The Politics of Conceptual and Critical Psychiatry

This post contains excerpts from the epilogue of my book “Conversations in Critical Psychiatry” (OUP, 2024), in which I am asked questions by Richard Gipps and Nev Jones, two people I admire greatly. This Q&A took place in mid-to-late 2022 and is best read in conjunction with the introductory chapter “Psychiatry and the Critical Landscape.”

Richard G. T. Gipps, PhD is a clinical psychologist in private psychotherapy practice, Research Fellow of Blackfriars Hall, and Associate of the Faculty of Philosophy at the University of Oxford, UK. He is the author of On Madness: Understanding the Psychotic Mind (Bloomsburg, 2022), and the co-editor of The Oxford Handbook of Philosophy and Psychiatry (OUP, 2013) and The Oxford Handbook of Philosophy and Psychoanalysis (OUP, 2019).

Nev Jones, PhD is Assistant Professor at the University of Pittsburgh, School of Social Work, USA. She has an interdisciplinary academic background in social and political philosophy, community psychology, and medical anthropology.

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Gipps: I’m very happy to be interviewing you for this project; it’s very fitting that your own voice now be added to those whom you’ve given a voice. Something I admire about your work—in this way, I confess, I contrast it with my own—is your attempt to bridge the divide between academic philosophical discussion and psychiatric practice. I’m thinking now in particular about your work on developing conceptual competence for psychiatrists. There’s little doubt that psychiatric and psychological practice ongoingly requires reform. I’m unclear though as to how much this depends on a reform of thought—of ideas, I mean—and how much what’s required is rather a reform of thoughtfulness—of attitudes, of ethical life, wisdom, and the humane encounter. I will get to this later though. Might you begin though by telling us what you mean by ‘conceptual competence’ and what it looks like in the clinical psychiatrist? What would you say to someone who says that philosophical thought really has no place in the clinic?

Aftab: I’m glad to have you and Nev Jones in the interviewer’s seat! By conceptual competence I refer to the health professional’s transformative awareness of background conceptual assumptions (held by clinicians, patients, and society) and their influence on various aspects of clinical practice, research, and education. The notion is intended to be an analogue of cultural competence and structural competence, which have received increasing attention in psychiatric education. In an Academic Psychiatry paper, co-authored with G. Scott Waterman (2021), we have described conceptual competence in terms of 4 elements of conceptual assumptions (and conceptual questions), conceptual tools, conceptual discourse, and conceptual humility. We are making the case that just as it is important for psychiatric clinicians to be competent in various other domains, it is also important for them to be competent with regards to conceptual issues that relate to psychiatry. Lack of such competence has had numerous negative consequences, both for the profession and for the patients…

I commonly encounter psychiatrists and trainees who are of the view that philosophy is of little relevance to clinical practice. They usually have a certain idea of what “philosophy” looks like, and they tend to think of either technical debates in philosophy of consciousness, language, existentialism, postmodernism etc. or they tend to think of various “antipsychiatry” critiques. I try to emphasize to such folks that good scientific and clinical work requires being aware of the assumptions that are guiding it. Philosophical assumptions are inherent to medicine and science; we cannot avoid them. We can, however, make them explicit. That way these assumptions can be explicated, challenged, and if needed, replaced. I especially try to emphasize how philosophy can enrich clinical and scientific work, and that the relationship doesn’t have to be antagonistic in the way it has been in the antipsychiatry and critical psychiatry literature.

Demonstrating this to a sceptical practitioner usually requires some form of Socratic questioning. 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 distinction 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.

I do agree the reform of “thought” is only a small part of what plagues the practices of psychiatry and psychology, and reform of “thoughtfulness” is more important in many ways.

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Gipps: You have written, against certain socially-minded critics of psychiatry, of how society needs to do better to address the causes of mental illness before we attempt to dismantle some of psychiatry’s biomedical provisions which mop up the damage. Is there anything specific which you think psychiatry can do to help politicians and the public sector build less demoralising and ill-making societies?

Aftab: I wouldn’t necessarily say “before we attempt to dismantle some of psychiatry’s biomedical provisions…” but at least it has to be concurrent. The best thing the profession can probably do is to put its weight behind the need for sociopolitical reform and to make a public case for why it is essential for the mental and physical health of the society. A clear scientific consensus about the necessity of social reform for health outcomes would meaningfully inform the legislators and the voters. I haven’t really seen psychiatric organizations in the US such as the American Psychiatric Association (APA) or the National Institute of Mental Health (NIMH) do that. APA has recently made social determinants of health a priority, but this has not, as far as I am aware, resulted in any sort of political lobbying or public awareness campaigns. I am not a politician, so I am being idealistic here. Given the current political situation in countries like the US and the UK, and in many other places in the world, such a stance would likely be accompanied by significant pushback from the conservative and libertarian political parties, and as politics around abortion and the COVID-19 pandemic has revealed, science can easily be sacrificed in the service of political rhetoric.

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Gipps: Coming back now to the role of philosophy in clinical psychiatry: I’m thinking about another, more venerable, and rather more important, form that philosophy has taken beyond the pursuit of conceptual clarity. This is philosophy ‘as a way of life’, to borrow the title of Pierre Hadot’s book: philosophy as the pursuit of wisdom, the cultivation of virtue, the art of living, and the embodiment of percipience. It is, I think, wise percipience which patients most often appreciate in their best psychiatrists and nurses, and the absence of this is what they most deplore in their poorest. An important aspect of such valued discernment is, I think, not so much reflective conceptual competence—in fact, we can readily imagine humanely wise clinicians who enjoy little of that intellectual facility - but something more like what psychologists call ‘reflective function’. (Which is to say: the ability to make sense of another’s predicament-aroused emotions without simply parsing that sense-making through one’s own person but instead by genuinely encountering the patient as an other, with her own values, experiences and sensibilities.) Now, I think it fair to say both that psychiatry as a field—and here, I should say, I’m not at all contrasting it with the field of psychology!—is not stacked full of wise percipience, and that the education of the virtues is no simple business. Sometimes—and I confess to finding this frustrating—psychiatry styles its practice in merely technical terms and attempts to outsource the business of an anyways now rather deprecated wisdom to the domain of the psychotherapist. And yet I rather feel—but what do you think?—that within the best of psychiatry’s own spirit or ‘eidos’ there lies the idea of a form of straightforward humane wisdom that’s rather distinct from what one finds in psychology or psychotherapy. This importantly includes the ability to remain thoughtful, realistically hopeful, and agential in the midst of even psychotic levels of anxiety. At any rate, my question is whether you can see a way forward for the profession to develop such philosophical wisdom in its practitioners?

Aftab: I completely agree with you about the need for such humane wisdom and the importance of inculcating it in practitioners. I am somewhat pessimistic about the prospects of bringing about such a transformation in the profession. Medical and psychological training not only takes place within a system governed by all the problems of capitalism but also the system increasingly emphasizes efficiency, productivity, uniformity, documentation, and risk averseness. The space to engage with another in a deeply human way has been steadily shrinking. Even when training programs try to create spaces of reflection and nurture such virtues, the clinic offers little to no opportunity to exercise them. So, the challenge is how to create systems that incentivize and nurture such virtues on an on-going basis. I don’t think anyone has quite figured that out yet! Technical knowledge and practical skills are easy to teach and measure, but thoughtfulness and wisdom are difficult to impart and assess. The solution likely involves attracting trainees with such virtues to join the profession and then reinforcing them through a variety of norms.

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Gipps: A particular interest of yours has been in bridging the gap between the fields of philosophy of psychiatry and critical psychiatry. The former tend to a (sometimes overly) conservative attitude to psychiatric categories, typically accepting their validity and trying to develop sense-preserving reflective analyses of their conceptual character, eschewing Marx’s injunction that we philosophers should aim to change rather than merely ‘interpret’ the world. The latter, by contrast, take direct aim at the psychiatric categories—but to my mind are not infrequently fueled either by a perfectly understandable, or by an unfortunately projective, animus against psychiatry and intolerance for actual philosophical analysis. Such an animus often has them, perhaps for ease of pursuing their own critical project, resist characterizing psychiatric thought in any terms other than its own most reductive self-understandings (as we find, for example, in the neo-Kraepelinian paradigm). Terms like ‘medicalization’, ‘disease entity’, ‘medical model’, ‘biomedical’, etc. now get thrown about with abandon as if both their meaning and their badness were self-evident. Another feature of the latter which I find dismaying is its tendency to overly easy armchair critique of allegedly stigmatizing or depersonalizing psychiatric language - as if changing our terms could really by itself do anything to address the ills of psychiatric practice. My question is what you think can be done to bridge the gap here between philosophy and critical thought - to urge philosophers to less complacently conservative analyses and to urge psychiatry’s critical theorists toward a more patient and less partial conception of their object?

Aftab: In the introductory chapter to this book I’ve tried to show how the gap between philosophy and critical thought can be bridged conceptually, but practically speaking, I suspect what is needed is for people to meaningfully occupy and participate in both philosophy of psychiatry and critical communities. I do inhabit both spaces, albeit somewhat awkwardly. With some exceptions, I can’t say I have had much success in getting the representatives of critical psychiatry to be more open to such perspectives. Increasingly I’m inclined to the pessimistic conclusion that the critical movements (especially in the UK) have become a largely reactionary force, and my hope for a critical, progressive dialogue now is between the scientific pluralist wing of psy-professions and Mad Pride, neurodiversity, and other service-user led movements. I do see a shift in psy-professionals who are interested in these issues, especially trainees and early-career professionals, in being much more open to integrative and pluralistic perspectives. Just as mainstream psychiatry stands to benefit from “conceptual competence,” so does critical psychiatry. It is astounding to me how uncritical the critical psychiatry community has been towards its own conceptual and philosophical assumptions.

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Jones: Can you say more about the sources of resistance to the perhaps deceptively reasonable approaches and principles you have laid out in the introductory chapter to this book? One keeps thinking, “why doesn’t / wouldn’t everyone agree with this?!”

Aftab: There are genuine philosophical disagreements at play, I don’t want to minimize or discount that. These are complex issues, and disagreement is inevitable. But it does seem to me that there has been little incentive or willingness to center the discourse, to find and explore common ground that exists despite disagreements.

Mainstream psychiatry has largely been indifferent to psychiatric critique. The attitude is predominantly one of defensiveness rather than one of dialogue. When psychiatrists have engaged with philosophy, they typically do recognize the value of the sort of integrative and pluralistic thinking that I’ve endorsed, so the challenge I see on the psychiatry side is overcoming the inertia and indifference of unreflective reductionistic thinking, and getting practitioners to appreciate the sources of dissatisfaction among service users.

Prominent critics have responded to mainstream psychiatry’s indifference by a rhetoric of increasing antagonism. Meaningfully accepting the existence of integrative and pluralistic approaches as legitimate is not compatible with cashing in on the sentiments of dismantling psychiatry or destroying public trust in the profession. Unfortunately, this also ends up appealing to reactionary societal forces, often far-right and mired in conspiratorial thinking (anti-vaccine movement, climate change denial, COVID-19 denialism, etc.), that challenge that authority of all scientific and medical institutions. I see the resistance from the critical side as arising from a combination of ideological entrenchment and political polarization. This has evolved into a dynamic of “culture war” that I’ve described in my blogpost Psychiatric Psychodrama. It is more important for some critics to hurt and delegitimize psychiatry publicly than it is for them to encourage pluralistic thinking in the profession. Many critics, once they have decided that the profession is beyond redemption, view calls for pluralism and integration cynically as being in the service of the status quo.

Jones: On a related note, you very patiently “endure” on Twitter, clearly committed to engaging often strongly polarized service users, activists, and clinicians, as you’ve just described. How and why don’t you just (so to speak) pack up and leave?

Aftab: Over time I have scaled back on my engagement with some groups with whom I’ve had repeatedly unproductive and negative interactions, but I do remain committed to the goal of engagement. Part of the reason is that many folks have never gotten to positively engage with psychiatrists who meaningfully inhabit the psychiatric, philosophical, and critical worlds without resorting to the sort of binaries that currently exist in popular discourse. There are many such psychiatrists and psychologists, but they tend not to be on Twitter, or they are driven to silence by the frustrating nature of the polarization. So, I try to make myself accessible. I want psy-professionals, trainees, and critics to be able to have access to psychiatrists who work within the integrative and pluralistic tradition.

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Comments are open. Ask me anything.

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P.S. From a review of “Conversations in Critical Psychiatry” published in the journal Cognitive Neuropsychiatry a few days ago by Cavanna et al.:

“With an introduction setting out the broad structure of the current debates and an extensive bibliography, this book provides an engaging and accessible account of the state of the art, through the words of some of the leading figures involved in mapping the psychiatric territory.”

”The choice of presenting complex concepts at the forefront of human science in conversational style is a brave—albeit not unprecedented—endeavor... By exploring its history and the need for pluralistic integration, this gallery of interviews allows us to better appreciate its challenges and its potential for progress. The themes covered in Aftab’s magnum opus are all connected by the common idea of the human condition as something complex, both physical and mental, biological and phenomenological, organic and emotional, individual and social, particular (so unique and unrepeatable) and general (so grouped into categories). This has led us to a problem of synthesis: scientific analysis has contributed to a fragmentation of the human experience that must be recomposed by psychiatry.” (Cavanna et al, 2025)

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See also:

Critical and Integrative Pluralism

Whereof One Cannot Speak: Richard Gipps on Madness and Rational Understanding

Psychiatric Psychodrama