This is an adaptation of Bruno Latour’s famous essay, “Why Has Critique Run out of Steam? From Matters of Fact to Matters of Concern” (Critical Inquiry, 2004). Some sentences are replicas or near-replicas of Latour’s.
Wars. So many wars. Diagnosis wars and medication wars. Wars against mental illness and wars against the mentally ill. Wars against psychopathology and wars out of psychopathology. Should we be at war, too, we, the intellectual critics of psychiatry? Is it really our duty to add fresh ruins to fields of ruins? More iconoclasm to iconoclasm? What has become of critical psychiatry? Has it run out of steam?
What has become of psychiatric critique, I wonder, when incompetent politicians, celebrity podcasters, snake-oil merchants, disgraced television hosts, and anti-vaxxers echo arguments scarcely different from those of academic critics? It does not seem to me that we have been as quick to prepare ourselves for new threats, new dangers, new tasks, new targets. Are we not like those mechanical toys that endlessly make the same gesture when everything else has changed around them?
A culture in the throes of conspiratorial thinking has set its sights on psychiatry, and this new world of discourse is a short step away from the respectable academics who call psychiatrists “shock doctors,” who compare the concept of mental illness to Santa Claus and think diagnoses are similar in validity to attributions of demonic possession, who think that psychiatric diagnoses are inherently stigmatizing and unscientific labels, that psychiatric medications are so ineffective and toxic that they cannot legitimately be called “treatments” and the best thing you can do is to avoid them and get off them, and that psychiatric interventions are backed by evidence that is comparable in scientific rigor to that for homeopathy. (IYKYK)
Do you see why I am worried? Those of us who intended to emancipate the public from prematurely naturalized objectified psychiatric facts, perhaps we were foolishly mistaken. We seem to be approaching a point where the real danger is no longer coming from an excessive confidence in ideological arguments posturing as matters of fact but from an excessive distrust of good matters of fact disguised as bad ideological biases.
It is about time we bring the sword of criticism to critical psychiatry itself and do a bit of soul-searching here: what were we really after when we were so intent on showing the social construction of psychiatric knowledge? There is no sure ground even for criticism. Isn’t this what criticism intended to say: that there is no sure ground anywhere? But what does it mean when this lack of sure ground is taken away from us by the worst possible fellows as an argument against the things we cherish?
Once, to show that diagnoses were constructed was to resist reification, to remind psychiatry of its entanglement with culture, politics, and values. Now, the same refrain is repurposed by movements that reject the reality of disability and ridicule professional attempts to alleviate suffering. The very tools of critique, once marshaled against premature certainty and biomedical hubris, are redeployed to erode trust in any psychiatric knowledge whatsoever. What has critical psychiatry become when its gestures of suspicion are indistinguishable from the paranoid accusations of medicine’s most fraudulent enemies?
What has become of critical psychiatry that it has no notion of disability to offer that makes demands on the state? What has become of critical psychiatry when the only experiences that count are the experiences of harm? What has become of critical psychiatry when the very arguments it honed for emancipation are now echoed in the mouths of those who would deny the existence of mental illness altogether and defund mental healthcare? What has become of critical psychiatry when its arguments are analogues of the arguments used by gender criticals and anti-vaxxers?
The critical mind, if it is to renew itself and be relevant again, is to be found in the cultivation of a stubborn practical realism dealing with matters of concern. Matters of fact, in the positivistic mindset, are supposed to stand on their own, detached from politics, culture, values, or the conditions under which the facts are produced. This is misleading, because it hides all the work, controversy, negotiation, and uncertainty that goes into the process of knowledge creation. Scientific knowledge is embedded in networks of care, debate, and responsibility. Matters of fact are more akin to gatherings of many different elements, actors, and interests (scientists, instruments, funding, political stakes, human values, risks, and uncertainties).
The mistake we made was to believe that there was no way to criticize psychiatric matters of fact except by moving away from them and directing one’s attention toward the conditions that made them possible. The mistake we made was to rely on anti-fetishism, a habitual posture of critique that prides itself on unmasking beliefs, exposing illusions, and revealing hidden powers behind what people take to be real.
The better critic is not the one who alternates haphazardly between anti-fetishism and positivism, but the one for whom, if something is constructed, then it means it is fragile and thus in great need of care and caution. All diagnoses and formulations are born things. All psychiatric knowledge requires, in order to exist, a bewildering variety of matters of concern.
The traditional gesture of critical psychiatry was to pour the acid of suspicion on the facts cherished by the field: to dismantle the authority of diagnostic categories, to reveal the fragility of trial results, to show how treatments and theories were shaped by culture and commerce. To criticize psychiatry by moving away from its facts, by treating every diagnosis as illusion, every trial as propaganda, leaves us with nothing but rubble.
The time has come to ask: have we been fighting the wrong enemies? Perhaps our task is not to subtract reality from psychiatry’s categories but to add to them. Not to debunk diagnostic concepts until they collapse, but to accompany them more closely, to follow the way they bring information into a precarious, contested form. The challenge before us is to get closer to the states of madness, disturbance, and suffering. If patients’ anguish is reduced to discursive invention, if clinicians’ attempts at care are dismissed as ideological imposition, what remains for psychiatry to be about?
If critique has grown sterile, it is because psychiatry has been forced to live between two impoverished poles of fact and fetish. Diagnoses are either nothing but projections or they are immutable truths. Treatments are either instruments of domination or they are disease-remedying interventions. Why not break the binaries? We need not reduce depression or schizophrenia to empty constructs nor canonize them as disease entities but treat them as tentative, preliminary steps in our organization of knowledge, a fragile gathering of symptoms, histories, neurochemistries, and cultural narratives, steps that coexist and collaborate with other such tentative, preliminary, fragile epistemic efforts.
Critical psychiatry too often treats heterogeneity as an inconvenience and narrows its gaze to social and structural responses, sidelining other registers of explanation. Neurophysiological and neuropathological factors are acknowledged in the abstract but waved away in the specifics, even as actors within a braided, multi-factorial story. Yet mental health problems arrive as a motley assembly in the clinical world: in one case or another, they are sometimes better described as faulty physiological or psychological mechanisms, extremes on continua, evolutionary mismatches, evolutionary adaptations, problems of living, maladaptive learning, poorly accommodated cognitive styles, unconscious conflicts, sequelae of trauma, varied responses to interpersonal and psychosocial stressors, neuroimmune disorders, and so forth. These problems are complex, value-laden, and multidimensional to a degree that strains tidy schemas, but they are not discontinuous with the rest of medicine and not impossible to study scientifically. They can’t be mapped by a simple categorical grid; they require a multi-perspective cartography that attends to dimensional, developmental, and idiographic aspects while still producing pragmatic classifications with clinical utility and scientific bite.
Treatments likewise tend to have broad, transdiagnostic effects across mental functions. Trials may be anchored to a target diagnosis, but the causal traffic usually runs through mechanisms that cut across our labels. “Physiological,” “psychological,” and “sociocultural” are not sealed ontological provinces; they are overlapping languages for a single, complicated reality. The neurophysiological strand is one thread among many—experiential, sociocultural, existential—and not always the most important one. Even so, because the mind is embodied, bodily mechanisms can be leveraged to produce desired effects, whether or not they count as “dysfunctional” in any simple factual sense.
We should resist a priori privileges for either technological fixes or hermeneutic readings. The posture must be Jaspersian: causal explanation and meaningful understanding as partners, with their relevance varying case by case and context by context. The perspectives of disease, dimensions, behavior, and life story all belong in the same forum. In that spirit, psychotropic medications earn their keep by modulating mechanisms and processes involved in mental functioning and that participate in the production and maintenance of symptoms. Explanations of therapeutic effects trace interactions between drug effects and psychopathology across multiple levels of description. Let medications be treated as they are—pharmaka that can heal and harm. We need a pharmacology that acknowledges ambivalence, uncertainty, and iatrogenesis, treating drugs as assistive technologies and supporting will and preferences.
We should borrow the philosophical pragmatist’s toolkit and aim for an assembled realism that refuses both fact and fetish: disorders are real as patterns that work across levels, yet corrigible when those patterns fray. Values are not impurities to eliminate; they are integral components of the fabric. Let go of the habit of comparing a value-laden psychiatry to an allegedly objective somatic medicine, a contrast that doesn’t hold and that punishes those whose bodies and minds fail to match a conjured norm. The terrain of diagnosis is made and remade by patients, clinicians, researchers, and the public together. Categories can be recognized as constructed without collapse.
The creation of knowledge is a delicate, collective process. It requires avenues of criticism, uptake of criticism, public standards, and tempered equality. It requires a diversity of fallible standpoints. Let critique make room for the voices of patients, for the ambiguities of neuroscience, for the textures of culture, for the uncertainties of practice, and for the wisdom of clinicians.
If something in psychiatry is constructed, this should be taken not as proof of its falsity but as a sign of its fragility as well as its strength—it’s something in need of care to exist and something that is made strong by virtue of that concern.
Learn more:
My chapter “Psychiatry and the Critical Landscape” in Conversations in Critical Psychiatry
Robert Chapman (
), “A Critique of Critical Psychiatry”Cresswell & Spandler, “Psychopolitics: Peter Sedgwick's legacy for the politics of mental health.”
Alastair Morgan, “Continental Philosophy of Psychiatry”
- , “Unshrunk and MAHA: A Diagnosis-Critical Case Study”
Helen Longino, “The Fate of Knowledge”
Peter Zachar, “A Metaphysics of Psychopathology”
Sanneke de Haan, “Enactive Psychiatry”
The more important question is: what has become of psychiatry?
We may be living in an age of conspiracy theorists, although I have never been one for faddish labels. But we do seem to be in an era of academic incompetence. We once had well educated people who could run laps around the laity, yet decades of publish-or-perish incentives and perfunctory academic practice have softened them to the point where the screwballs of the world are nipping at their intellectual heels.
And what of psychiatry? Surely it is at its lowest scientific and intellectual ebb. Never has a field run so hard back towards where it came from; soon we will be within sight of Galen. The discipline’s amnesia is breathtaking: the rediscovery of old, well-understood diseases; the inability to recall biomarkers it once identified; the erasure of its own technical vocabulary; forgetting basic facts about disease entities; forgetting half the mechanisms of action of its own drugs; forgetting large parts of its armamentarium; neglecting pathophysiological observations; an eccentric preoccupation with rating scales; and a bizarre penchant for the most abandoned faddishness.
I can only think that the backwards momentum is produced by the combined thrust of the fields forebears as they spin furiously in their graves.
The entire idea of critical psychiatry as something apart is born of the same wank. All scientific disciplines should be self critical and all scientists practising within it. If you look at the history of science it is only since it became so workmanlike that it has lost the ability to fully reflect.
Thank you for this. I agree that the debate about psychiatry and medications has become polarized in a way that is too reminiscent of our current political climate.
I think it's notable that there exists such a discussion as "Critical Psychiatry," but probably not "Critical Cardiology" or "Critical Nephrology." I think this is a reflection of not only the fact that mental illness and suffering is less well-located than other illness (although there are many poorly-understood medical illnesses) but also that psychiatry lends itself to reflection. I am critical of many aspects of psychiatric treatment, but I also think that we can't throw out the baby with the bathwater.
It reminds me of Heidi Schreck's play, "What the Constitution Means to Me." In it, Schreck examines all the failures of the U.S Constitution in terms of its treatment of women and people of color. At the end of the play, the audience members are asked to vote on whether to throw out the Constitution or not. When I attended, the vote was to keep it. I think that is the most common outcome.
Would I change many aspects of psychiatric training? Absolutely. Revamp the curriculum. Add books and talks by people who have been patients, have residents spend time as patients on a unit, change the paradigm, educate trainees about the risks and ethical challenges inherent in what they do. But still train them.