Psychiatry in crisis and schism
Psychiatry is itself in crisis. As outlined in the major Department of Health report into the status and future of psychiatry ('New Ways of Working’, in which I was a major participant)32 rates of divorce, alcohol and drug use, sickness absence and even suicide are higher in psychiatrists than in the general public or other medical specialities. At the same time, recruitment into psychiatry is also in crisis - psychiatry is one of the least popular medical specialities, and consequently the quality of recruits into psychiatry generally tends to be low. Psychiatry is also under fire from outside. Instead of forming groups with names like ' ... Friends of ... ', former patients describe themselves as 'survivors', and they frequently explicitly regard themselves as having survived psychiatry itself rather than being survivors of the distressing experiences for which they sought help.
The discussion of alternative models for the delivery of mental health care is absolutely not a dispute between psychologists and psychiatrists. Sadly, many psychologists themselves use diagnostic labels and, publicly at least, do not question the 'disease model' or the widespread use of psychiatric medication. (Privately, I sometimes wonder whether their beliefs are at least partly influenced by the financial consequences of their practice and our traditional reluctance as a profession to challenge the presently dominant world-view). Equally, many psychiatrists reject these views. Historically, psychiatrists such as R.D. Laing and Jacques Lacan as well as the arch anti-psychiatrist Thomas Szasz all rejected the biomedical, diagnose-treat, model of psychiatry. More recently, a total of 29 eminent psychiatrists co-authored a paper entitled 'Psychiatry beyond the current paradigm',33 arguing that ' ... psychiatry needs to move beyond the dominance of the current, technological, paradigm ... '.
There is a big difference, then, between what I regard as entirely justifiable scientific scepticism, frustration, sadness, even anger at unscientific, unhelpful, old-fashioned biomedical determinism, disease-model thinking and a diagnose-treat model on the one hand, and scorn for the profession of psychiatry on the other. I have great respect for my colleagues who are psychiatrists, and feel I have learned greatly from those clinical leaders with whom I've worked. As will be made clear throughout this book, my vision for the future of mental health care is predicated on a central role for psychiatry and for psychiatrists. I am opposed to ways of thinking, of service organisations and modes of practice that I believe to be profoundly unhelpful but that doesn't mean I am critical of psychiatrists. This means I need (as I've learned over the years) to distinguish carefully between criticisms of the current ethos and practice of mental health care and criticisms of psychiatry. This occasionally leads to clumsy language - for which I apologise. I shall try to use the phrase 'mental health care' rather than 'psychiatry'. And if, in my frustration, I tar all my psychiatrist colleagues with a biomedical brush, I also apologise.
This crisis is also revealed in internal schism. In the past few years we have seen three very different visions for the future of the profession - from within the profession. The psychiatrist Professor Nick Craddock, in an editorial in the British Journal of Psychiatry, argued that psychiatry needs to re-establish itself as a branch of medicine, re-establish mental ill-health as a medical concept, re-establish the biological and neurological basis of 'real' mental illness and re-establish the authority and status of the psychiatric, medical consultant.34 Professor Craddock suggested that much of the business of psychiatry is - as I would argue - normal human emotional response to difficult social circumstances. But he suggested that this should be separated from the 'genuine' mental illnesses - leaving the profession of psychiatry in what he would regard as appropriate hierarchical authority in a disease model, medical model, mental health care service. It seems (reading somewhat between the lines of Craddock's article) that he is suggesting that psychiatry should have little to do with 'normal' responses, although this presupposes (wrongly in my opinion) that this is a valid distinction. Pat Bracken, another psychiatrist, and also in an editorial in the British Journal of Psychiatry, argued almost exactly the opposite. He suggested that the vast majority of mental health problems, including those traditionally seen as symptoms of serious 'illnesses' such as 'schizophrenia' should instead be understood from the perspective of social psychiatry - as normal, human, responses to difficult social circumstances. He argued for a social, psychosocial, empathic response. Refreshingly, and rather wonderfully, this stance has been repeated by Dinesh Bhugra, as incoming president of the World Psychiatric Association.3 5 Not that different from my own position ... except that Pat Bracken, Dinesh Bhugra and colleagues also argued that this psychosocial perspective was the proper role for psychiatry in a mental health care system still centred on medical primacy. Personally, I would argue that the logical consequence is that, therefore, a medical subspecialty (psychiatry) should play an important contributory role in a predominantly psychosocial service.
A third model emerged from the multi-professional discussions that were part of the 'New Ways of Working' project,36 championed by the consultant psychiatrist Christine Vize. This model suggested that proper care for people in deep personal distress was a team effort: a multi-professional effort. Since people have a range of needs, from social, through psychological to medical needs (and in different proportions for different people), the team requires a range of specialists who would work together (in different cases in different ways) to offer help. In this model, psychiatry would be a valuable partner, but would have an entirely different - more 'democratic' and much more along the lines of genuine consultancy, contributing to a multidisciplinary mental health care team's work where necessary, rather than necessarily having hegemonic authority.
I strongly orientate to the third model in practice, but have a lot of sympathy with Bracken's approach in terms of ethos and framework of understanding. Rather unexpectedly, I also think that Craddock's approach has merit. In my clinical experience, I have frequently been disappointed at the medical care offered to clients. I am unconvinced that clients are offered the physical healthcare that they need and which is particularly important for people who are both often poor and taking powerful medication. In particular, I think it would be ideal if all clients were able to consult with an expert psychiatrist who was able to understand and explain the mode of action of the medication and its potential risks. I do not always find this expertise in practice. I agree with Nick Craddock that expert medical input should be part of every mental health team. What I do not agree with is that this expertise renders a medical colleague the natural leader of a clinical team, or that a medical perspective is a natural guiding ethos for the service. I therefore conclude that none of these models fully addresses the depth of psychiatry's malaise, and none has a fully-developed solution.