23 Contentions

Keeping an argumentative blog has the strange effect of "placing" you within the broader debates your writings touch. In the context of discussion, supporting or denying any claim raises questions about which other related claims you also might also endorse or contest. This gets tricky. In virtue of a position I have taken, other parties to a debate have often assumed they know my views on similar but different points. Frustratingly it can be mistakenly suggested that a claim I support entails another which I do not. Of course for my part I've frequently made precisely the same mistake in return. This experience has made me wonder what general statements about mental health I do feel broadly committed to. In turning over this question over the last months I have collected a rag-bag list of claims and suggestions that I think I would stand by, but which don't necessarily warrant more developed blog-posts in their own right. The only thing uniting them thematically is that writing this blog has brought me into contact with all the issues here at various times. Some of my contentions will seem trivial and others more challenging depending on your starting point, but I have included them for three reasons. The first is that many of them go too often unsaid, which is a shame. The second is that some of them may trigger interesting discussion with people who don't agree about them. The third is that I am curious to see which of them will stand the test of time and which I might end up being persuaded to abandon.

1. Individual case studies are significantly less informative than large scale controlled trials when it comes to determining the efficacy of a treatment. That said, the label "anecdote" can seem to be needlessly dismissive of people's experience.
2. Case studies and testimonials are extremely valuable in virtue of their potential to improve services and highlight malpractice. However, they also have much value in their own right.
3. Empirical research in psychology and psychiatry has historically been deployed toward both progressive emancipatory political ends and restrictive conservative political ends, but generally facts are a powerful corrective to bias, bigotry and oppression. 
4. Given the ways in which mental function is rooted in brain function, it would be extraordinary if a moderate amount of what we call "psychological distress" was not determined principally by biological factors.
5. An apparent thematic similarity between early life experiences (i.e. being bullied) and later symptoms (i.e. being paranoid) can easily mislead us into overestimating the extent of any causal link.
6. Childhood Sexual Abuse would be just as abhorrent if it played no role at all in psychosis.
7. Whatever the disadvantages of psychiatric diagnosis, it has validated the experiences of millions of people who have felt themselves to be suffering from serious illnesses.
8. Whatever the advantages of psychiatric diagnosis, it has saddled millions of people with labels they find inaccurate and invalidating.
9. The DSM project has almost certainly led to a huge rise in the diagnosis of certain mental disorders that is probably not commensurate with a change in anything other than diagnostic practices around those categories.
10. "Personality Disorder" is no way to talk about people.
11. There is no satisfactory way of cleanly distinguishing "mental disorder" from "mental health". This does not in itself invalidate these categories or render talk about them nonsensical.
12. The fact that gay people were "cured overnight" by the removal of homosexuality from the DSM does not provide a good analogy for other DSM diagnoses. If the DSM were scrapped, people currently diagnosed with many of its disorders would continue to suffer from their experiences. This would be in virtue of facts about those experiences that have little to do with how they are described.
13. That being said, the way we choose to describe people's experiences has real and substantial impact on the people who have them. People's lives can be improved dramatically by changing the way their experiences are constructed.
14. The statement " schizophrenia exists" may capture reality in important ways, but it cannot be regarded as straightforwardly true.
15. It can be overly general and dismissive to make statements of the form "Schizophrenia does not exist", even though the considerations that often motivate such statements are rooted in fact.
16. The claim that CBTp is not effective does not amount to a claim that people with psychosis should not be offered psychosocial support. It is claim about the relative efficacy of a specific treatment.
17. To promote CBTp is to privilege, over other approaches, a particular technical and hierarchical way of talking to people. In virtue of this it is more in line with a "medical model" than many of its advocates generally emphasise.
18. The provision, by health services, of CBTp stands to benefit the profession of clinical psychology in ways that are analogous to (though different in scale from) gains that have accrued to psychiatry through the provision of drug treatments.
19. It seems to be the case that different parties in the broad conversation about mental health want for it to be true that mental health problems are "mainly biological" or "mainly environmental". This is a decidedly strange fact and should stimulate our curiosity.
20. In the broad conversation about mental health, we all show a tendency to align into loose (but real) groups. Once in these groups we are more forgiving of the rhetorical excesses, rudeness and inaccuracy perpetuated by those with whom we are aligned.
21. On balance, "antipsychiatry" and "critical" psychiatry and psychology have been extremely valuable contributions to the discussion on mental health.
22. Sometimes asking questions can be an effective rhetorical strategy for avoiding the existence of people's efforts to provide answers whose implications we would benefit from talking about.
23. Mental disorders would not need to be geographically or temporally invariant to be considered real in a meaningful sense.

Who Owns "Critical"?

This post is about "critical psychology". Or rather (as i don't think there is one cohrent movement under this heading) it is about the fact that some people call themselves "critical psychologists".

I like the idea of a "critical" psychology. Being critical is something I aspire to in this blog and in my research and clinical work, though I don't know how often I manage it. But what do I mean by critical? Something like thinking as hard and as intelligently as possible about what I do and say. I think that when some people talk of being "critical psychologists" they are using the word in a more complicated way.

Partly this is because the word "critical" does not refer only to acuity of judgement, but also denotes a specific historical/philosophical intellectual project. To identify as "critical" is to invoke "critical theory", an approach to culture and knowledge which stresses the importance of analysing communication intensely for hidden assumptions. This project is specifically engaged in liberation from oppression by implicit historical structures supported by texts. It is interested in the ways that power gets played out in the deployment of knowledge. As such, critical theorists are open to ways of talking that move outside the "traditional discourses" of any given subject. It's also a project I with which I feel aligned.

Critical theory has been very fruitfully used by critical mental health professionals. The notion of clinical practice as the exercise of power has found particular traction in UK Clinical Psychology, and this is a good thing. You can find it in the work of David Smail, Dorothy Rowe, and in Joanna Moncrieff's critique of diagnosis as a political tool.

But there is a difference between doing critical psychology, and saying you're a critical psychologist. Identifying oneself as "critical" is more than just a description, is an action, which different people undertake to different ends. Many people may want to signal that they are amenable to thinking in particular ways (often in psychology it signifies a willingness to consider the relevance of non-quantitative evidence). "Critical" here is a shorthand for an interest in the use of political and social theory as well as psychological.

Critical or "Critical"?

Being "Critical" often also marks people out as holding particular views. For some it has explicitly provided a way to get distance from. "antipsychiatry" (a term which at least has the virtue of accuracy). Thus many psychologists are "Critical" in virtue less of an approach than an entire system of beliefs, and this is where things get tricky. Calling oneself "critical" might be intended to signal a particular perspective, but it also (in virtue of the word's broader meaning) serves as the subtle assertion of superior judgement.

Often in reality "Critical" simply serves to flag that you take for granted that certain things about mental health are true; that some treatments are necessarily "good", others "bad"; some ways of describing mental health problems as inherently morally superior. That is not what Foucault had in mind when he wrote "Madness and Civilisation". Saying you are "critical" under these circumstances is both a distraction and an untruth.

If calling oneself "critical" is no guarantee that a person will always be critical, nor is it a necessary condition for being so. There is much uncritical, partisan nonsense written under the banner of Critical Psychology, and many sharp critical voices outside it.

You Don't Own Critical:

When we consider the power of our blind-spots and personal biases, it seems unreasonable that any person can say accurately or in good faith that they are more critical than anyone else. Certainly no-one can be critical all the time. If there is a viable "critical psychology" project, it is probably the sort of thing we should do without feeling the need to draw attention to ourselves in the process. If you want to be critical you are better off showing people than telling them.