Making Sense of Psychiatry
Linda Gask reviews "Conversations in Critical Psychiatry"
Dr. Linda Gask is a British psychiatrist and Emerita Professor of Primary Care Psychiatry at the University of Manchester. Now retired, she has been the Royal College of Psychiatrists Presidential Lead for Primary Care and has written about her own experience of mental illness in two memoirs, “The Other Side of Silence” (2015) and “Finding True North” (2021). Her latest book, “Out of Her Mind: How We Are Failing Women's Mental Health and What Must Change,” was published by Cambridge University Press in Oct 2024.
The following is her review of “Conversations in Critical Psychiatry” (Oxford University Press, 2024). It was originally published on her personal blog.
Conversations in Critical Psychiatry, edited by me, brings together a selection of interviews from Psychiatric Times, updated with new and previously unpublished material. It is out in Europe/UK, available digitally everywhere, and is available for preorders in North America (US print release date has been pushed to Dec 20, 2024). For those with academic affiliations, Conversations in Critical Psychiatry is also available digitally through OUP’s Oxford Medicine Online collection.
Reading Awais Aftab’s masterful interviews with prominent commentators on psychiatry is rather like returning to when I was first trying to make sense of what psychiatry is all about. Moving from one placement to another as a young trainee, I was confused by the different models of mental illness—biological, psychological, social, and, yes, even existential—applied by the consultants with whom I worked and sometimes (I thought) too ferociously adhered to. They all broadly worked to the ‘biopsychosocial model’ but each clearly had his (and they were all men just then) favourite lens through which to try and make sense of what a patient was experiencing and how best to help them.
I’m critical of much psychiatric practice, but I’ve never identified with the British version of ‘critical psychiatry,’ finding it rather like having to adopt a complete ideology that will only consider hypotheses that are self-confirmatory. But it was refreshing to find a much wider range of thinkers who inhabit the borderlands of psychiatry, psychology, and philosophy.
I was reminded of everything that had really fascinated me about psychiatry in my own training. The knowledge about descriptive psychopathology conferred by the older consultants who looked beyond the restrictions of modern ideas and introduced me to the classical descriptions from old German texts that sometimes fitted so much better with what the patient was conveying to me (usually involving long German words such as my own favourite ‘Sensitiver Beziehungswahn’). And the weekly case conferences where biological, psychological, and social perspectives on formulation were fiercely debated and questioned. Together, these demonstrated for me the need for both nosological (referring to how we classify mental experiences) and explanatory pluralism (how we understand them). Additionally, a strong grounding in social psychiatry resulted in my interest in working with primary care, where there really are no absolute certainties when a person first presents to a health professional and a pragmatic approach is essential.
Reading “Conversations in Critical Psychiatry,” I was reminded of everything that had really fascinated me about psychiatry in my own training.
This acquired knowledge didn’t ‘fit together’ into a coherent logical whole of checklists like DSM-5. We now seem to have lost the awareness that psychiatry is an ‘imperfect community.’ Aftab’s conversation with psychologist and philosopher Peter Zachar about the conversations around the ‘bereavement exclusion’ in version 5, which caused controversy at the time because of fears about medicalisation of grief clearly demonstrates this. It reminded me of those students who would simply list the DSM symptoms when asked, ‘What do you think it feels like to experience depression?’
The need for pluralism and pragmatism reverberates through most of Aftab’s interviews, which were initially published in Psychiatric Times and have been brought together in this volume by Oxford University Press. They explore current controversies in psychiatric theory and care, and in particular the history and philosophical underpinnings of psychiatry. Awais employs a ‘critical’ lens, but he doesn’t define it, instead ‘approaching the notion as a tool to explore the rich multifaceted space of psychiatric critique.’ There are 27 interviews with many leaders of the field, some of whom I knew of already, such as the British Critical Psychiatry group (Duncan Double, Joanna Moncrieff, and Sami Timini). Some whose work has informed my own thinking, such as Allen Francis (‘diagnoses should be written in pencil’) and Paul McHugh, whose book with Slavney, The Perspectives of Psychiatry, has been helpful in making sense of how a particular person’s distress or mental illness develops.
There are others to whom I was delighted to be introduced to in this way, such as Sanneke De Haan talking about enactive psychiatry. De Haan sees psychiatric disorders as disorders of sense-making, of the way that we make sense of ourselves and the world around us. Her interview provides a different way of making sense of how body, mind, and world interact: “All living beings engage in some basic sort of sense-making… it remains an embodied and embedded capacity.” That really resonated for me.
I have yet to read Robert Chapman’s book The Empire of Normality, but their critique of Szaszian views (‘it undermines and gaslights those who do find a medicalized approach helpful’) has encouraged me to do so!
The views of Dainas Puras, the psychiatrist and human rights advocate whom I briefly met many years ago on a journey to Lithuania, have not been well-received by many psychiatrists. However, the interview with him helped me to understand much more about how and why he has arrived at his conclusions about ‘liberating global mental health care from coercive practices.’ Aftab writes how he has struggled too with the United Nation’s Convention on the Right’s of Person’s with Disabilities, but…
“… simply invoking the necessity of involuntary care in our present circumstances doesn’t render our current practices just or ethical, especially if we are not also trying to improve them.” (p 20)
Particularly notable for me was the conversation with Nev Jones (who has herself experienced psychosis), where she movingly describes how:
“…at multiple points I felt heartbroken hearing other individual’s stories and the extent to which they felt they could not open up, had never even tried to describe so much of their experience to clinicians, or had long ago given up trying. Many of these were folks who had been in the public mental health system for decades; who had worked with dozens and dozens of different clinicians and social workers. The areas of misunderstanding or silencing or invisibilization took different forms, and I listened to this and really this is what informed my initial research.” (p 63)
I would have liked to hear more from others who have used services themselves, particularly those created from a critical standpoint—but I suspect that would have required another volume.
Ultimately, Aftab himself, in an interview with Richard Gipps and Nev Jones, shares his own views, and I agree with him that much of the ‘diagnostic reification, eclecticism, reductionism, and over-reliance on psychopharmacology and neglect of iatrogenic harm’ we see is related to a failure to address the underlying concepts of psychiatry in our training. What do we really mean by a diagnosis? By ‘normal’ and ‘disordered’? What does it all mean?
We need to encourage those training to be psychiatrists to not only be more thoughtful but listen to as many patients’ stories as they can and read widely, even the work of those they are convinced they will disagree with.
That’s only how we will begin to make sense of psychiatry.
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