“Western psychiatry is in crisis.” Not just our words, but the opening line of the powerful recent statement by Mental Health Europe (2013), a large and respected umbrella organisation representing both professionals and service users. It goes on to deplore “the simplistic and imposed application of… reductionist science” which can “encroach on basic human rights.”
In this post we examine the ways in which the profession of psychiatry is, in the UK, re-positioning itself in response to the widely-acknowledged threat to its power and status arising from the DSM-5 debacle and the ongoing failure to find the biomarkers that will confirm its theories. There are likely to be parallels with the response in the US and elsewhere. We illustrate this by reference to recent national radio debates between Lucy Johnstone and two psychiatrists who represent respectively the ‘biological wing’ (Professor Nick Craddock) and the ‘social wing’ (Professor Tom Burns) of the profession. These discussions took place in the wake of the Division of Clinical Psychology’s call for a move away from diagnosis and the ‘disease’ model of mental distress.
The controversy about DSM has been presented in the British media as ‘turf wars’ between the professions of psychology and psychiatry. In writing a joint post, we are sending the message that this debate is not about narrow professional interests, but about genuinely alternative ways of thinking, which many psychiatrists (e.g. Pat Bracken, Suman Fernando, Joanna Moncrieff, Phil Thomas) have written about and now call for as a group of critical psychiatrists (Bracken et al., 2012).
The crisis in the profession of psychiatry has been looming for a while, as discussed in a series of articles in the British Journal of Psychiatry. The suggested solutions fall into two very different camps. On the one hand, there are calls to strengthen psychiatry’s identity as neuroscience (eg Craddock et al., 2008; Oyebode and Humphreys, 2011) and thus go further down the road condemned by Mental Health Europe. Advocates of this approach make bold statements such as: “Psychiatry is a medical specialty… Major advances in molecular biology and neuroscience over recent years have provided psychiatry with powerful tools that help to delineate the biological systems involved in psychopathology” (Craddock et al., 2008). In this view, other professions have a role to play but need to be kept firmly in their place, and the “creeping devaluation of medicine”, along with an “increasing tendency of many services to be based on non-specific psychosocial support” is lamented.
Meanwhile, in the opposite corner, another wing of the profession is disputing these claimed advances and advocating exactly the kind of generalised benevolence that the neuroscientists deplore, as a replacement for the failure of the neuroscientific approach:
“The past 30 years have produced no discoveries leading to major changes in psychiatric practice. The rules regulating research and a dominant neurobiological paradigm may both have stifled creativity. Embracing a social paradigm could generate real progress and, simultaneously, make the profession more attractive” (Priebe, Burns and Craig, 2013).
“Psychiatry is utterly based in and dependent on a relationship… It is the core of the activity” (Burns, 2013).
The one thing that both wings agree on is that the profession faces a threat to its survival. “Some… have questioned whether the psychiatrist is an endangered species… Urgent action is required to… ensure the future of psychiatry as a profession” (Oyebode and Humphreys, 2011); “British psychiatry faces an identity crisis… It is imperative that we specify clearly the key role of psychiatrists” (Craddock et al., 2008); “We believe that such a focus… has potential to strengthen our identity, give psychiatrists more societal relevance, and make psychiatry more attractive as a profession” (Priebe et al., 2013.) As these quotes suggest, the solutions are presented primarily in terms of their benefits to the profession, with little attempt to claim, for example, improved outcomes or greater acceptability to service users themselves.
Commentary on the Interviews
The first interview is with Professor Nick Craddock, a research psychiatrist from Cardiff University and first author of the paper referred to above (Craddock et al., 2008). His career has been based on research into categories such as ‘bipolar disorder’, an approach now discouraged by the National Institute of Mental Health. As such, he clearly cannot afford to agree with the recent admission of the chair of the DSM-5 committee, Dr David Kupfer, that ‘We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting’ which Lucy Johnstone quotes at the start of the discussion. He responds confidently: “For the core disorders like schizophrenia, bipolar disorder, ADHD there is very very strong evidence… that there are differences between people.” How this fits with Dr Kupfer’s admission is not clear – is there lots of evidence, or none at all? And of course, differences between people, even biological ones, do not imply anything about causality or aetiology. This is an example of a familiar tactic in which experts simply assert that something is the case in the knowledge that a radio interview is not enough time to unpick the subtleties.
The other strategies used by Craddock have been extensively deployed in the media debate about DSM. The first is blatant question-begging – in other words, assuming the very point that needs to be proved. Thus Craddock states that “If you went back 30 or 40 years in studying cancers or heart disease or whatever, you would also find that medicine wasn’t at that stage…” In a similar vein in his interview, Burns asserts that “There is no need in any branch of medicine for treatment to mirror the cause of the disorder”, etc. This simply sidesteps the main issue which is: ‘But is psychiatry a legitimate branch of medicine?’
The second strategy is to present the profession of psychiatry as considering a wide-ranging selection of social and psychological factors in mental distress. This is the line taken by Burns as well. The intended messages seem to be: ‘We are not the narrow-minded pill-pushers of your critiques’, along with: ‘And we have lots in common with all the other mental health professions and work happily alongside them.’ But before this argument is pushed to its logical conclusion, it is swiftly noted that doctors are the only ones who do everything – psychological, social, medical, the whole lot. No other profession measures up to our extensive range of skills. The message is: You need us in charge.
The credibility of the ‘but we do everything’ claim depends to a large extent on another strategy – the assertion that critics are ‘ignoring the role of biology’, a position which is self-evidently ridiculous. It would indeed be ridiculous to ignore the role of biology – and of course no one is suggesting such a thing. Lucy Johnstone makes it clear in both interviews that the argument is not about the undoubted existence of biological factors which accompany all human experience, both ‘normal’ and ‘abnormal’, but about whether these are seen as causes or effects (or correlates) of distress. But Craddock does not stick around to debate this further. His last contribution is to assert that people prefer to be called ‘patients’, not service users or survivors. We then hear from a very articulate service user, Michael, who vividly describes the despair and hopelessness induced by a diagnosis of personality disorder, which he now rejects, along with the other 5 psychiatric diagnoses he was given. He also, incidentally, rejects the term ‘patient.’
Craddock is seen as adopting a fairly extreme position even within his own profession, and as such is not necessarily its desired public face. That position is increasingly occupied by spokespeople from the opposite wing – the ‘social wing’ such as, for instance, Professor Burns whose new book Our necessary shadow: the nature and meaning of psychiatry (2013) claims (quite wrongly) to be the first in a generation to attempt to “explain the subject fully to the interested outsider.” The book received a glowing review from Raymond Tallis (The Times 1.6.13), who is normally the first to dismiss simplistic biological explanations of human experience. Presumably he was so seduced by statements in the book such as “mental illnesses… exist between people. They are not contained within an organ or body” that he failed to grasp the implications of retaining all the trappings of the same old biomedical model (the language of illness, the essential role of medication, the psychiatrist in charge, and the call for “recognition of the massive good it (psychiatry) does.”) Burns, then, is a sophisticated player, and one whose arguments require careful scrutiny.
In his co-authored article in the British Journal of Psychiatry (Priebe et al., 2013), Burns frankly admits that the last 30 years have seen no scientific breakthroughs or better treatments, and argues that psychiatry needs to re-introduce the social and relationship contexts of people’s lives, rather than “simply pressing on with ‘more of the same”’. This new vision acknowledges “the abundant evidence of the importance of personal relationships in shaping both cause and cure of disorders.”
Re-defining the profession as virtually indistinguishable from counsellors or social workers (apart from the status and salaries, of course) requires some fairly extensive re-writing of history – his own, and that of the profession as a whole. Burns appears in a rather different guise as the consultant in a 1995 television documentary Whose Mind is it Anyway? As described in Lucy Johnstone’s book ‘Users and abusers of psychiatry’ (2000):
“John Baptist is the adopted name of a black man who believes that he was born white, that he is descended from the royal family, and that his sister has been cannibalised, but he is apparently coping perfectly well with his life. He does not see himself as mentally ill and does not want medication… He… describes how last time he ‘came out of this hospital hardly able to brush my teeth, hardly able to eat, hardly able to stand… I was less than a baby. Now, what sort of medicine is that?’ He demands to know what proof the consultant has that his beliefs are untrue, and forces the consultant to admit that this is in fact a matter of personal judgement: ‘Well, you’re right in a way there… the only way I make that diagnosis is on people’s thoughts and feelings.’ However, in this unequal power battle there is little doubt whose delusion is going to carry the day, and we see the consultant telling the camera that ‘I’ve no doubt this is a schizophrenic illness’, while John is threatened with a locked ward if he tries to leave.
“The rest of the programme charts John’s determined but unsuccessful attempts to gain his freedom, while insisting on retaining his beliefs. His assertiveness and refusal to compromise about his ideas clearly count against him, for the chief evidence against him at a tribunal hearing is that he used to be ‘angry, irritable, shouting at people, verbally aggressive’ and that he still has ‘inappropriate beliefs.’ Meanwhile, forcible administration of the medication he so hates gradually reduces him to a silent, shambling wreck of his former self, with a heart-breaking expression of sadness and hopelessness. This, to his consultant, is actually seen as progress; by a deft shifting of the goalposts, he is able to claim that, though John still retains his beliefs, his sadness indicates that he is ‘more of a whole person’ and has therefore improved. In one of the final scenes, we see a team member persuading John, in ultra-caring tones, to set the seal on his degradation and defeat by signing a form to confirm that he is ‘permanently and substantially disabled’, in return for a bus pass. John’s mental illness is at last being properly treated; or to put it another way, he has now been permanently and substantially disabled for obstinately refusing to regulate his thoughts according to white cultural norms (pp.231-232.)”
Burns’ apparently colour-blind and culture-blind approach in diagnosing John Baptist in 1995 may well have resulted in an institutionally racist outcome to the latter’s hospital experience as a result of invalidation of his subjective reality in the interactions depicted in the film. Perhaps Burns has undergone a dramatic conversion recently, in line with the call for change issued by critical psychiatrists (Bracken et al., 2012). If so, a public apology to John Baptist is merited in view of the apparent injustice done to him in 1995.
In his radio interview, Burns does not refer to this documentary, although he is at pains to find areas of agreement with his critics. He enthusiastically welcomes the fact that DSM “has come in for a real kicking” and openly admits the lack of progress of the last 30 years. Naturally, he does not extend this to an argument for dispensing with diagnosis, or psychiatrists, altogether, but nevertheless the position is clear: The profession has gone too far down the biomedical route. Burns and his allies present themselves as reasonable people who can acknowledge these errors – as a profession, that is, not as individuals – and usher in a new, humanitarian era of psychiatry.
Curiously, Burns hardly bothers to deny the range of charges that Lucy Johnstone forcefully puts to him: that there is no evidence for biological causal factors in mental distress; that psychiatry is not a legitimate branch of medicine; that there is overwhelming evidence that service users are experiencing the understandable consequences of traumatic life experiences; that psychiatric treatments often do not ‘work’ but create disability; and that many survivors only recover by escaping psychiatry and renouncing their labels. Instead, he escapes into lofty generalisations in which psychiatric activities simply become a sensible, pragmatic way of finding out what works in practice.
Burns has also developed an ingenious, if contradictory, set of new defences, as illustrated in the interview. These are 1) that medicine has no particular theoretical basis, and that is a good thing and 2) that medicine draws on every possible theoretical basis, social, psychological and biological, and that is an even better thing.
It is worth examining these claims in more detail. Both rely on the assumption that mental distress is best understood in medical terms – exactly the point that is at issue, as Lucy Johnstone reminds him. Leaving that aside, the admission that psychiatry has no specific theoretical basis at all could perhaps be seen as an honest response to the fact that its evidence-base has now been officially acknowledged as entirely absent. However, Burns takes this to quite an extraordinary level. Rather than elevate psychiatry to the status of neurology, as Craddock et al. attempt to do, he seeks to reduce the whole of medicine to the state of psychiatry, and in doing so, describes a scenario reminiscent of the days of blood-letting and leeches, with interventions drawn out of a hat because there is no established theoretical basis for the discipline. Medicine is, he argues, ‘a pragmatic, atheoretical approach…the advantage of medicine is that it is NOT a theory-driven activity.’ This describes psychiatry very accurately, but extending it to the whole of modern medicine is quite bizarre, given that other branches are supported by clear theoretical frameworks and evidence bases which have brought about the progress that is conspicuously absent in psychiatry.
This exposition leaves psychiatrists in a very vulnerable position. If medicine and psychiatry are in such a primitive state, why shouldn’t other professionals or indeed lay people take over their role? However, Burns quickly moves to counter this threat by slipping into the ‘but we can do everything’ rhetoric. No specific theoretical knowledge is needed, but this very fact means that we might have to call on almost any type of skill. And who has the broadest range of skills around here? Why, psychiatrists! Just to be clear on this point, we are reminded that this brave new world of psychiatry will not involve “in any way diluting its core medical responsibility” (Priebe et al., 2013).
Of the two responses, the second presents the bigger threat to the wholesale change that survivors are calling for, because it is superficially more plausible and, up to a point, welcome. If psychiatry maintains its dominant position, then at least let’s have psychiatrists who acknowledge the role of social factors, relationships and personal meanings – as many already do. The dwindling band of neuro-enthusiasts can be left to pursue their fantasies about mysterious brain dysfunctions even further down a dead-end alley. However, the new re-branded social psychiatrists are hard to pin down, and not everyone is convinced by their change of heart. In the words of one blogger:
“For the past 30 years, psychiatry has conceptualised human problems as illnesses and has promoted drugs as the only viable ‘treatment’ for these pseudo-illnesses. They have ruthlessly expanded their spurious, disempowering and stigmatising ‘diagnoses’. They have developed corrupt and corrupting relationships with pharma….They have legitimised the widespread prescription of dangerous drugs, and have stood by complacently as clients succumbed to the most devastating side effects… Now, with their reputation in tatters, and the survivors of the ‘treatments’ in open revolt, they seek to rehabilitate themselves. But there’s no apology. Not even an oops, sorry. Just ‘We’ve messed up our own patch. Can we come over to yours? And by the way, we’ll still be in charge.'” (Phil Hickey at www.behaviorismandmentalhealth.com, May 8th 2013)
Important clues to this group’s real position can perhaps be found it two linked areas. First, there is the failure, as above, to make any acknowledgement at all of the appalling damage and suffering (vividly illustrated by John Baptist’s story) that the existing paradigm has inflicted. Second, there is the cavalier attitude to survivor testimony – a perspective not even mentioned in their articles and airily dismissed by Burns in his interview with the words ‘We’re not perfect.’
This woefully inadequate response fails to acknowledge the devastating harm that many psychiatric survivors have experienced at the hands of biological psychiatry, along with the urgent need to address how to prevent such harm continuing in the future. Instead, intelligent people are expected to continue to accept discredited diagnoses for fear of being labelled as `lacking in insight’ and having treatment forced on them, incarcerated against their will, ‘for their own good’. People are coerced, both within hospital settings and even within their own homes through the widespread use of Community Treatment Orders (which as Burns notes regretfully in the documentary, did not exist in 1995, thus preventing him from imposing neuroleptics on John Baptist for even longer), into taking medication that they don’t want and which frequently does more harm than good (Whitaker, 2010).
Rather than re-positioning itself in response to the widely-acknowledged threat to its power and status arising from the DSM-5 debacle, psychiatry, along with colleagues from all professional disciplines, needs to work in genuine partnership with people with lived experience of diagnoses, in order to find less damaging and more humane ways of making sense of, and responding to, madness and distress. Fighting for the rights of those labelled mentally ill has been called the last great civil rights movement. Let us not allow the vested interests and dubious arguments of a powerful minority to waste this vital opportunity to replace the discredited biomedical model and its unscientific and stigmatising labels.
Bracken, P. et al (2012) Psychiatry beyond the current paradigm. British Journal of Psychiatry, 201, 430-434.
Burns, T. (2013) Our necessary shadow: the nature and meaning of psychiatry. London: Penguin
Craddock et al. (2008) Wake-up call for British psychiatry. British Journal of Psychiatry, 193, 6-9.
Mental Health Europe (2013) More harm than good: DSM 5 and exclusively biological psychiatry must be completely rethought. http://www.mhe-sme.org/news-and-events/mhe-press-releases/dsm5_more_harm_than_good.html
Oyebode, F. and Humphries, M. (2011) The future of psychiatry. British Journal of Psychiatry, 199, 439-440.
Priebe, S., Burns, T. and Craig, T. (2013) The future of academic psychiatry may be social. British Journal of Psychiatry, 202, 319-320.
Whitaker, R. (2010) Anatomy of an epidemic: Magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. New York: Crown Publishing Group.