Critical!!!.......Who’s Critical? What’s Critical?

By Alan Bristow

Take a momentary glance at social work, or the allied mental health professions, and you're likely to stumble across the requirement for practitioners to behave, practice and think critically. Critical reflection, critical analysis, critical perspectives, critical assessment, critical this and critical that.

It seems also that criticality is embedded within every aspect of the AMHP role from training through to advanced practice. Indeed, even outside of immediate professional interests, one is likely to find the need to foster ‘critical thinking skills’ to be the bedrock of most, if not all, social science courses, degrees, and forms of professional accreditation.

But what is this ‘criticality’ to which we are referring, and crucially how should it, or could it, relate to the role of the AMHP? 

I venture a wager. Ask someone what we mean by, say, critical thinking and the answers invariably will touch upon analytical skills, the sorting and application of information, recalling relevant facts, and the utilization of differing frames of understanding; things that sound a lot like, well, err, thinking! Only perhaps it's about thinking a little harder, in a more nuanced fashion or maybe with more attention to detail. Some may reference how our thinking is constrained, conditioned, or caused by certain modes of cognition, habit, or language; the things that impact upon our thinking processes. Which in turn sounds a bit like, well, reflection. Critical reflection? 

Now, there's nothing essentially wrong with any of this. But what exactly is this critical skill that makes critical thinking or reflection qualitatively different from plain old thinking? If we wish to establish a critical approach to AMHP practice, a truly critical approach, then we may be minded to first establish precisely what this term ‘criticality’ denotes. And in doing so, draw from the term’s rich and varied history in respect of the social sciences (and dare I say it, philosophy). So, indulge me as we take a whistle stop tour through the development of 'critical theory' before asking what forms of knowledge may be built upon to fashion a critical AMHP practice worthy of the name.

Without wishing to exclude nursing and OT colleagues, the major strands of knowledge underpinning social work theory -and therefore the majority of AMHPs’ disciplinary knowledge- arguably comprises sociology, psychology, and law. The first two of which, or rather the intersection between them is a helpful place to start. 

It was this interaction between the private world of one’s mind and the social world of politics and culture that drove the research agenda of a slew of philosophers and intellectuals during and following the catastrophe that was the Second World War. Leading academic lights such as Theodor Adorno, Max Horkheimer and Herbert Marcuse asked how it was that the world was traipsing headlong into authoritarian control and barbarism. The answer for them, which centred around the Frankfurt School for Social Research, lay not just in theoretical understandings of politics and economics, of societal workings and personal psychology, but rather in the collision between them all. The two major intellectual enterprises during the first half of the 20th century that informed these spheres of thought were found in the works of Karl Marx and Sigmund Freud. An analysis of political economy conjoined with psychoanalysis was deemed to be the means by which a much fuller account of psychosocial life could be derived. From this was born ‘critical theory’; an interdisciplinary concern that attempts to reveal the deep structures that permeate the world in which we live, and crucially the individual thinking mind that perceives it. 

Critical theory since the time of Adorno et al has come to encompass numerous other philosophical trajectories. Feminism, queer theory, post-colonial studies, postmodernism, post-structuralism, post-everthingism….. all now comprise an ever expanding, often contradictory and hugely complex body of thought. Yet what all of them do to a greater or lesser degree is attempt to unveil or reveal the sometimes hidden, implicit ways in which things happen or occur. How language or unconscious mental life conditions political or cultural action. For critical theorists, the world is never just as it seems. The world of appearances and surfaces is but part of the whole. There are always deeper, occluded networks or structures of power and knowledge that condition the surface level of the day-to-day. The task of the critical theorist is, therefore, to uncover such structures but always with emancipatory, progressive change at the core of any such unveiling.

‘Critical social work’ is a well-established field within the discipline. Often in tandem with another prominent critical theorist, Michel Foucault, critical social work draws on these disparate theoretical strands to foster anti-oppressive practice, or directly challenge the taken for granted assumptions about the state's role and the agendas behind forms of ‘caring’ intervention. 

Yet, I want to offer another critical domain which may well assist us in building a critical AMHP practice. This time in the guise of ‘critical psychiatry’. Again, a complex body of theory and practice that draws its lineage from the radicalism of the 1960s where Messrs R.D Laing and Michel Foucault once again, along with several others began to seriously question the place, power, and purpose of ostensibly medicalised forms of psychiatry. Although the popularity and in some senses credibility of this anti-psychiatry position have weakened over recent decades, its legacy, critical psychiatry, I would argue, offers a clear and useful terrain from which a critical AMHP practice can be devised. 

Contemporary critical psychiatry encompasses everything from the questioning of pharmacology, the role of draconian legal intervention, the psychopathologizing of numerous aspects of one's emotional and mental life, through to the problematizing of medicine and illness as in themselves being the best frameworks from which we can situate aspects of mental distress. For those interested in such a position, a good place to start would be with Richard P. Bentall who in his well-received works such as Madness Explained: Psychosis and Human Nature (2004) and Doctoring the Mind: Why Psychiatric treatments Fail (2010) has provided a thorough critique of psychiatric practice and the predominance of the biomedical paradigm. Likewise, Lucy Johnstone remains an influential thinker in this arena. Her co-authored Power, Threat, Meaning Framework (2018) recently published by the British Psychological Society represents perhaps the first attempt to provide a robust schema for dealing with states of mental distress that does not rely on the DSM model of classification.

Outside of critiques emerging from the world of clinical psychology (from which Bentall and Johnstone originate) there are a number of practising psychiatrists who themselves are working towards a much more social and rights-based approach. Joanna Moncrieff, a practising Consultant Psychiatrist in London, remains the foremost outspoken critic of the many myths surrounding psychiatric medication and has tirelessly published a range of papers and books which not only question the evidence base of anti-psychotic and anti-depressant drugs but also expose the myriad harms they can create, particularly for long-term users (see, https://joannamoncrieff.com/). Lastly, R. Whitaker’s (2010) Mad In America  and  J. Davies’ (2012) Cracked: Why Psychiatry is doing more harm than good offer valuable if somewhat unnuanced and one-sided introductions to many of these debates.

Critical AMHP practice stands to gain considerably from such bodies of thought and will find close alliance with the neuro-diversity movement, mad studies, mad pride, survivor/activist and expert by experience voices that are attempting to redress the power that psychiatry has over people's lives and bodies. In between battling bed managers and booking s.12 doctors, we might pause and a take a lead from critical psychiatry in order to seriously question what we mean by DSM diagnoses, more closely scrutinise the cost-benefit analysis of psychotropic drugs, or problematise the structures and pillars of state power that devise inpatient units as well as care in the community (or the failure thereof). Structures of state power, we might remind ourselves, that we ourselves are very much a part.

Acting, thinking, practicing critically is about all of this. And although we may query the art of naval gazing via the Freudian unconscious or wonder quite what Marx’s analysis of the commodity form has to do with determining a nearest relative or scrutinizing MHA paperwork, the underlying ethos of such schools of thought may well be useful. Do Foucault’s impenetrable tracts on the history of discourse and mechanisms of power assist us? Maybe. But, who in truth has time for this either practically or in terms of head space I hear you cry! When inpatient beds become the mantra of all jobbing AMHPs, recourse to avant-garde French theory and philosophy might seem misplaced at best and indulgent, nay, negligent at worst.

There is a job to do after all.

True enough. But if we wish to be something more than the handmaidens to psychiatric power, carving out a space that challenges this will only ever be bolstered by drawing from these critical frameworks. Unpacking patriarchal, racist, and hetero-normative aspects of society and in turn our own role must surely be part of any critical AMHP practice. That process of unpacking, I maintain, can be guided by the critical theorists and traditions mentioned. 

So, when we assert proudly that we are practicing critically as AMHPs, it will for certain invoke those advanced thinking and reflecting skills to which we have grown accustomed. But I wonder if there may also be room for us to draw from those aforementioned allied traditions in psychiatry, social work, clinical psychology and wider philosophical thinking. 

Rather than paying lip service to being critical without stopping to think what the term might mean beyond just being good at our jobs, let's insert a little of that radical spirit from those traditions that precede us. With impending changes to the structure of the NHS and statutory mental health care hovering on the near horizon, to make no mention of a much-reported looming mental health crisis, a commitment to renewed ways of thinking about our role seems pressing. It might just even be essential. 

Picture by Marc Wathieu (CC BY-NC-ND 2.0)