Psychiatry and Critique: Integrative or Dialectical?
A Review of “Conversations in Critical Psychiatry”
This is a review of “Conversations in Critical Psychiatry” by George Ikkos. It was originally published in the Spring 2025 issue of the official newsletter of the Royal College of Psychiatrists’s History of Psychiatry Special Interest Group (HoPSIG).
George Ikkos is a consultant psychiatrist in the Department of Liaison Psychiatry at the Royal National Orthopaedic Hospital, London, and immediate past Chair of HoPSIG. He is joint editor (with Nick Bouras) of the 2021 volume Mind, State and Society: Social History of Psychiatry and Mental Health in Britain 1960–2010, which was a runner-up in the Association of American Publishers’ PROSE 2022 Awards in the category of History of Science, Medicine, and Technology (available open access). To mark the centenary of Emil Kraepelin’s death, he is co-editing Psychiatry after Kraepelin: Ambition, Images, Practices 1926-2026 (Springer Nature), with Leipzig academic and social psychiatrist Thomas Becker, to be published in 2026.
HoPSIG publishes an online newsletter twice a year. It includes various reports from its Chair and from the Historian in Residence and the Archivist at the College as well as accounts of past and forthcoming meetings and events. HoPSIG newsletter also publishes 5-6 short articles on a range of topics related to the history of psychiatry as well as book reviews. Submissions are open to all, and for more information, contact the Editor, Professor Nicol Ferrier (nicol.ferrier@newcastle.ac.uk).
Introduction
I read with great pleasure this flowing collection of 25 thought-provoking conversations first published in Psychiatric Times, starting in 2019, and brought together in a 2024 volume by Oxford University Press with new material.
Early on, it includes contributions by two professional-intellectual giants of psychiatry, Robin Murray and Allen Frances. In his foreword, British psychiatrist Murray references his remarkable papers on mistakes he has made in his career1 and on listening to psychiatry’s critics2 and writes:
“I ask my psychiatric colleagues: are our critics more or less likely to be sympathetic to psychiatry after encountering us? If they are less sympathetic, we must reflect on how this helps psychiatry’s case and what needs to be done differently” (p. vii-viii).
American psychiatrist Frances is the first interviewee (ch. 3, Diagnosing Psychiatry). He was a member of the leadership group of DSM-III and DSM-III-R and the Chair of the DSM-IV task force who turned vocal critic of subsequent editions and published Saving Normal in 2013, his “impassioned plea to curb diagnostic inflation in psychiatry and recognise the harms of medicalisation of ordinary life” according to Aftab (p. 33). Though a critic, Frances continues to find value in DSM. In contrast, without rejecting the practice of diagnosis altogether, far from it, the vocal critic of the biopsychosocial model, Iranian American psychiatrist Nassir Ghaemi (ch. 12, Beyond Pragmatism in Psychiatry), states that “DSM’s legacy has been largely harmful” (p. 134). As I hurtle rapidly towards my 45th year of continuous practice in the specialty, I find myself agreeing with him. Indeed, I am inching towards the conclusion that future historians will accord DSM-III and its aftermath a similar position in the 20th-century history of psychiatry as the one we do today to degeneration theory in the history of the 19th. Crucially, well beyond psychiatry, both have had an enormous impact on culture3. The DSM-III’s insistence on use of the term “disorder” is particularly culpable from this broader cultural as well as individual perspective. In his interview, British psychiatrist Samei Huda (ch. 23, The Medical Model in Theory and Practice), a defender of the utility of diagnostic classification and fierce critic of some critics of psychiatry, expresses a preference for use of the term “condition.” I agree, not least because this term primes us to think of the physical condition and social conditions as well as the psychological distress the individual patient finds himself in.
Awais Aftab and his Conversations
Aftab is a Pakistani American psychiatrist whose first love was philosophy. It is a great fortune for our specialty that he concluded that a philosophical career would be financially precarious in his native Pakistan, whilst psychiatry would secure him both a reliable income and opportunities for philosophical discourse. He has since then emigrated, trained, and now works in the US. The conversations brought together here, each 5-12 pages long, were conducted online in an iterative manner, and this somewhat leisurely approach, no doubt, has contributed to the high quality of content. Aftab’s deep philosophical and clinical outlook is evident by his wide reading and his persistently respectful and incisive approach to his interlocutors.
The book is divided into 11 sections: an untitled introductory section (2 chapters); Psychiatry at the Crossroads (4 chapters); Disorder and Diversity (3 chapters); History and Philosophy of Psychiatry (3 chapters); Enactivism and Psychiatry (2 chapters); Pluralistic and Integrative Psychiatry (3 chapters); Psychiatric Institutions and Human Rights (2 chapters); Critical Psychiatry Network (3 chapters); Psychoanalysis (1 chapter); Psychiatry and the Medical Model (3 chapters); Critical Neuropsychiatry (1 chapter); and Epilogue. Among the contributors/interviewees, I counted 18 psychiatrists (all sharing a commitment to the specialty but diverging in opinions) and 11 others (history, philosophy, psychology, psychotherapy, and service user perspectives). The published pieces are not one-way critiques of psychiatry. They come across as genuine dialogues. Critiques of the critics of psychiatry recur too.
Reflection
Of the individual chapters, the most immediately clinically relevant is Italian psychiatrist Giovanni Andrea Fava’s critique of psychopharmacology in clinical practice (ch. 5, Impoverishment of Psychiatric Knowledge). Most clinically-philosophically incisive is that of American psychologist and philosopher Peter Zachar’s Psychiatric Disorders as an Imperfect Community (ch. 11). To my mind he persuasively highlights that psychiatric conditions are not “natural kinds.” Recently Steven Hyman, psychiatric researcher and Director of the US National Institute of Mental Health (NIMH) from 1996 to 2001, has written in self-critical terms4 about his failure, widely shared with others, to appreciate this before DSM-III. He has been particularly scathing in his assessment of the man who, above all, on the back of this failure, built DSM-III.
Readers interested in the history of psychiatry may want to turn particularly to Harvard historian of science Anne Harrington’s interview, The Structure of Scientific Revolutions (ch. 10). On the basis of her detailed research that culminated in her 2019 book Mind Fixers, she comments:
“I am not a critic of neurobiological approaches to mental disorder—that would be absurd. My quarrel, such as it is, is only with the tendency we see repeatedly in the field (with the 1980s biological psychiatrists being only the latest example) to pursue narrow, even hegemonic approaches to forms of suffering and disorders” (p. 114).
When Aftab asked her for advice for the profession, she responded:
“My answer might surprise you, but it is an answer you might expect from a historian rather than a clinician! It is sometimes to read the literature, including textbooks against the grain. That is to say, do not just read to absorb the information being offered, but look also for possible gaps, contradictions, or incidental references to factors or issues that are not pursued, and then ask why not.”
Indeed!
Of the various sections, the one I appreciated most as a whole is entitled “The Critical Psychiatry Network,” with its conversations with British psychiatrists Duncan Double, Joanna Moncrieff, and Sami Timimi. They all emphasize that their network is not one of uniform interests and views. I found myself in agreement with many points that they share: mind relates to but is not uniquely determined by brain; medical disorders, e.g. thyroid disease can cause psychiatric conditions but such direct correlations are absent in most cases; there are statistical deviations in measurements of biomarkers in psychiatric compared to general populations but these remain non-specific and of doubtful aetiological significance in most cases; our current nosology lacks validity in crucial respects5 ; it is impossible to argue that psychotropic medication is specific to particular psychiatric conditions6. Timimi (ch. 22, Psychiatry and the Shores of Social Construction) offers a well-informed narrative on the relationship between psychiatry and market-based societies and paints a vivid picture of the “McDonaldization” of contemporary child development.
Confession and Profession
A confession of a historical lapse is in order here. On May 30, 2008, a proposal was brought to the Royal College of Psychiatrists Central Executive Committee, of which I was a member, to establish a Special Interest Group in Critical Psychiatry. I spoke against it and, together with most members, voted against it. My rationale was that a previous proposal to establish a Psychopharmacology Special Interest Group had been rejected on the grounds that this is/should be of interest to all psychiatrists, not just a special interest group. I reasoned that the same should apply to critical thinking about our specialty. As is evident from a variety of interviews here, this has not been sufficiently the case, and I regret the decision and my contribution to it. Despite having argued against it, if the proposal had been accepted, I would have joined the group back then. Although now I do not find it necessary to join the Network, I think it is a pity it sits entirely outside our College.
Be that as it may, Paul Summergrad, President of the American Psychiatric Association from 2014 to 2015 (ch. 26, Psychiatry and the Long View) comes closest to “my kind of psychiatrist” here, including when he speaks of his personal and professional formation and when he criticizes those who are too anxious that we be like any other specialty. His preference for taking the long-term view is essential in our times, subject as we are to the constant commands of immediacy.7
Dialectical Critique
The variety of interviewees in “Conversation in Critical Psychiatry” demonstrably share a passion for reform, including institutional reform (e.g. see section on Institutions and Human Rights). Nevertheless, there is a sense that the volume as a whole remains at a rather abstract level. This probably reflects the thin historical contribution. Yet, as emphasized by Summergrad, it is essential to take the long-term view, something I have attempted to do here by suggesting affinities between degeneration theory and DSM-III. More contributions by social historians of psychiatry could have added flesh and blood on the, admittedly sturdy, intellectual bones offered here. Though one does not have to agree entirely with him8, University of California social historian Andrew Scull has done more than most when it comes to original research and informative monographs to contribute this way, and I missed his voice.
Though Aftab and I share a commitment to pluralism in psychiatry, he works within the Anglo-Saxon tradition and aims for an integrative perspective (see ch. 13 interview with Dan Stein, From Classic and Critical to Integrative Psychiatry). Yet the integrative impulse carries its own risks to knowledge and scientific progress9 Perhaps his future work may benefit from adding Continental (negative) dialectics10 in the plurality of his perspectives. It is the traditions of both pluralism and dialectics that help me sustain any tension between the views of the Critical Psychiatry Network on the one hand and Paul Summergrad and similar on the other. Recently Becker and Hoff have published an illuminating paper comparing the approaches of Emil Kraepelin and one of his distant contemporaries and foremost dialectical thinkers of the 20th century, Walter Benjamin.11
Conclusion
Aftab is correct when he states:
“In my experience, it tends to become obvious quickly that most clinicians have little clarity on what they mean by concepts like ‘brain disorder’, the distinctions between ‘normal’ and ‘disordered’, the ‘reality’ of psychiatric diagnoses, the relationship between the biological and psychological, the explanatory role of diagnosis, and the ‘biopsychosocial’ model, etc.” (p. 308).
This volume is essential reading for all psychiatric trainers and trainees and those in kin professions too. It can promote and deepen dialogue between psychiatrists and our critics.
See also:
Murray RM. (2017). Mistakes I have made in my research career. Schizophrenia bulletin, 43(2), 253-256. https://doi.org/10.1093/schbul/sbw165
Murray RM. Listening to our critics; the care of people with psychosis. Psychol Med. 2020 Dec;50(16):2641-2642. https://doi:10.1017/S0033291720004341
a. Scull A. (2015) Degeneration and Despair, Ch 8. in Madness in Civilisation: A Cultural History of Insanity from the Bible to Freud, from the Madhouse to the Present, Thames and Hudson
b. Horwitz AV. Diagnosing Mental Illness. Ch 1 in DSM: A History of the Psychiatry’s Bible, John Hopkins University Press
Hyman S. (2024) A Note From Hyman on the Genetic Complexity of Psychiatric Disorders “Our brains are not like Mendel’s peas.”, blog in Psychiatry at the Margins, January 2028 https://www.psychiatrymargins.com/p/a-note-from-hyman-on-the-genetic
Cohen BM, Öngür D. The need for evidence-based updating of ICD and DSM models of psychotic and mood disorders. Molecular Psychiatry 2023; 28: 1836–8.
Belmarker RH, Lichtenberg P. (2023) Introduction in Psychopharmacology Reconsidered: A Concise Guide to Exploring the Limits to Diagnosis and Treatment, Springer Nature
Kornbluh A. (2023) Immediacy or, The Style of Too Late Capitalism, Verso
Ikkos G. (2016) Madness in Civilization, Book Review: Scull, A., Madness in Civilization: a cultural history of insanity from the Bible to Freud, from the madhouse to modern medicine, HoPSIG News and Notes, Newsletter of the Royal College of Psychiatrists History of Psychiatry Special Interest Group, 2016 (2) 11
Gijsbers V. (2016). Explanatory pluralism and the (dis) unity of science: the argument from incompatible counterfactual consequences. Frontiers in psychiatry, 7, 32. https://doi.org/10.3389/fpsyt.2016.00032
Ikkos G, Stanghellini G, & Morgan A. (2024). History, ‘nowtime’ (jetztzeit) and dialectical images: introduction to Walter Benjamin for psychiatry (I). International Review of Psychiatry, 1–15. https://doi.org/10.1080/09540261.2024.2359468
Becker T & Hoff P. (2024). Emil Kraepelin and Walter Benjamin: distant contemporaries, diverse working methods, any resonance? International Review of Psychiatry, 1–17. https://doi.org/10.1080/09540261.2024.2355994
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