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Is Private (Contract-Based) Practice an Answer to the Problems of Psychiatry?
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We are very grateful to both Matthew Ratcliffe and Thomas Szasz for taking the time to read and respond to our paper. Ratcliffe is broadly sympathetic to our efforts and provides a very convincing argument against mind–body dualisms by drawing on work from the phenomenological tradition. His comments extend rather than challenge our central thesis. Szasz, however, is dismissive of our position. As a result, most of our response is directed to his commentary.

Ratcliffe uses the work of van der Berg to make the case that any easy distinction between bodily and mental illness or suffering is false to our lived reality as human beings. Of course, in the day-to- day world of contemporary medical practice, the problems that we encounter can be separated broadly into those that emerge primarily from the psychological aspects of our lives and those that are more centrally somatic. But our position, and that of Ratcliffe and van der Berg, is that there are no clear or easily defined boundaries between the two. Ratcliffe is right when he says that our aim is “not to ditch such language altogether but to awaken a sense of intellectual humility, a realization that categories which structure much of our current thinking are specific to contingent and easily overlooked sociocultural practices” (2010, 235).

One element of the sort of critical psychiatry we propose is an exploration of the categories we use in psychiatry: their historical and cultural origins and the role they play in shaping the practices of contemporary mental health work. To the extent that Thomas Szasz has contributed to this work, we are indebted to him. His efforts in this regard have made a huge contribution to the critical mental health literature. Where we part company is his insistence on a dualistic approach to medical practice, an approach that encounters binary thinking, not as something problematic to be overcome, but as emerging from the vary nature of the world itself. Our thesis is not, as Szasz claims, “binary bad, non-binary good” (2010, 230). Rather, our argument is that the sort of dualistic categories we often use such as good/bad, normal/abnormal, and psychological/medical are not as simple or as innocent as they sometimes seem to be. Nevertheless, we (perhaps particularly those of us raised in the Western world) seem drawn to them. Such distinctions often serve to give us a false sense of clarity. Furthermore, they can serve to obscure complexities and work to maintain a social and political order in which some people are silenced and excluded. For example, on one level, the binary ‘male/female’ seems simple enough. It seems, as Szasz puts it, “an attribute of the natural world” (2010, 230). The question is: what we do with this? Do we take this binary and rigidly order our personal and social worlds according to it? Do we insist that we work to distinguish male and female social spaces, social roles and personal identities? What happens to those of us whose sense of self is not so clear cut? If this binary is “an attribute of the natural world” where does that leave those whose gender is somehow ‘in-between’? Our point is that the dualism ‘male/female’: where it comes from, how it is conceived, used, the effects it has in our lives, and even how we see it operating in the natural world is not something simply ‘given.’ Rather, like other linguistic categories it emerges from our specifically human attempt to understand the world and to bring some order to it. As a result, it is bound up with all the other cultural and social dynamics involved in that struggle.

We are not suggesting that we should never think in binary terms; this would be ridiculous. Every day, we need to compare and contrast events, situations, and people (as we do in our article with Szasz and Foucault). Our point is that we should avoid reifying the distinctions we make. We agree with Ratcliffe that there are ways in which Foucault’s thought and that of Szasz can be seen as complementary rather than as being opposites. Indeed, Foucault has made very positive remarks about Szasz’s...

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