BJPsych Advances (2019), vol. 25, 47–54 doi: 10.1192/bja.2018.38 † Critical psychiatry: a brief overview ARTICLE Hugh Middleton & Joanna Moncrieff psychiatry and of the aims and organisation of Hugh Middleton MA, MB, BChir, SUMMARY mental health 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 mental disorder, 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 psychiatrist. 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 medicine 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 psychopharmacology ment are practising psychiatrists keen to grapple and psychophysiology, and subse- be gained by openly embracing the controversies with the intellectual and practical challenges that quently included social science 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 psychiatric medication 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. Sciences 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. 47 Downloaded from https://www.cambridge.org/core. 29 Sep 2021 at 00:41:15, subject to the Cambridge Core terms of use. Middleton & Moncrieff 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- Thomas Szasz (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 therapeutic community for people with psychosis.a iour, thoughts and feelings that are reported by the individual or those around them and that depend, Michel Foucault (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 Erving Goffman (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