Critical Psychiatry in The UK: A Personal View

Of all tyrranies, a tyrrany sincerely exercised for the good of its victims may be the most oppressive.

C. S. Lewis, God in the Dock

This is the English version of a paper originally translated into French by Patrick Landman, to be published in the journal Espace Analytique.

The revolution of the 1960s, aborted almost immediately it was conceived, nevertheless left its traces on the later years of the twentieth century. These are the movements of liberation and emancipation – of women from the authority of patriarchy, of Black people from the oppression of racism, of former colonial subjects from the ravishment of colonialism, of gay people from the tyranny of heterosexuality, and most significant of all for psychiatry, of mad people from subjugation and incarceration imposed by rationality.

Madness found a place in the ferment of the time, through the Dialectics of Liberation conference organised by a group of antipsychiatrists, which took place in London (Cooper, 1968). Themes of revolution and liberation featured prominently at the event, but there was no contribution from radical or critical survivors. In those days there was no survivor movement.

In this paper I will outline the origins of contemporary critical psychiatry in the UK. There is a sense in which critical psychiatry can be seen as a legacy of the 1960s, but there is much more to it than that, and to equate critical psychiatry with antipsychiatry is to commit serious historical and conceptual errors. For this reason I will set out my personal view of the main points of agreement and disagreement between antipsychiatry and critical psychiatry. Then I will describe the main areas of work of the Critical Psychiatry Network (CPN) in the UK, before dealing with what has come to be known as postpsychiatry. I will end with a personal view of the future challenges that face critical psychiatry.

Antipsychiatry

The South African psychiatrist David Cooper coined the term ‘antipsychiatry’ in his book Psychiatry and Antipsychiatry (Cooper, 1967). Since then the expression has been widely used to refer to the writings and activities of a heterogenous group that includes the psychiatrists R.D. Laing, Aaron Esterson, David Cooper, and Thomas Szasz (although the latter rejected the use of the label), the sociologists Erwin Goffman and Thomas Scheff, and the early work of the French historian / philosopher Michel Foucault.

In The Divided Self Laing (1960) developed a powerful critique of positivistic (scientific) psychiatry. He argued that madness is potentially intelligible, but the objective methods of scientific psychiatry rendered it unintelligible. Instead, Laing proposed a hermeneutic approach to madness based in the Object-Relations theory of Winnicott and Fairbairn and the existential phenomenology of Heidegger and Sartre as the basis for understanding and helping people who experience madness[1], as in the case of Peter (Chapter 8). In contrast Thomas Szasz (1960) turned to a very different philosophical tradition, that of the Vienna Circle. He argued that psychiatry is conceptually confused in its use of words relating to the mental and physical worlds. Whilst it is logical to speak of physical disorders that arise from pathological disturbances in bodily function, it is illogical to speak of mental disorders because there is no empirical evidence that they are associated with causal pathological disturbances in brain function. Thus he argues that there is no legitimate role for doctors in dealing with madness. Instead people with mental health problems should pay for psychotherapy on a contractual basis.

Critical psychiatry would broadly agree with Laing on the importance of meaning and understanding in psychosis, and whilst respecting aspects of Szasz’s conceptual critique (for example, his insistence on the illogicality of the expression ‘mental illness’) would see this as ultimately dualistic, based as it is in a contrived division between body and mind. In addition Szasz’s views on contractual psychotherapy represent a libertarian preoccupation with freedom and autonomy that is ill-suited to a multi-cultural society. Finally, the great majority of members of CPN are practicing UK psychiatrists who have to work in a context that involves coercion and medication. A key aim of CPN therefore has always been to minimise coercion, and harmful psychiatric interventions such as ECT, psychosurgery and medication.

The Origins of Critical Psychiatry

We can mark the passage from antipsychiatry to contemporary critical psychiatry through three key texts, those by David Ingleby, Peter Sedgwick and Suman Fernando. David Ingleby (1981), a social psychologist, edited a collection of essays under the title Critical Psychiatry. With his contributors he set out a detailed and cogent critique of psychiatry that differs fundamentally from that of the antipsychiatrists. Whilst his own contribution acknowledges the influence of antipsychiatry he is critical of its ‘…vague theories, its detachment from traditional politics, and its disregard for strategy…’ (Ingleby, 1981: 9) Ingleby’s underlying premise is that mental illness is primarily a political issue. In this work we can see a new set of concerns at work. The historical and philosophical work of Michel Foucault provides an important framework with which he questions the legitimacy of psychiatry’s involvement with madness. In addition, he is influenced by the Frankfurt School, and is critical of the assumption that the scientific gaze is one of neutral objectivity. The influence of Habermas (1968) can be seen in his critique of positivism in psychiatry, and the value he attaches to psychoanalysis (or ‘depth hermeneutics’) as an alternative to positivism. Finally, he argues that the context of mental health care had changed since the 1960s. Moving the locus of care from institution to community had not, as some claimed, altered the fundamental problems of psychiatry.

The critique of antipsychiatry developed by the British Marxist psychologist Peter Sedgwick (1982) also sees the problems of psychiatry as fundamentally political. Sedgwick argued that antipsychiatry was problematic for a number of reasons. He criticised Szasz (1960) for his rigid dualism, based in a problematic distinction between a biological, value-free world of physical illness, and a value-laden world of mental illness. Sedgwick also argued that there is an inconsistency in Laingian arguments that deny the applicability of the methods of natural science in psychiatry, whilst claiming that there is still a role for medicine in psychiatry. Sedgwick accused Foucault (1967) of failing to grasp the importance of the modes of production of different political systems. As a result he argued that Foucault viewed psychiatry apart from the social conditions in which it operated. Foucault’s analysis of psychiatry, argued Sedgwick, was couched in terms of medical and scientific insights in isolation from the social and political realities that shaped them, particularly those of class and production.[2] Ultimately Sedgwick accused the antipsychiatrists of cynicism. They opposed positivistic psychiatry, but did so from such widely different perspectives that it was impossible to see a constructive way forward in terms of developing alternatives for mad people. This led to a position of nihilism[3].

The work of Sri Lankan-born British psychiatrist Suman Fernando is important for a number of reasons. In the 1980s and 1990s he was part of what was called the transcultural psychiatry movement (Fernando, 2014). His book Mental Health, Race and Culture (Fernando, 1991) is arguably the first critical work written by a practicing British psychiatrist working in the National Health Service (NHS). More important, however, is that he brings together a range of disciplines, postcolonial theory, anthropology and historical analyses, to develop a comprehensive critique of the Eurocentric and racist nature of psychiatry. He draws on the work of Franz Fanon, of anthropologists such as Obeyesekere and Kleinman, and a historical analysis of the influence of racial science on the origins of psychiatry. He points out that the imposition on non-Western people of European assumptions about the nature of the self, of psychological development, and family structures is a constant theme running through the history of Western psychiatry. This obscures the value and importance of non-Western understandings of and responses to madness and distress. Fernando’s work is particularly important today given the increasing cultural diversity of most Western societies.

The Critical Psychiatry Network

The first meeting of the Network took place in January 1999 in Bradford. It was attended by over twenty consultant psychiatrists from across the UK, and ever since has met twice a year. It has organised conferences, and members of the group have been responsible for a large number of publications and books[4]. It functions on a day to day basis largely through an email discussion group. It has also functioned as an important support network for psychiatrists who question and challenge orthodoxy. In broad terms it has been concerned with three main issues: the problem of coercion and the role of psychiatry in social control, the role and use of scientific knowledge in psychiatry; the problems of meaning and contexts in psychiatry.

The problem of coercion and social control

The practice of psychiatry involves achieving a balance between the need to respect individual rights on one hand, and on occasions the protection of other people on the other. Shortly after its election in 1997 the New Labour government introduced proposals to reform the 1983 Mental Health Act. Although many recognised the need to change the act to reflect the shift to community care, there was serious concern that the proposed changes were driven by sensationalist media coverage of a small number of high profile tragedies presented as ‘failures’ of community care. The government’s proposals raised serious concerns that the new act would shift the balance too far in the direction of public protection, emphasizing the social control function of psychiatry. Two proposals were particularly problematic. One involved the introduction of new legislation – reviewable detention – to enable psychiatrists to detain indefinitely people with so-called dangerously severe personality disorders (DSPD), even though they had not committed or been convicted of an offence. The other involved the introduction of community treatment orders (CTOs) to make it possible to treat people against their wishes in the community. CPN submitted evidence to the government’s Scoping Group (CPN, 2001), which set out ethical and practical objections to CTOs, and ethical and human rights objections to the idea of reviewable detention. It was critical of the concept of personality disorder as a psychiatric diagnosis. The Network called for the use of advance statements, crisis cards and a statutory right to independent advocacy as ways of sustaining autonomy at times of crisis.

The Network carried out a questionnaire survey of over two and a half thousand consultant psychiatrists working in England seeking their views of the proposed changes (Crawford et al, 2001). The responses (a response rate of 46%) confirmed that members of the profession were indeed worries about reviewable detention and CTOs. These fears were widely shared outside the profession, which resulted in the formation of the Mental Health Alliance[5] to campaign for the protection of patients’ rights, and to minimise coercion. CPN joined the Alliance’s campaign, but resigned in 2005 when it became clear that the Alliance accepted the introduction of CTOs.[6]

The role of scientific knowledge in psychiatry

Many psychiatrists have been concerned about the domination of psychiatry by scientific knowledge. This is not to say that CPN is anti-science, far from it, but there are concerns with two aspects of the use of science in psychiatry. One relates to the improper use of scientific evidence by the pharmaceutical industry and those psychiatrists with links to it. The other is the limitation of biological science in understanding distress and madness.

There is a strong view that contemporary psychiatry relies too much on the medical model, and attaches too much importance to a narrow biomedical view of diagnosis (Double, 2000). The desire of psychiatry to be seen as ‘scientific’ as other branches of medicine can in part be understood as the response of an earlier generation of psychiatrists to the challenge of anti-psychiatry. It can also be seen against wider epistemological shifts, such as the rise of neo-Kraepelinianism[7] (Wilson, 1993) through DSM-III and DSM-IV, and the so-called decade of the brain in the USA. This has had a number of consequences.

First, the aggrandisement of biological research creates a false impression inside and outside the profession of the credibility of the evidence used to justify drug treatments for psychiatric conditions. Clinical practice guidelines for the treatment of depression such as those developed by the National Institute for Health and Clinical Excellence (NICE) in UK, create the impression that the evidence for the efficacy of selective serotonin reuptake inhibitors (SSRIs) is established beyond doubt. This is simply not the case. Recent studies have re-examined drug trial data from meta-analyses, and found that most of the benefits seen in active treatment groups also occur in the placebo groups (Moncrieff & Kirsch, 2005; Kirsch et al, 2008). NICE even acknowledges that the difference between antidepressant medication and placebo is not clinically significant, yet despite this continues to recommend the use of these drugs (Turner & Rosenthal, 2008).

As far as schizophrenia is concerned (and setting aside serious doubts about the validity of the concept) neuroleptic drugs may confer limited short-term benefits by ‘damping down’ or numbing distress associated with the experiences of psychosis, but these drugs do not possess specific ‘anti-psychotic’ properties. It is also extremely difficult to establish whether or not they confer advantages in the long-term management of psychosis because of the severe mental state disturbances that occur when people on long-term medication are abruptly switched to placebos. These disturbances are traditionally interpreted as ‘relapse’ when in fact there are several possible interpretations for the phenomenon (Moncrieff, 2013).

Meaning and contexts in psychiatry

Critical psychiatry (and post psychiatry) is concerned about the waning of interest in hermeneutics in psychiatry. Within critical psychiatry there is a range of views about the value of psychoanalysis as a hermeneutic tool. One strand of thought is that psychoanalysis does not possess any special knowledge of the mind; others value the hermeneutic role of psychoanalytic theory as a way of foregrounding social factors and personal narrative in understanding madness.

There are many factors responsible for the waning of interest in hermeneutics in mainstream psychiatry, including the ascendancy of clinical neuroscience, the preoccupation with an increasingly narrow, ‘neo-Kraepelinian’ view of diagnosis, and the waning influence of psychodynamic and other forms of insight-orientated psychotherapy. There is also a long-established tradition in clinical psychiatry that sees limits in the extent to which it is possible to understand the experiences of psychosis. In part this may be traced back to the work of the German psychiatrist and philosopher, Karl Jaspers, and his interpretation of Edmund Husserl’s phenomenology.[8]

Postpsychiatry

Postpsychiatry started life as a series of short articles in Open Mind magazine from 1997 – 2001, co-authored by Pat Bracken and Philip Thomas. This was followed by an article in the British Medical Journal Education and Debate section (Bracken & Thomas, 2001), and a book of the same name four years later in Oxford University Press’s series on philosophy and psychiatry (Bracken & Thomas, 2005). In some ways, postpsychiatry can be seen as a more explicitly ‘philosophical’ form of critical psychiatry. Postpsychiatry broadly welcomes and supports critical psychiatry, but not all critical psychiatrists would necessarily agree with the key arguments of Post-psychiatry.

Post-psychiatry is heavily influenced by what English speaking philosophers call continental philosophy (in contrast with the English language tradition of analytic philosophy) especially the work of Heidegger, Merleau-Ponty, and later Wittgenstein, as well as that of post-structuralist thinkers, especially Michel Foucault. Bracken (2002) developed a sustained critical analysis of the concept of PTSD based in Heidegger’s (1962) philosophy. He argues that PTSD is not a disturbance of cognitive processing, but an existential threat following the rupture of the person’s social, cultural, spiritual and political ties occasioned by war and disaster. Thomas et al (2003) used Merleau-Ponty’s philosophy to show how, within the person’s narrative, the experience of hearing voices is meaningful.

The work of Heidegger and Merleau-Ponty proposes that our being-in-the-world is irreducible and comes before everything else. It cannot be explained by science. Scientific thought originates like all aspects of human experience in being-in-the-world, and for this reason it is not neutral and objective, but already shaped and coloured by the world in which we find ourselves. Science is just one way in which the world becomes meaningful for us. Merleau-Ponty (1962) argues that the starting point for any account of experience must be experience itself. This is because the world of experience is present to us before anything else. This view of phenomenology implies that we must set to one side scientific explanations of experience in favour of descriptions grounded in our being-in-the-world (Matthews, 2002).[9]

The work of Michel Foucault is another important influence on postpsychiatry. In the introduction to Madness and Civilization Foucault famously drew attention to the historical silencing of unreason by reason (Foucault, 2006 see p. xxviii). One of the most significant developments in the contested field of mental health over the last 40 years has been the emergence of a wide range of critical service user / survivor groups. Foucault’s later work on power and subjectivity helps us to understand the importance of this. Foucault argued that political struggles around identity are primarily directed at the analysis of power, and furthermore, they are ‘immediate’ in the sense that those involved in the struggle are those who are most directly affected by the source of their oppression (Foucault, 1982). This is why liberatory movements over the last 50 years have been led by those most directly affected by the source of their oppression. The critical / radical survivor movement stands in this tradition.

Philosophical Investigations is a complex, multi-layered work in which Wittgenstein (1967) deals with many profound philosophical problems. Most notably for postpsychiatry is his view of the problematic relationship between mind and the external world. This is important when we come to examine critically the claims made for some forms of psychotherapy, especially cognitive therapy and the cognitivist view of mind in which this is based. This proposes that our experience of the world arises from the operation of inner mental processes that build up inner representations of the external world from our senses. Wittgenstein’s philosophy challenges this. How is it possible for me to talk about my inner world with others, when I am the only person with direct knowledge of my inner world? One answer to this, he suggests, is to be found through language games, an argument that leads directly to the fundamental importance of culture and contexts in relation to meaning. Thomas et al (2009) used Wittgenstein’s notion of language games to argue the importance of cultural referents in the work of interpreters in clinical settings, especially when non-English speakers from non-Western cultures are being assessed by English speaking mental health staff.

It is important to stress that postpsychiatry is not a new form of ‘therapy’. Like many postmodern critiques, it is sceptical of the role of expertise and technology in human affairs. Its sensitivity to issues of power, authority and the dangers of subjugation and oppression gives rise to the aphorism – ethics before effectiveness (Bracken & Thomas, 2000). For this reason postpsychiatry is broadly supportive of the work of Romme and Escher (1993) and initiatives like the Hearing Voices Network (http://www.intervoiceonline.org), and the work of radical and liberatory survivor activist groups like Mad Pride (http://madpride.org.uk/index.php), and Recovery in the Bin (https://www.facebook.com/groups/711653172207623/). Finally, analyses of the Eurocentrism of biomedical psychiatry postpsychiatry have resulted in alternative systems of support for people from Black and Minority Ethnic communities experiencing distress, most notably the community development project Sharing Voices Bradford (http://www.sharingvoices.net) (Thomas et al, 2006).

Future Challenges Facing Critical Psychiatry

There are three main challenges facing critical psychiatry; the problems of psychotropic drugs, the role of the consultant psychiatrist in mental health work, and further extensions of the social control function of psychiatry.

The role of psychiatric drugs

It is now generally accepted that psychiatric drugs are neither as effective nor as safe as was once thought. Much of the evidence here comes from the work of critical psychiatrists, particularly Joanna Moncrieff in her two recent books (Moncrieff 2008, 2013). The problem as far as neuroleptic drugs is concerned is particularly serious. Most people given a diagnosis of schizophrenia end up taking them for many years. However, as Moncrieff (2008) points out, most of the evidence used to justify their use comes from randomised controlled trials (RCT) most of which last only a few weeks. In contrast most episodes of psychosis last at least a few months or longer. It is thus difficult to draw any conclusions about the value of the long term use of these drugs. In fact, the evidence from the very small number of RCTs that have followed up patients for longer periods (up to a year) found better outcomes in patients on placebo at 12 months than those remaining on active medication. There is also evidence that some people who experience acute psychosis do well without receiving neuroleptic drugs (Bola et al, 2009).

It is almost impossible to interpret the evidence for the effectiveness of neuroleptics in the long-term prevention of ‘relapse’ of psychosis. For example, evidence from long-term double-blind discontinuation studies of neuroleptic treatment indicates that the risk of relapse is significantly greater in the six to ten months following discontinuation (Harrow & Jobe, 2013). This suggests that the re-emergence of psychotic experiences on discontinuation may be more than simply a ‘recurrence’ of a schizophrenia, but a discontinuation syndrome.[10] Finally, is the evidence that neuroleptics are associated with the risk of serious physical health problems, including diabetes, obesity and sudden cardiac death, with reduced life expectancy compared with people not on these drugs (for example, Chang et al, 2011).

The role of the psychiatrist in mental health work

Over the last 50 years the locus of mental health care has shifted from the Victorian asylums to community care. Foucault (2006) described how the power and authority of the psychiatrist was born in the nineteenth century institutions. The move to community care has presented a major challenge to psychiatric power, and there is evidence that the profession in crisis (Thomas, 2014a). One the one hand are those who argue for the maintenance of psychiatric power and authority, asserting that despite new patterns of service delivery the profession must cling to its biomedical identity (Craddock et al, 2008; Bullmore et al, 2009; Oyebode & Humphreys, 2011). The critical psychiatry perspective has been articulated by Bracken et al, 2012). This paper argued that good psychiatric practice primarily involves the non-technical, or non-specific, aspects of clinical care, particularly human relationships. In this view the crisis of psychiatry has arisen because technical aspects of care, or the ‘technological paradigm’ (diagnostic systems, causal models of mental distress, evidence-based medicine) has obscured the significance of the non-specific aspects of care.

There are two questions that arise from this analysis, and both concern in a fundamental sense the role of the psychiatrist as a medically qualified practitioner working in the field of madness. First, given the evidence for the ineffectiveness and risks of psychiatric drugs, how exactly should medication be used? Second, how can psychiatrists work in ways that foreground the importance of non-technical aspects of psychiatric care? The answer to the first question can in part be found in Moncrieff’s (2008) distinction between disease-centred and drug-centred model of psychotropic drugs action. The two models cast the relationship between doctor and patient in a quite different light. In the former the doctor is the expert by virtue of his or her possession of specialist knowledge about the supposed mode of action and properties of psychotropic drugs. In contrast the drug-centred model helps us to understand how some people may gain benefit from psychiatric drugs at least in the short term, through the idea that they induce an abnormal state in the central nervous system. This has the potential to lead to a more collaborative approach between patient and doctor in the use of psychiatric drugs (Yeomans et al, 2015). The second question is partly answered by the growing interest in narrative psychiatry as a way of facilitating collaborative, less authoritarian relationships between service users and psychiatrists that see the search for personal meaning in the experiences of madness as an important element of the doctor’s role (Lewis, 2011; Hamkins, 2014; Thomas, 2014b).

Extension of the social control function of psychiatry

Recent events in Paris, London and elsewhere linked to conflicts in the Middle East, and particularly to the action of Al Qa’ida and ISIS, have opened up new areas in which the social control function of psychiatry may operate. The British Government’s anti-terrorism strategy, Contest, was originally introduced in 2003 in the aftermath of the 9/11 atrocity in New York. It was reviewed in 2009 following the London bombings of 2007, and now consists of four work-streams aimed at reducing the risk to UK citizens from terrorism. One of these work-streams, the Prevent strategy, was revised in 2011 to include the NHS through the organisation’s safeguarding procedures for vulnerable individuals considered to be at risk, in this case, of radicalisation. This has resulted in local mental health service providers attending mandatory training on the identification and management of those at risk.

A heated debate has recently taken place on the Critical Psychiatry list serve about this. Some psychiatrists support the view that there is a legitimate role for psychiatrists in these activities. Others disagree, pointing out that the strategy raises serious ethical and human rights concerns[11]. Prevent is arguably an instance of the extension of the governmental role of psychiatric power to deal with a perceived threat. The fact that it targets a marginalised and highly visible minority (young disaffected Muslim men and women) is neither here nor there as far as the governmental function is concerned. They are perceived as a problematic group who threaten the neoliberal status quo.

There are two concerns here. The first is the silence, to date, of the Royal College of Psychiatrists – the professional body for psychiatrists in the UK – on the issue. The CPN is currently trying to establish the College’s position on the strategy. It is also worth noting that the Division of Clinical Psychology (the clinical psychologists’ professional organisation) has at the time of writing to set out its position in relation to the strategy. Equally worrying is the growing interest in academic psychiatry in the search for links between common mental disorders (especially depression) and radicalisation (Bhui et al, 2014). The lack of a sound scientific basis for deciding whether or not a person is suffering from depression throws open the possibility that the concept will be used in regard to radicalistion for political purposes.

Conclusions

Arguably the most important contribution made by British critical psychiatry over the last fifteen years has been the encouragement and expression of a self-critical and self-reflective approach to psychiatric theory and practice. This is essential in a situation in which beneficence is widely perceived to be a virtue, and is also assumed to be an inevitable consequence of membership of a caring profession. A genuinely critical psychiatry is the bearer of uncomfortable truths for those who see themselves as inevitably doing good for others. Whether or not CPN can maintain the stance in the future remains to be seen. In the light of recent comments in the debate about radicalistion, I doubt it.

References

Bhui, K., Everitt, B. & Jones, E. (2014) Might Depression, Psychosocial Adversity, and Limited Social Assets Explain Vulnerability to and Resistance against Violent Radicalisation? PLoS ONE 9(9): e105918. doi:10.1371/journal.pone.0105918

Bola, J., Lehtinen, K., Cullberg, J. & Ciompi, L. (2009) Psychosocial treatment, antipsychotic postponement, and low-dose medication strategies in first-episode psychosis: A review of the literature. Psychosis, 1, 4–18.

Bracken, P. (2002) Trauma: Culture, Meaning and Philosophy London & Philadelphia, Whurr Publishers.

Bracken, P. & Thomas, P. (2000) Putting ethics before effectiveness. Open Mind, 102, 22.

Bracken, P. & Thomas, P. (2001) Postpsychiatry: A new direction for mental health. British Medical Journal, 322, 724–7.

Bracken, P. & Thomas, P. (2005) Postpsychiatry: Mental health in a postmodern world. Oxford: Oxford University Press.

Bracken, P., Thomas, P., Timimi, S., Asen, E., Behr, G. et al (2012) Psychiatry beyond the current paradigm. British Journal of Psychiatry, 201: 430–4. doi: 10.1192/bjp.bp.112.109447.

Bullmore, E., Fletcher, P. & Jones, P. (2009) Why psychiatry can’t afford to be neurophobic. British Journal of Psychiatry, 194, 293–5. doi: 10.1192/bjp.bp.108.058479.

Chang, C.-K., Hayes, R., Perera, G., Broadbent, M., Fernandes, A., Lee, W. et al (2011) Life expectancy at birth for people with serious mental illness and other major disorders from a secondary mental health care case register in London. PLoS One 6(5), e19590. Accessed on 14th February 2012 at http://www.plosone.org/article/info:doi/10.1371/journal.pone.0019590

Cooper, D. (Ed.) (1967) Psychiatry and Antipsychiatry. London, Paladin.

Cooper, D. (Ed.) (1968) The Dialectics of Liberation. Harmondsworth, Penguin.

CPN (2001) Response to the Consultation Document – Reform of the Mental Health Act 1983 Accessed on 26th November 2015 at http://www.critpsynet.freeuk.com/ResponseReform.htm

Craddock, N., Antebi, D., Attenburrow, M.-J., Bailey, A., Carson, A. et al (2008) Wake-up call for British psychiatry. British Journal of Psychiatry 193, 6–9. doi: 10.1192/bjp.bp.108.053561.

Crawford, M., Hopkins, W., Thomas, P., Moncrieff, J., Bindman, J. & Gray, A. (2001) Most psychiatrists oppose plans for new mental health act British Medical Journal, 322, 866

Double, D. (2000) Critical Psychiatry CPD Bulletin Psychiatry, 2, 33-36. Accessed on 26th November 2015 at http://www.critpsynet.freeuk.com/criticalpsychiatry.htm

Fernando, S. (1991) Mental Health, Race and Culture. Basingstoke/London: Macmillan/MIND Publications.

Fernando, S. (2014) Mental Health Worldwide: Culture, Globalization and Development Basingstoke: Palgrave Macmillan.

Foucault, M. (1967) Madness and Civilization: A History of Insanity in the Age of Reason. London, Tavistock.

Foucault, M. (1982) Afterword in Dreyfus H. and Rabinow, P. Michel Foucault: Beyond Structuralism and Hermeneutics. New York, Harvester Wheatsheaf. (pp. 208 – 216).

Foucault, M (2006) History of Madness (Preface to the 1961 edition) (J Murphy & J Khalfa, Trans). London: Routledge.

Frank, A. (1995) The Wounded Storyteller: Body, illness and ethics. Chicago: University of Chicago Press.

Habermas, J. (1968) Erkenntnis und Interesse, Suhrkamp, English trans., Knowledge and Human Interests, Heinemann, London 1972.

Hawkins, S. (2014) The Art of Narrative Psychiatry New York, Oxford University Press.

Harrow, M., Jobe, T, & Faull, R. (2012) Do all schizophrenic patients need antipsychotic treatment continually continuously throughout their lifetime? A 20-year longitudinal study. Psychological Medicine, 42, 2145 –5655. doi: http://dx.doi.org/10.1017/S0033291712000220.

Heidegger, M. (1962) Being and Time (Trans. J. Macquarrie & E. Robinson). Oxford: Basil Blackwell.

Ingleby, D. (1981) Understanding ‘Mental Illness. In D. Ingleby (ed.) Critical Psychiatry: The Politics of Mental Health. Harmondsworth: Penguin. (also accessible at http://www.critpsynet.freeuk.com/InglebyCritical.htm 18th December 2015)

Kirsch, I., Deacon, B.J., Huedo-Medina, T.B., Scoboria, A., Moore, T.J. and Johnson, B.T. 2008. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. Public Library of Science: Medicine 5, e45.

Laing, R.D. (1960) The Divided Self: An existential study in sanity and madness. London: Tavistock Publications.

Lewis, B. (2011) Narrative Psychiatry: How stories can shape clinical practice. Baltimore, MD: The Johns Hopkins University Press.

Matthews, E. (2002) The philosophy of Merleau-Ponty. Chesham, Acumen.

Merleau-Ponty, M. (1962) Phenomenology of Perception. (Trans. C. Smith), Routledge & Kegan Paul, London

Moncrieff, J. & Kirsch, I. (2005) Efficacy of antidepressants in adults. British Medical Journal. 331, 155-157.

Moncrieff, J. (2008) The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment. Basingstoke: Palgrave Macmillan.

Moncrieff, J. (2013) The Bitterest Pills: The troubling story of antipsychotic drugs. Basingstoke: Palgrave Macmillan.

Olssen, M. (2004) Foucault and Marxism: rewriting the theory of historical materialism. Policy Futures in Education, 2, 454-482

Oyebode, F. & Humphreys, M. (2011) The future of psychiatry. British Journal of Psychiatry, 199, 439–40. doi: 10.1192/bjp.bp.111.092338.

Romme, M. & Escher, S. (1993a) Accepting Voices. London: Mind.

Sedgwick, P. (1982) Psycho Politics, London, Pluto Press

Szasz, T. (1960) The myth of mental illness. American Psychologist, 15, 113–18.

Thomas, P., Bracken, P. & Leudar, I. (2004) Hearing voices: A phenomenological-hermeneutic approach. Cognitive Neuropsychiatry, 9, 13–23.

Thomas, P., Seebohm, P., Henderson, P., Munn-Giddings, C. & Yasmeen, S. (2006) Tackling race inequalities: Community development, mental health and diversity. Journal of Public Mental Health, 5, 13–19.

Thomas, P., Shah, A. & Thornton, T. (2009) Language, games and interpretation: A Wittgensteinian thought experiment. Medical Humanities, 35, 13–18.

Thomas, P. (2014) Psychiatry in Context: Experience, Meaning and Communities. Ross-on-Wye, PCCS Books.

Thomas, P. (2014a) Professional relationships and the crisis in psychiatry. Clinical Psychology Forum, 261 (September) 30-34.

Thomas, P. (2016) Psycho Politics, Neoliberal Governmentality and Austerity forthcoming in Self and Society

Turner, E.H. and Rosenthal, R. (2008) Efficacy of antidepressants. Is not an absolute measure, and it depends on how clinical significance is defined. British Medical Journal 336, 516-17.

Wilson, M. (1993) DSM-III and the Transformation of American Psychiatry: A History. American Journal of Psychiatry, 150, 399- 410.

Wittgenstein, L. (1967) Philosophical Investigations (3rd edn) (trans. G. E. M. Anscombe). Oxford: Blackwell.

Yeomans, D., Moncrieff, J. & Huws, R. (2015) Drug-centred psychopharmacology: a non-diagnostic framework for drug treatment British Journal of Psychiatry Advances, 21 (4) 229-236; DOI: 10.1192/apt.bp.114.013094


[1] The expressions ‘mad’ and ‘madness’ are used to avoid the epistemological assumptions that permeate words like psychosis or schizophrenia. They also resonate with the political reclamation of these words by survivor activists.

[2] Foucault had an ambivalent relationship with Marxism . Olssen (2004) points out that although he was often critical of Marxism, there are similarities between Marx’s and Foucault’s analysis of power in social relationships, but there are important differences. Foucault rejected historical materialism because it was rooted in the problematic traditions of the Enlightenment. Where classical Marxism saw power relationships between subjects in terms of class struggle between the proletariat and capital, Foucault’s key insight was that any analysis of power had to engage with the way that power relationships constituted the subjects involved in them.

[3] The impact of neoliberal austerity on the lives of disabled people and those who experience episodes of madness has generated new interest in Sedgwick’s work, with attempts to reconcile his ideas with Foucault’s later work on neoliberal governmentality (Thomas, 2016)

[4] see http://www.criticalpsychiatry.co.uk/index.php/articles

[7] In brief, neo-Kraepelinism can be seen in the increasing preoccupation of psychiatry with diagnosis, and the disease model of madness. Wilson’s (1993) paper sees the publication of DSM-3 in 1980 as a key moment in the recent history of psychiatry in which psychoanalytic theory was abandoned as the discipline became increasingly preoccupied with description and classification in the search for a biological basis of madness.

[8]. It is important to note in passing that there is controversy in philosophical circles about the interpretation of the relationship between Husserl and Jaspers view of phenomenology. This is discussed at some length in Chapter 4 of Bracken & Thomas (2005), pp. 105 – 134.

[9]. The position of post psychiatry in relation to the role of science and technology in human affairs is close to that of Matthew’s (2002) reading of Merleau-Ponty. Some have argued that Merleau-Ponty was anti-science, a view contested by Matthews, who points out that in the original translation of Phenomenology of Perception, the French word désaveu was incorrectly rendered as a ‘rejection’ (of science), when a better word is foreswearing as it appears in the later translations. This indicates that Merleau-Ponty was not hostile to science, but wanted to place it in a more appropriate relationship to human experience. Thus the question of the position of science in relation to madness is one of values and priorities.

[10]. If a recurrence of psychosis on neuroleptic discontinuation was really a relapse of schizophrenia, then one would not expect the re-emergence of psychosis to occur more frequently in the 6 to 12 months following discontinuation. One would expect ‘relapses’ to be evenly distributed over time afterwards.

[11] It is worth noting in passing that these concerns are shared by one of UK’s leading independent Human Rights organisations, Liberty, see https://www.liberty-human-rights.org.uk/unsafe-unfair accessed 18th December 2015