Critical psychiatry is a relatively new approach to psychiatry and its popularity is growing steadily. The Critical Psychiatry Network (CPN), formed in 1999, is an informal group of psychiatrists who follow this approach.

Critical psychiatry is sceptical of reductionist approaches to mental health which try to explain emotional distress in terms of biochemical imbalances and neurological deficits. Instead, critical psychiatry prefers to understand emotional distress (such as depression or psychosis) in terms of the patient’s social context and life experiences.

Following on from this, critical psychiatry sees drug treatment as only a minor part of treatment. For example rather than seeing neuroleptics as the central essential treatment for people with psychosis, critical psychiatrists would focus on psychological and social support and use drugs as an adjunct, for instance on a short-term basis to help a patient cope with overwhelming experiences.

In contrast to mainstream psychiatry, critical psychiatry is keen to value and work with patients’ own explanations for their experiences. For example, if a patient considered the voices they were hearing to originate from spirits and saw their experiences as being a spiritual crisis, this explanation would be respected.

Additionally critical psychiatry has a strong ethical focus and working alongside survivor organisations is a voice for human rights in the mental health system. For example, the CPN was active in campaigning against Community Treatment Orders.

As with any approach which challenges the status quo, those who follow the critical psychiatry approach often face resistance and harassment from the proponents of the mainstream. Members of the CPN have experienced false accusations, bullying and persecution because of their critical psychiatry beliefs and practices.

In order to help those currently working in critical psychiatry and to encourage more trainees to use this approach a number of strategies for ‘coping and causing change as a critical psychiatrist’ have been developed. A list of questions was distributed to the CPN email group and the following suggestions developed from the answers received.

If you become aware of hostility from colleagues the first step could be to talk to someone you trust about the situation while trying to avoid a knee-jerk reaction. See if those being hostile towards you are open to talking and try and understand each others’ perspective. If colleagues make inappropriate accusations be prepared to defend yourself robustly.

Pursuing bullying and harassment through the complaints procedure is a possibility although it is accepted that in a bullying culture this will make things worse. Some CPN members have found it helpful to remind colleagues that it is a requirement of Good Medical Practice to respect colleagues and not allow personal opinions to adversely affect professional relationships.

Build a local power base and strong relationships with other staff such as nurses and social workers (who may potentially be more likely to share CPN’s concerns about mainstream psychiatry) and local service user organisations who can support you and back you up should you start to be harassed by medical colleagues or management:

‘When I had problems at work many years ago, at the final hour it was the nurses and social workers in the team who supported me. None of my medical colleagues did. This is maybe the answer – to build a local power base’ – Rhodri Huws

For some people however, it may become necessary to move to a different area where colleagues are more supportive:

For trainees facing harassment it can be helpful to bear in mind that once you are a consultant you will be able to have a much greater influence on healthcare - both on individual patients and on policy. On some occasions it may be worth just putting up with hostility from colleagues and keeping quiet or ‘going along with’ things you don’t agree with in order to get through training.

Support from likeminded colleagues is extremely important in coping. These colleagues can be found through alternative mental health organisations, the survivor movement and perhaps most importantly, the Critical Psychiatry Network:

Even when taking note of all the above it can still be difficult to cope with harassment and lack of support from work colleagues. In these situations, finding and talking things though with a psychotherapist may be helpful.

It is important to remember that NICE guidelines are only guidelines and even NICE accepts that they cannot completely override clinical judgement. Unfortunately however some Trusts take the position ‘if you follow NICE guidelines and things go wrong, we will support you, but if you don’t then you’re on your own’.

There were two main viewpoints regarding the problems with NICE guidelines. Some members feel the problem with NICE guidelines is that they focus on Evidence-Based Medicine (EBM). These members feel the CPN has a key role in challenging the idea that EBM is the Gold Standard that everyone must follow. Indeed, they note an important aspect of the academic writings of critical psychiatrists has been to question and challenge two aspects of EBM. Firstly, its reliance on a very selected and limited notion of effectiveness, and secondly the influence on the pharmaceutical industry on what passes for scientific knowledge in psychiatry. They feel these challenges are very important to provide a clear line of dissent against blind and thoughtless adherence to NICE and other clinical practice guidelines.

Other members feel that the problems with NICE guidelines are due to the guidelines being consensus driven not evidence-based. These members feel EBM should be embraced as mainstream psychiatry would be severely challenged if it followed the evidence. For example, they note if the NICE guidelines for depression and ADHD had kept to the evidence both the diagnosis and the recommendation for medication would have been severely challenged.

Trainees are advised to be very careful about expressing their critical psychiatry opinions:

Demonstrate that you have a good knowledge of mainstream positions (even if you disagree) for example show that you can do a detailed standard mental state examination and a mainstream assessment of differential diagnosis. Then as time goes on and you have been demonstrating your competencies, gradually introduce less mainstream ideas:

‘As a trainee for most of the time I was getting very positive feedback because I made sure I could do things by the book (even through from a very early stage in my career I was sceptical about the basis of diagnosis, ECT, medication etc, however I also accepted that I needed to learn from more experienced colleagues). As time went on I would introduce the, to me more interesting critical ideas I was discovering through journal clubs and training events, where I often put myself forward to present something in the spirit of trying to get a ‘can we talk about his’ type exchange. On the whole this was received positively.’ – Sami Timimi

Argue your case using evidence and principles such as the importance of informed consent and patient choice. Use papers to back up your argument where possible. This will mean keeping up to date with the critical literature. Try not to get into a hostile verbal exchange however much you feel provoked. Instead get advice from others you can trust or if necessary a representative from the BMA. If the advice after all this is to do the thing you disagree with, then do it anyway as many more will loose out from having the benefits of your insights and skills if you end up unable to progress in your career while a trainee.

Unfortunately the current situation is that the College requires trainees to know how to use ECT in order to complete their training. One perspective on this is that perhaps you can only fully understand ECT if you are trained in it and so by participating enables you to speak from a more considered perspective. Since ECT is currently mandatory most members advise that trainees participate in order that they are able to complete their training and so be in a better position to change things. Several members suggested that the CPN should discuss the issue of ECT and work with the college to make this training optional. In addition, Phil Thomas states that he would personally support any trainee who did not wish to participate in ECT training.

Training in psychotherapy and working in the voluntary sector are two ways to learn alternatives. Regarding working in the voluntary sector:

In respect to psychotherapy training the importance of gaining a variety of perspectives and in particular not just cognitive therapy was emphasised:

Additionally, learning from the therapeutic community movement and gaining experience from working in such an environment is another method trainees can use to learn alternative ways of working with patients.

Finally, by being open to the ideas the patients you work with have about the nature of their problems, and by working closely with colleagues from a variety of perspectives, you can discover different ways of working.

In order to enter the debate it is necessary to have a good knowledge of the evidence against whatever it is that you oppose – for example biological reductionism, compulsion or ECT. There are also ethical arguments surrounding these issues. The CPN website contains articles and links to books covering a variety of arguments and positions against mainstream psychiatry. An article particularly recommended for trainees is Thomas P & Bracken P (2004) Critical psychiatry in practice Advances in Psychiatric Treatment 10: 361-70. Each person is likely to favour a different style in opposing mainstream psychiatry – some focus on, for example, the conceptual issue about not needing to say that the brain is disordered in mental illness, others on opposing the ‘chemical imbalance’ idea.