff 2013; Ripke 2014). The fact that there legitimacy on psychiatry as a professional enterprise

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because its practitioners are seen to hold and exploit BOX 2 The social construction of depression expert medical knowledge. Medical knowledge is identified with the scientific approach that was Mental illness in Eastern Europe developed to study the natural world; systematically investigating assumed-to-be immutable truths by The work of anthropologist Vieda Skultans demonstrates how the Western concept of measurement and manipulation of particular ele- depression was contrived to replace prior understandings of distress popular in the Soviet era (often diagnosed as ‘neurasthenia’) (Skultans 2007). The growth of pharmaceutical marketing ments in a controlled environment. The application influenced doctors’ behaviour and helped to effect this change. Her analysis of medical con- of this form of knowledge-seeking to the world of sultations in Latvia reveals how the transition to the concept of depression involved doctors ‘ ’ human affairs is referred to as positivism ,an imposing an increasingly objectified view of suffering onto their patients’ complaints, ignoring approach that has been criticised for oversimplifying personal explanations and context. Skultans’ analysis illustrates how the diagnosis and treat- human affairs. Earlier scholars distinguished ment of psychiatric complaints reflect their social context; in this case, the effects of an between Geisteswissenschaften, human or moral emerging market economy. sciences, and Naturwissenschaften, natural Mental illness in Japan sciences. The distinction remains a core feature of The introduction of the Western concept of ‘depression’ into Japan has been carefully docu- social science, where it is argued that the study of mented by anthropologists Lawrence Kirmayer and Junko Kitanaka. They describe how prior human beings is irreducibly different from the understandings emphasised somatic symptoms and anxiety, with high use of . study of the natural world. Human behaviour is Moreover, sadness and were not regarded entirely negatively as in the West, and were intentional, interactive and inextricable from its valued for indicating sensitivity, bravery and honour. Ihara (2012) has documented how social setting. It has meaning, rather than causes, pharmaceutical marketing and public health campaigns introduced the Western concept of that can only be discerned by reference to its context. depression as an illness, using the slogan the ‘cold of the soul’. This has been accompanied by Therefore, if mental disorders are to be understood soaring rates of use. as human reactions rather than as physical diseases, a positivist perspective cannot provide adequate or comprehensive knowledge. Different approaches the discourse that is prevalent within a particular are needed that can study social phenomena culture. Feelings of distress can be perceived as appropriately. depression, anxiety, or neurasthe- Hermeneutics is one such alternative. A hermen- nia, depending on the cultural availability and pro- eutic approach emphasises how mental disorder motion of different concepts. These concepts are, should be regarded not as intrinsically meaningless in turn, shaped by social and cultural developments, phenomena that arise as a result of an underlying including the expansion of Western medicine and morbid process but as meaningful responses to indivi- pharmaceutical marketing. duals’ life histories and particular social, cultural and In other work, philosopher Jeff Coulter describes familial contexts (Bracken 2007). In this way mental the social construction of concepts relating to more disorder is not fundamentally different from all severe mental disorder. According to Coulter, com- human thought and behaviour. This view was munities designate certain patterns of behaviour embraced by the leading mid-20th-century American that infringe rules of conduct and social expectations psychiatrist Adolf Meyer, who argued that mental dis- as ‘mental illness’. He argues that it is this social orders can be seen as meaningful, if misguided, reac- process that defines situations as requiring official, tions to real-life challenges. His thought prefigured psychiatric attention, rather than professionally laterthinkerssuchasR.D.Laing,andsimilarideas constructed categorisations or ‘diagnoses’, and he inspired clinical innovations, including therapeutic highlights how this process contrasts with the communities. Recent therapeutic movements such as process of diagnosis in physical medicine (Coulter open dialogue also embrace hermeneutic principles. 1979). Social constructivism presents another challenge to positivism by emphasising the social nature of cog- nition and knowledge. Knowledge is the product of Psychiatry as a social institution interactions among members of groups or societies Historical analyses also reveal how psychiatry has and expressed in ways that are particular to that evolved out of institutions developed to manage group or culture. Social construction also empha- troubling behaviour or ‘deviance’. Productive inter- sises the role of language in expressing locally actions between people depend on the maintenance accepted ideas and values. Examples from psych- of social order. Confusion, despair, misunderstand- iatry include cross-cultural research exploring varia- ing and dependency are all disruptive, though not tions between cultures in the way that mental distress necessarily unlawful. How they are understood is expressed, and analyses of how diagnoses evolve and responded to is determined by prevailing over time. Two examples are outlined in Box 2. social and political structures. Critical psychiatrists From this perspective people come to define their have highlighted how contemporary psychiatry is a own or others’ behaviours and experiences through current embodiment of the need to contain

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disruptions of social order, a perspective articulated it is easily open to abuse, and powerful groups can by French philosopher Michel Foucault (1965) and define any socially repudiated behaviour as historian Andrew Scull (2015), as well as by Szasz. ‘mental illness’ in order to eradicate or control it. Foucault traced how attitudes to madness were Generally agreed examples of this include the desig- transformed over the 17th and 18th centuries. As nation of male as a mental disorder industrial society started to emerge, conformity up until the 1970s, and the application of a ‘diagno- and discipline became important. In France, the eco- sis’ of drapetomania to African American slaves nomically unproductive were brought together in intent on escaping. the hôpitaux généreaux; Foucault identified this as Unlike anti-psychiatrists, most critical psychia- the ‘Great Confinement’. In England, those without trists accept the need for recourse to coercion in cir- means were provided with minimal subsistence in cumstances where individuals are so overwhelmed, the community under the Tudor Poor Laws, and confused or desperate that they fail to cope with then increasingly in the workhouse. Asylums everyday demands or place others in intolerable or reflected the segregation of ‘paupers’ into the ‘able- dangerous situations, and that under such circum- bodied’, who were kept in the workhouse and who stances lawful restraint and other related measures could be obliged to work, and the incapacitated, are justified. However, veiling these situations as who were moved to the workhouse hospital or the ‘medical disorder’ disguises the real reasons for local asylum. Thus, the birthplace of institutional taking coercive action, which are usually to maintain psychiatry can be considered arrangements for man- social order and to support the dependent. A more aging unproductive behaviour in a system of wage transparent approach would acknowledge these labour and industrial production. The growth of pressures and scrutinise authorised interventions psychiatry in the 19th century legitimated this more rigorously. Legislation based on the concept system by presenting it as a medical and therapeutic of ‘capacity’ rather than the presence of ‘illness’ (or endeavour. From Foucault’s perspective, ‘psychiatry its legalistic pseudonym, ‘disorder’) is one such pos- is a moral practice, overlaid by the myths of positiv- sibility (Szmukler 2008). This would avoid the med- ism’ (Foucault 1965: p. 276). In the 20th century the icalising assumptions woven into current legislation medical framework became more strongly cemen- and would require explicit justification for coercive ted, so that the social functions of mental institutions and paternalistic actions. It would also challenge and services were further obscured. the extension of coercion into the community, as occurred with the introduction of ‘community treat- The sick role ment orders’. Most patients able to live in the com- munity would be considered to have capacity to Psychiatry’s institutional functions are legitimated decide whether or not to take psychiatric medica- by the designation of its clients or patients as ill or tion. However, capacity-based legislation, such as ‘sick’. This inevitably enters them into a ‘sick role’. the Mental Capacity Act 2005, requires contentious The ‘sick role’ (Parsons 1951) is a contract and subjective judgements about the best interests of between the sick person and society, whereby the individuals and the safety of society. Replacing a sick are provided for and the social costs of sickness medically justified system of control is not easy, are minimised. The ‘ill’ person enjoys relief from but balancing the interests and freedoms of different responsibilities and access to care in exchange for groups and individuals is inherently fraught and submission to expertly defined treatment. Through deserves greater attention and transparency. its association with medicine, psychiatry has There is a substantial body of work addressing the extended the sick role to a wider range of situations. political implications of the ‘medicalisation’ of Most would concur with a need for care and support human experience, which dates back at least to the of the mentally disturbed, but using the sick role to writings of Ivan Illich in the 1960s and 1970s (e.g. achieve this has limitations. Power relations Medical Nemesis, Illich 1974). The widespread, enshrined in it encourage long-term passivity, pharma-funded promotion of the idea that impair investment in change and can contribute to unwanted emotions or behaviour can be understood dissatisfaction as the promised cure (the physician’s as ‘abnormal brain chemistry’ has taken this process part of the contract) may fail to materialise. to a new level, encouraging large swathes of the population of Western countries to view life difficul- Psychiatry and social control ties as brain events that need chemical correction. Anti-psychiatrists highlighted that when behaviour Several commentators, many in the Marxist trad- is designated as disease, individuals’ rights and lib- ition, have highlighted how this helps to support a erties can be overridden in the name of acting in pliable society in which imperfections are attributed their own interests. The fact that this can be pre- to individuals rather than social injustice, obscuring sented as an objective, scientific endeavour means the systemic difficulties that cause widespread

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misery and distress (e.g. Cohen 2016). American Critical psychiatrists do not eschew drug treat- sociologists Conrad & Potter (2000) discuss how ment. Instead, they offer an alternative framework the availability of the diagnosis ‘adult ADHD’ can for understanding and using it that is more transpar- be seen as a form of ‘medicalisation of underper- ent and involves patients more centrally in determin- formance’, which diverts attention from the increas- ing how it happens. ing competitiveness and performance-driven culture of modern society. Gary Greenberg (2011) high- Models of drug action lights how the concept of depression as an illness obscures social and economic hardships and dis- Conventional psychopharmacology assumes that courages opposition to the structures that maintain psychiatric drugs work by modifying an underlying these. physiological abnormality responsible for the disorder. This might be referred to as a ‘disease- ’ Responding to mental disorder centred model of drug action. Drug treatment is presented as restoring a normal or healthy state. Critical psychiatrists (and many others) argue that Psychiatric drugs ‘counter or compensate for the mental disorders do not simply occur in individuals, abnormal pathophysiology’ (Hyman 1997). but are patterns of behaviour expressed during However, critical psychiatrists have argued that interpersonal and social interactions. Social condi- there is little evidence to support the disease- tions contribute, and social and political interven- centred model and they propose an alternative, tions are required if the burden of mental disorder ‘drug-centred’ model. This suggests that, as psychi- is to be reduced. Moreover, non-professional activ- atric drugs are psychoactive substances, they modify ities such as peer support, befriending schemes and symptoms through the alterations they produce in community initiatives help individuals who struggle normal mental processes, emotion and behaviour to cope with everyday demands without designating (Moncrieff 2008; Breggin 2008)(Table 1). ‘ ’ them as mentally ill and consigning them to the , , anxiolytics and sick role. Thus, critical psychiatry recognises that ‘mood stabilisers’ all induce significant cognitive, ‘ ’ the best ways of responding to mental disorder emotional and behavioural alterations in animals are not necessarily psychiatric, although psychiatry and in normal volunteers. The drug-centred can provide help too. This section examines the two approach focuses on making judgements about main forms that this help generally takes and consid- when these alterations might be useful. Intrusive ers how they can be offered to people in ways that psychotic symptoms may be muted and rendered fl re ect the preceding discussion about the nature of less distressing by the cognitive slowing and mental distress and the role of psychiatric services. emotion-blunting effects of antipsychotics, for example. Intense anxiety may be relieved by the Drug treatment state of mental and physical relaxation induced by There is considerable criticism of the dominant role benzodiazepines. However, although drugs may drug treatment plays in contemporary psychiatry. reduce unwanted feelings and behaviours, this Critics point to the enormous influence of the approach also highlights their adverse effects on , accusing it of overselling other aspects of mental and physical functioning. its products, inflating their benefits and understating A more detailed discussion of disease- and drug- adverse effects (Whitaker 2010). Prescriptions for centred approaches to the use of psychiatric medica- most drugs are rising steadily, with little evidence tion was published in Advances in 2015 (Yeomans that this is producing better outcomes (Ilyas 2012). 2015).

TABLE 1 Psychoactive effects of psychiatric drugs

Type of drug Psychoactive effectsa

Antipsychotics Sedation, subjective and objective cognitive slowing or impairment, emotional blunting/indifference, reduced libido, demotivation, dysphoria Tricyclic antidepressants Sedation, cognitive impairment, dysphoria Selective reuptake inhibitors (SSRIs) Drowsiness, lethargy, emotional blunting, loss of libido, ‘activation’ (agitation, and related antidepressants irritability) Sedation, cognitive impairment, lethargy, emotional blunting, dysphoria Benzodiazepines Sedation, cognitive impairment, physical and mental relaxation, euphoria Increased arousal, vigilance and attention, euphoria

a. The effects of different drugs within each class vary, particularly drugs classified as antipsychotics. The information provided is necessarily a summary which glosses over distinctions between individual agents. For more detail and references see Yeomans et al (2015).

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‘’ effects Psychological therapies Alongside their established pharmacological proper- Differing psychotherapeutic models have reputa- ties, the use of psychotropic has psycho- tions for greater efficacy in certain situations, are logical, social and ritualistic dimensions, commonly claimed by some to be effective in all conditions, grouped together as the ‘placebo effect’. and all are sometimes ineffective. This questions dis- The prescription of drugs regarded as ‘medicines’ tinctions between them and whether ‘psychother- has many potential received meanings: the user has apy’ really differs from other forms of therapeutic a brain disease; other explanations are irrelevant; the encounter; questions which are taken up by critical user cannot affect the outcome; they are entitled to psychiatry. financial, material and emotional support; the doctor cares. These meanings, some of which relate to the Defining psychotherapies sick role, may bereinforcedby family and other profes- Therapists generally present themselves as adhering sionals, and willinteractwith thesubjective alterations to one or more therapeutic traditions that reflect dif- the drug produces. Furthermore, although placebo fering theoretical frameworks, how a therapy might effects are generally regarded as positive, some of be conducted and the problems for which it might be these meanings may entrench people in a role of best suited. These also reflect training and qualifica- chronic dependency and hinder long-term recovery. tions, inform commissioning and offer the curious client some idea of what to expect. Collaborative prescribing From a critical perspective, ‘psychotherapy’ also Critical psychiatrists are clear that there is more to shares territory with wise counsel, training, coach- prescribing a psychiatric medication than simply ing and religious teaching. It also has much in introducing a chemical into the patient. It is import- common with supportive and caring interactions ant to explore the reasons why patients want medi- found throughout human experience: love, friend- cation, what they expect it to achieve and the ship, advice and mentoring. This perspective has a functions it is intended to fulfil. In this way it may long and respectable background. be possible to identify other ways of achieving desired outcomes. When drug treatment is consid- The ‘Dodo bird verdict’ ered, a drug-centred approach to psychopharma- Rosenzweig adopted Lewis Carroll’s ‘Everybody has cology readily lends itself to a collaborative won, and all must have prizes’ when suggesting that discussion of the potential benefits and harms of dif- psychotherapeutic outcome might reflect influences ferent agents. It changes the relationship between common to all forms of therapy rather than effects patient and prescriber because drug treatment is attributable to technique or theoretical position no longer justified on the basis that it normalises (Rosenzweig 1936). The ‘Dodo bird verdict’ is underlying pathology. The drug-centred model widely accepted (Budd 2009) and supported by advocates a form of self-medication, in which the reviews and meta-analyses of outcome data over psychiatrist acts as a reservoir of information and the past half-century, which all agree that different evidence, helps to explore the likely impact and lim- psychotherapeutic approaches produce broadly itations of drug treatment and consideration of alter- similar results. It appears to reflect the operation of native, non-drug-based approaches (Box 3). common factors most famously articulated by Jerome D. Frank (Frank 1971):

• a confiding relationship BOX 3 An example of collaborative prescribing • rationale • personal qualities, status and a setting that Discussing antidepressant medication strengthen expectations of help The psychiatrist should explain that there is no evidence that antidepressants work by correcting • success experiences a chemical imbalance or other identifiable abnormality. They should inform the patient of the • emotional arousal as a prerequisite to psycho- mental and physical alterations produced by common antidepressants (Table 1), acknowledging the paucity of research data about these effects. They might highlight the reduction in intensity logical change. – – of emotions both desired and undesired that appears to be produced by some antide- Each of the main psychotherapeutic approaches pressants and how this effect may be linked with sexual impairment. As in any consultation, emphasises some of these. Psychodynamic approaches they should discuss known adverse effects, including withdrawal effects. The psychiatrist attend to intense feelings (transference). The relation- should attempt to understand what the patient expects to gain from drug treatment and whether ship between client and therapist is a central feature their expectations match the evidence of what antidepressants can achieve. They should dis- cuss alternative options and help the patient to weigh up the pros and cons of taking an of humanistic approaches. Behavioural and cogni- antidepressant in the light of all these considerations. tive–behavioural psychotherapies offer an explicit rationale for the client’s distress, ways of relieving it and opportunities for ‘success experiences’.

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Humanistic approaches place particular emphasis disordered behaviour with physical disease. MCQ answers on clients’ growth, hopes and interpersonal compe- Critical psychiatry does not reject science, but ques- 1 d 2 a 3 e 4 d 5 a tences. The experiential experiments of behavioural tions the applicability of positivist research para- and cognitive–behavioural psychotherapy, analyses digms to the study of complex human responses, of transference and defence mechanisms in the suggesting that other epistemologies may often be course of a psychodynamic psychotherapy, and the more enlightening. For critical psychiatry, the insti- identification of self-defeating strategies during a tution of psychiatry can be considered an element of humanistic therapy are all challenges to the client’s society’s arrangements for caring for the incapaci- status quo. They encourage uncomfortable risk- tated and maintaining productivity and social taking in the pursuit of change, which is only likely order, which is legitimated through the medical to happen if the therapist is able to engage positively framework of disease, illness and treatment. with clients’ anxieties and heightened emotions. Nevertheless, critical psychiatry believes that Common ingredients of psychotherapy are also there are real social problems to be addressed and reflected in the ‘ordinary’ helping relationships that psychiatrists can contribute through judicious that people develop in the course of everyday life. use of drug treatments and a perspicuous approach They are illustrated by some of the words used to to therapeutic relationships. Traditional under- describe them: ‘a shoulder to cry on’, ‘reliable and standings of psychopharmacology ignore the univer- trustworthy’, ‘they know what they are talking sal - and behaviour-altering properties of about’, ‘helped to put things in perspective’. psychiatric drugs and their interactions with symp- toms, as well as the important non-pharmacological Supportive relationships effects of prescribing medicines. Although specialised psychotherapeutic expertise Whether presented as a formal psychotherapy or and training are valuable and play important parts not, all professionally orchestrated relationships in service provision, it would seem that the most can be a healing encounter. They have the potential important contribution any practitioner can make to be a supported and bounded opportunity to to patients’ well-being is to provide and engage in address problems and effect personal change. They a supportive, accepting, understanding and appro- can do this when everyday relationships have priately bounded relationship. broken down or become strained. Specific theoret- ical frameworks and techniques might be of value in particular situations, such as addressing safety References behaviours in someone disabled by anxiety or in elu- Bracken P, Thomas P (2007) Postpsychiatry: Mental Health in a cidating the fuller meaning of psychological defences Postmodern World. Oxford University Press. troubling someone with personality difficulties, but Breggin P (2008) Brain-Disabling Treatments in Psychiatry: Drugs, the most important ingredient of therapeutic prac- Electroshock, and the Psychopharmaceutical Complex. Springer Publishing Company. tice is the formation and maintenance of a support- Budd R, Hughes I (2009) The dodo bird verdict – controversial, inevitable ive and accepting relationship. This is not always and important: a commentary on 30 years’ meta-analysis. Clinical easy when the client is someone who has reason to and Psychotherapy, 16: 510–22. be fearful or suspicious, and critical psychiatry Cohen BMZ (2016) Psychiatric Hegemony: A Marxist Theory of Mental does not minimise the need for professionalism and Illness. Palgrave Macmillan. experience. However, at present services are Conrad P, Potter D (2000) From hyperactive children to ADHD adults: commissioned and organised around the provision observations on the expansion of medical categories. Social Problems, 47: 559–82. of specific forms of therapy for specific forms of fi Coulter J (1979) The Social Construction of Mind: Studies in mental health dif culty. Perhaps much more explicit Ethnomethodology and Linguistic Philosophy. Macmillan. priority should be given to the relational dimensions Foucault M (1965) Madness and Civilisation: A History of Insanity in the of what practitioners do. Although this may read as Age of Reason. Tavistock. motherhood and apple pie, critical psychiatry draws Frank J (1971) Therapeutic Factors in Psychotherapy: Eleventh Emil A. attention to the many ways in which resource pres- Gutheil Memorial Lecture of the Association for the Advancement of sures and institutional arrangements hinder this Psychotherapy, New York City, November 1, 1970. American Journal of Psychotherapy, 25:350–361. important aspect of practice and instead encourage Greenberg G (2011) Manufacturing Depression: The Secret History of a paternalising and instrumental approaches. Modern Disease. Bloomsbury Publishing. Ho BC, Andreasen NC, Ziebell S, et al (2011) Long-term To summarise treatment and brain volumes: a longitudinal study of first-episode schizo- phrenia. Archives of General Psychiatry, 68: 128–37. Critical psychiatry is not ‘anti-psychiatry’, but there Hyman SE, Nestler EJ (1997) Drs. Hyman and Nestler reply. 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MCQs

1 The following is true of critical psychiatry: 3 The medical sick role is problematic in d the drug-centred model of action explains how a it is a new term for what has been known as anti- psychiatry because: altered mental functions can interact with mental psychiatry a it does not accommodate the need for treatment and behavioural symptoms b it believes patients should never be subjected to without e modern drugs have been shown to act through a coercion b not all carers agree with patients’ wishes disease-centred mechanism. c it believes there is no place for drug treatment in c psychiatrists cannot always be honest with their psychiatry patients 5 The importance of common factors in d it offers constructive criticism of assumptions d the classic sick role no longer has a part to play in determining psychotherapeutic outcome underpinning conventional practice modern medicine suggests that: e its views are held by a small minority of e the sick role inhibits autonomy and self-reliance. a a great deal can be achieved by anyone able to psychiatrists. supportively engage with distressed individuals 4 Concerning models of drug action: b only mental health professionals should attempt 2 Thomas Szasz was critical of psychiatry a the disease-centred model rules out the placebo to form a helping relationship because: response c only qualified psychotherapists are capable of a he felt the language and logics of medicine did b the disease-centred model was developed in the developing a therapeutic relationship with clients not apply to it early 20th century d psychological therapies have to be conducted in b he was religiously opposed to it c the drug-centred model of action classifies special settings c patients complain about it drugs according to their target condition or e technical skills are the key to successful practice. d people should not be restrained when they symptoms threaten to harm themselves or others e treatments are ineffective.

54 BJPsych Advances (2019), vol. 25, 47–54 doi: 10.1192/bja.2018.38 Downloaded from https://www.cambridge.org/core. 29 Sep 2021 at 00:41:15, subject to the Cambridge Core terms of use.