Book Review: Psychiatry in Context: Experience, Meaning & Communities, by Phil Thomas

Psychiatry in Context: Experience, Meaning & Communities
by Phil Thomas, Ross-on-Wye, PCCS Books, 2014, 304 pp.,
$45.00 (paperback), ISBN 978-1-906254-72-8

Psychiatry in Context follows on from Phil Thomas’s previous ground-breaking analysis Postpsychiatry (Bracken & Thomas, 2005), and is set to become just as influential and indispensable to anyone concerned with the politics, practice, and philosophy of mental health. In some respects this is almost ironic, because a book like Psychiatry in Context would ideally be unnecessary.

Its central premise, that mental wellbeing is inextricably entwined with one’s social, emotional, and cultural circumstances, appears so self-evident as to not justify a lengthy piece of scholarship to explain why. Yet the context in which the book itself is placed – that of a medical discipline enmeshed in what Thomas describes as a fatally flawed ‘technological paradigm’ – is a context in which wisdom that should be intuitive and obvious is besieged by a series of powerful messages to the contrary. Across the course of the book, Thomas provides a lucid, authoritative, and frequently damning analysis of contemporary mental health services, highlighting where we have gone so terribly wrong before laying out humane and practical suggestions for how can we attempt to put things right.

By deconstructing the major principles and assumptions on which biomedical psychiatry is based, Section One sets the scene by presenting “a profession in crisis”, outlining why prevailing biomedical frameworks are failing in both therapeutic and empirical terms. In addition to a trenchant critique of diagnoses and drug therapy, Thomas also presents the concept of the ‘technological paradigm’ of psychiatry: the notion that 1) mental health difficulties arise from disordered processes within the individual, (2) can be modelled universally and causally, independent of personal context, and (3) that resulting interventions can be implemented and evaluated separately from interpersonal values, narratives, and relationships. This is a position memorably laid out in a multi-authored editorial in the British Journal of Psychiatry (Bracken et al., 2012), and premises Thomas’ recurring message: that such a framework is incapable of engaging with human suffering in a moral or humane way.

Section Two examines social contexts for psychosis, specifically through an exploration of two major environmental factors: childhood adversity and racism. Section Three, entitled On Neuroscience and Narrative, further contextualises the role of social influences by arguing why reductionist neuroscientific methods can never hope to truly “crack the problem of psychosis”. This section includes a sensitive and thought-provoking exposition on the nature of consciousness, identity, and intentionality, and where Thomas’ background in both medicine and philosophy reach a highly readable fusion of ideas.

Section Four comprises a series of moving and instructive survivor testimonies, where Thomas steps back from his authorial role to gently guide the reader through the power of narrative and restorative truth-telling. In turn, Section Five is devoted to an exposition of the Service User/Survivor Movement before laying out a series of suggestions for promoting “meaning and healing” in mental health, particularly in terms of community development. Section Six weaves together the work of previous chapters to prevent a stark challenge to psychiatry: “ethics before technology”, in which caring, narrative, and moral imagination are proposed to a central role.

Taken together, Psychiatry in Context is a remarkably insightful, challenging, and impeccably researched book that functions both as impressive scholarship and as a call to arms. Phil Thomas – himself a psychiatrist – issues a prescription for a medical discipline that, in his own words, is mired in turmoil and crisis. His proposed solutions are far-reaching in application, compassionate in scope, and outline a charter for a version of mental health services that, if implemented, could truly be approached with hope and reassurance rather than uncertainty, stigma, and fear.

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References: 

Bracken, P. & Thomas, P. (2005). Postpsychiatry: Mental health in a postmodern world. Oxford: Oxford University Press.

Bracken, P., Timimi, S., Asen, E.,  et al. (2012). Psychiatry beyond the current paradigm. British Journal of Psychiatry, 201, 430–434.