by Sandra Steingard (Editor)
Review by Duncan Double on May 21st 2019
In a tweet, Sandra Steingard, the editor of this book, says that her book is "The only current guide to critical psychiatry". There are in fact several other books with the same title 'Critical psychiatry'. The first was by David Ingleby (1980), who probably coined the term. My own edited book (2006) deliberately echoed this title and was written after the formation of the Critical Psychiatry Network in 1999. More recent publications - okay, David's and my books may be somewhat dated - include Critical psychiatry and mental health: Exploring the work of Suman Fernando in clinical practice (2014). This book highlights how much critical psychiatry overlaps with issues about race and culture in psychiatry. David had a chapter in my book on transcultural mental health care. For me, these aspects of critical psychiatry are central, but they don't figure in Sandra's book at all. And even more recently there is Ian Cummins (2017) book Critical psychiatry: A biography. This account of critical psychiatry mainly references a collection of books published in the 1960s, which might be better described as 'anti-psychiatry'. Cummins prefers the term 'critical psychiatry' because 'anti-psychiatry' was never a term that writers, such as R.D. Laing and Thomas Szasz, were happy to use. It is true that anti-psychiatry has generally been a term used within mainstream psychiatry in response to criticism which it does not accept. But critical psychiatry does arise out of anti-psychiatry. Anti-psychiatry is acknowledged in the introductory chapter of Steingard's book but not much is made of the link; nor is anti-psychiatry mentioned in the subsequent chapters.
Maybe what Steingard meant is that her book is the first American book on critical psychiatry, which I think is true. The only non-American contributor to the book is Joanna Moncrieff, a UK psychiatrist and co-chair of the Critical Psychiatry Network. If this book reflects the Americanization of critical psychiatry, should we be concerned, like Freud was for psychoanalysis? Mass cultural effects could be said to have reduced critical psychiatry to a general term for alternatives to the biomedical model in psychiatry, as for example in the Mad in America website. It is important that critical psychiatry is assimilated within the USA. I'm not convinced there is a doctrinal purity about critical psychiatry, which in some ways is quite a broad church incorporating several different opinions. But there is a need to disentangle the different strands of critical psychiatry, which this book does not attempt to do.
Attached to Steingard's tweet is a link to the publisher's webpage for the book, which expands on her quote: "The only current guide to critical psychiatry designed for mental health physicians". So, maybe the significant element of this book is that it was written for doctors. The book does aim to be clinically relevant. In some ways, I agree, it is written more for psychiatrists than the general public. Psychiatrists may experience a certain indoctrination in their training. For example, they are expected to think that mental illness is a brain disease. In USA in particular, they might come to see the Diagnostic and Statistical Manual (DSM) produced by the American Psychiatric Association as the definitive statement about mental disorder. Hence the second chapter in the book looks at critiques of DSM. The third chapter describes the institutional corruption introduced into research and practice because of the influence of the pharmaceutical industry. Steingard herself describes the influence on her practice (in chapter 5) of utilizing Joanna Moncrieff's drug-centred rather than disease-centred model of prescribing (described in chapter 4 by Jo herself). Psychiatrists commonly believe, without much evidence, that medication is correcting a chemical imbalance in the brain. Maybe this false belief contributes to an overprescribing of psychotropic medication and the sixth chapter explores the need for deprescribing. Psychiatrists have to practice within the legal requirements for detention in psychiatric hospital and chapter 7 looks at the issue of coercion. These days doctors tend to be trained in a patient-centred way but this doesn't always mean they are necessarily very good at listening to people with lived experience of mental health problems (the subject of chapter 8). Steingard herself provides a concluding ninth chapter.
There probably isn't too much new in this book. In many ways there have been too many published books criticizing psychiatry and the debate needs to be taken forward, which this book does not really do. Mainstream psychiatrists themselves tend to ignore these critiques. Maybe because this book is edited by someone who does appreciate the realities of psychiatric practice, it will have more influence, but I'm afraid I doubt it. I'm not sure how psychiatry can be helped to move on from its dominant biomedical paradigm. I accept the wish to find a biological basis of mental illness will never go away. But let's hope, psychiatry, including American psychiatry, can become more pluralistic. After all, US psychiatry was one part of the world where at least academic psychiatry was taken over by psychoanalysis. And where Meyer's Psychobiology was influential. So up to about 1970, US psychiatry was more open-minded in its ideological approach. But the so-called neo-Kraepelinism of DSM III and subsequent DSM editions has made biomedical psychiatry again dominant. Let's hope this book can help reverse this trend.
© 2019 Duncan Double
Duncan Double is a Consultant Psychiatrist and Honorary Senior Lecturer, Norfolk & Suffolk NHS Foundation Trust and University of East Anglia, UK; blogs at critical psychiatry.