A Review of "Conversations in Critical Psychiatry"

A review of psychiatrist Awais Aftab’s new book.

Reviewed by Margaret Foley

Key points

• Awais Aftab's new book captures the spirited debate that exists within and about psychiatry.
• Topics include how we classify mental disorders, the use of medication, and the meaning of mind.
• It represents a must-read for those interested in the philosophy of psychiatry.

I have followed Awais Aftab's career from a distance for years now. We are around the same age, have followed somewhat similar paths, and have many overlapping interests concerning the history and philosophy of psychiatry. Both of us have been intrigued by the debate and discussion that occurs within the world of critical psychiatry, sometimes referred to as anti-psychiatry (though not everyone accepts this latter term).

When I saw that Dr. Aftab had published a new book, I jumped at the opportunity to obtain a copy and review it here. The book, titled Conversations in Critical Psychiatry (Oxford University Press), was published earlier this year and contains a series of interviews with major figures in the worlds of psychiatry and critical psychiatry.

Interviewees include: Allen Frances (chairman of the DSM-IV Task Force); Paul Summergrad (former president of the American Psychiatric Association); Jonathan Shedler (co-author of the Psychodynamic Diagnostic Manual); Nassir Ghaemi (philosopher, psychopharmacologist, and expert on bipolar illness); Kenneth Kendler (famed psychiatric geneticist); Anne Harrington (historian of psychiatry at Harvard); Joanna Moncrieff (well-known critical psychiatrist in the United Kingdom); and others.

While many of the interviews have previously appeared in Psychiatric Times, there is also new content, including a foreword by Sir Robin Murray; a detailed introductory chapter by Dr. Aftab, which includes a synthesis of the ideas encountered in the book and his own views on these matters; new interviews with Richard Gipps and Nev Jones; and new appendix material. Additionally, many of the interviews have been updated with new questions.

Both Dr. Aftab and I "came of age" professionally at a time when psychiatry was recovering from a decades-long recess into biological reductionism, encapsulated by the 1990s slogan, "the Decade of the Brain." Both of us followed along as the DSM system was being revised in the late 2000s and early 2010s and took note of the significant controversy that developed during this process. Both of us were fortunate to connect with Allen Frances, whose work on these issues inspired our own writing and ideas.

In a way, it would have been easy to look at what was happening within psychiatry at that time and simply conclude that it was a failed experiment. Maybe Thomas Szasz was right after all; maybe there is no mental illness and all of it is just "made up," an attempt to control people who simply deviate from normal. Maybe the drugs are toxins. Maybe psychotherapy is hogwash. Maybe psychiatrists and psychotherapists should just "pack it in" and admit that their whole venture has ultimately proven to be a disastrous failure.

In fact, I think many people associated with the anti-psychiatry and critical psychiatry movements did just that.

Yet, one has to just look around to see hordes of people suffering in characteristic ways from syndromes (collections of symptoms that group together) to realize that yes, these problems really do exist, and yes, maybe we can try to make sense of them, to categorize and classify them, and to help ameliorate them in different ways. This does not mean that psychiatry "gets it all right," but it does mean that at its core, at its essence, are real issues that need dealing with.

Conversations in Critical Psychiatry brings together leaders of various professional stripes and colors to help us understand and make sense of the human problems called mental disorders. Within its covers, you will find ideas that you may personally embrace and others you may detest. Some will appear conceptually sound while others seemingly illogical. And this is what keeps you turning page after page.

Some of the questions tackled in the book by Dr. Aftab and interviewees include: Are psychiatric disorders diseases? Do they exist as discrete entities or do they fall on a continuum with normal? What is normal, anyway? Do drugs do more harm than good? Is involuntary psychiatric hospitalization morally defensible? Do we have a problem with overtreatment, undertreatment, or both? What separates psychiatry from neurology? What is the mind? What is the relationship between the mind and the brain? How should we classify psychiatric disorders, if at all? And many more.

Dr. Aftab and I agree on many things, but perhaps what we agree on most is the need for pluralism in psychiatry. That is, a field as vast as psychiatry (and, by extension, psychology, psychotherapy, psychoanalysis, etc.) demands a plethora of ideas, for no single approach could possibly capture the intricacies and nuances of a field that contains such diverse territory. As Seymour Kety wrote in 1960, "A truer picture of the nervous system and of behavior will emerge only from its study by a variety of disciplines and techniques, each with its own virtues and its own peculiar limitations."

It is in this spirit that Conversations in Critical Psychiatry emerged. Whether you're a clinician, a student, or someone with a keen interest in the philosophy of psychiatry, this book is essential reading for anyone who seeks a deeper understanding of the sheer complexity, and beauty, of some of the most important issues of our day.