Biological psychiatry is afflicted by an ague. Or maybe it’s the pox. The precise diagnosis in unimportant, and it may not even be a terminal decline, but there is serious discontent with the brain that was once thought to be broken. The pharmaceutical industry is cutting back its funding for neuroscience research. Astra Zeneca has cut 2,200 jobs from research and development for 2014. This follows on from similar cuts by Glaxo-SmithKline, Pfizer, Merck, Sanofi and Novartis (InPharm, 2012). Most of these cuts are in ‘serious mental illness’ research, not Alzheimer’s disease. As far as day-to-day clinical practice is concerned Professor Tim Kendall (2011) has pointed out that there is no evidence that so-called second generation neuroleptic drugs are any more effective than first generation drugs in the management of psychosis. He is funded by the National Institute for Health and Clinical Excellence (NICE) in England to develop clinical practice guidelines for the National Health Service. Blockbuster drugs are turning out to be a busted flush; their days are numbered. Their decline is hastened by the problem of the harm they cause. Their long-term use is associated with seriously adverse effects on health, including obesity, heart disease, brain atrophy, sudden cardiac death and increased mortality. Graham Thornicroft has recently described this as a violation of the right to health under Article Twelve of the International Covenant on Economic, Social and Cultural Rights (Thornicroft, 2011). So, where does psychiatry go from here?
In his book Narrative Psychiatry, New York psychiatrist Brad Lewis points out that neuroscience has restricted psychiatrists’ ability to practice, especially when it comes to working with people empathically and on a deeply personal level. The failure of neuroscientific research to deliver interventions that are safe and effective means that the profession must face up to the question where do we go from here. The search for the answers to this is now the most pressing task facing critical and postpsychiatry. Lewis’s book is an important step forward in this search.
I admire the approach he adopts. His style is approachable with a gentle pétillance. He doesn’t denigrate biological psychiatry. He doesn’t attack neuroscience. He doesn’t even develop a critique of the field. Rather, the real problem with biological psychiatry is its sterility. It has nothing to say about the complexity of human lives and their dilemmas. He makes his point through his skilful use of Chekhov’s play Ivanov, which he uses to illuminate what he means by a narrative view of psychiatry and psychiatric practice. This is a view that engages with the multiplicity of meanings and thus the indeterminacy of human lives. There is no single, monological truth about human beings, but this does not mean a descent into the morass of relativism. Instead, he argues that it forces us to engage with our patients’ (and our own) values, and ultimately the moral implications of psychiatric practice. This is because narrative psychiatry is not concerned with the truth status of different stories, but with the consequences of different stories about madness and distress, and the sort of lives arise that from these stories.
In chapters two and three he shows how narrative in medicine and psychotherapy have illuminated clinical practice, as a prelude to setting out his ideas about narrative psychiatry in chapter four. Narrative ‘…provides a way for savvy educators, reformers, and practitioners to negotiate the contradictions in the field without falling into swirling polemics or developing rigid ” anti-this” or “pro-that” dichotomies – such as antipsychiatry versus propsychiatry, or drug therapy versus talk therapy.’  Of course, this is talk that will make biological fundamentalists, the seekers of the ultimate truth about madness, rail and rant. Instead, Lewis sees psychiatric practice in terms of prioritizing clinical stories. Psychiatric patients enter the clinic with a vast array of complex narratives. The most important task for the psychiatrist is to engage with these stories respectfully and empathically. This means caring for and about the person whose story you are listening to. His use of Chitra Divakaruni’s short story Mrs. Dutta Writes a Letter in the final chapters of his book sets out how narrative psychiatry works in practice, whilst drawing attention to the value of literary narratives in understanding clinical practice.
Brad Lewis’s view of narrative psychiatry sits comfortably, in my view, alongside Jo Moncrieff’s drug-centred model of psychotropic medication (Moncrieff, 2008). Both books are really important in moving from critique to practice. Furthermore, narrative psychiatry opens the way for much-needed future work, for example how psychiatrists might use diagnosis, medication (especially the placebo effect), psychotherapy (especially the non-specific factors common to all forms of psychotherapy). Most important of all narrative psychiatry has the potential to equip us to work more respectfully with people whose cultural beliefs differ from our own. And, until such time as governments decide that the practice of psychiatry is to be uncoupled from social control, how we might work with coercion. In conclusion, this is an important book. All psychiatrists, psychologists, and mental health professionals should read it.
Lewis, Bradley (2011) Narrative Psychiatry: how stories can shape clinical practice. The Johns Hopkins University press, Baltimore.
Hardcover: 240 pages
Publisher: The Johns Hopkins University Press (31 Jan 2011)
InPharm (2012) The Brain Drain published on 05/04/12 at http://www.inpharm.com/news/172099/brain-drain accessed on 25th September 2012.
Kendall, T. (2011) The rise and fall of the atypical antipsychotics. British Journal of Pychiatry, 199, 266–268.
Moncrieff, J. (2008) The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment. Basingstoke, Palgrave Macmillan
Thornicroft, G. (2011) Physical health disparities and mental illness: the sandal of premature mortality. British Journal of Psychiatry, 199, 441-442