Review of Johnstone L (2000) Users and abusers of psychiatry: a critical look at psychiatric practice. (Second edition) London: Routledge
Lucy Johnstone was once harangued for 45 minutes after a clinical presentation by three medically-minded psychiatrists in an effort to make her retract her views about psychiatry (Johnstone 1997). The conversation was only terminated by her driving her car away. After eleven years in a NHS clinical psychology post she left mainly because she found her dissenting views could not be countenanced. Thankfully, being at a distance from psychiatry in a lecturer post has allowed her to rewrite her book Users and Abusers of Psychiatry for a second edition. Her criticism of psychiatric theory and practice located in the underlying medical model has become even more forceful and passionate. Dorothy Rowe in the foreword to the new edition describes her as "one of the leaders in her generation of psychologists" (p. xvi).
Towards the end of Users and Abusers its argument is ably summarised:
. . . [P]sychiatry not only fails to address emotional and relationship problems, but actually reinforces them, for lack of a whole-person, whole-system way of understanding them. By using a medical label to 'Rescue' people, it takes responsibility away from them, encouraging them to rely on an external solution which is rarely forthcoming, and then blaming them for their continuing difficulties and powerlessness. The personal meaning of people's distressing experiences and the psychological and social origins of their difficulties are obscured by turning them into the 'symptoms' of an 'illness' located within one individual; the resulting treatment barrier keeps both patients and staff stuck and undermines alternative approaches such as psychotherapy. (p. 201)
This critique continues by noting how medications and ECT are given instead of needed emotional and practical support. The rationale of such practices lies in a medical model for which there is no evidential basis, "leaving traditional psychiatry with no justification for either its theories or its practices."
Although there may be disagreement about excesses and emphases, this book probably gives the best contemporary expression to the critique of the psychiatric system. Its strength lies in its comprehensive analysis that gives a new status to the challenge to the orthodoxy of mainstream psychiatry. The views need to be taken on board by the recently formed Critical Psychiatry Network (http://www.criticalpsychiatry.co.uk).
The most obvious leaning of the book is towards psychotherapy; for me, its most noticeable weakness is its tendency to reject the social role of psychiatry. Although psychotherapists practice on a voluntary individual basis, the social responsibility of caring for the mentally ill should not be neglected. Something of such neglect can be glimpsed in "Elaine's story", the narrative with which this book, like the earlier edition, begins. On Elaine's twenty-second admission, a new member of the mental health team suggested she may benefit from psychotherapy sessions to try and understand the reasons for her depression. After giving an account of the therapy, the story concludes with Elaine commenting that if she had had this help previously she would not have needed medication for so long. Despite the eleven year gap between the publication of the two editions, no attempt was made to give an update on Elaine's progress. I am not nihilistic about therapy, but psychiatric treatment is concerned with more than simplistic wish-fulfillment, and Elaine may well have continued to have had further admissions.
Neglect of the social appears more obviously at one point in a dismissal of the 'biopsychosocial model' (p. 250) without clear reference. There have been a minority of psychiatrists who have adopted a common sense model of psychiatry. The most consistent philosophical underpinning of this approach has probably been Adolf Meyer's psychobiology. A contemporary example would be the work of Arthur Kleinman, who of course can understand the social perspective because of his training in anthropology as well as psychiatry.
As recognised in the book, the so-called antipsychiatry critiques of the 1960s are now generally regarded as "mistaken, irrelevant and damaging". I do not think that the contemporary critique of psychiatry should dissociate itself from such ideas quite so lightly. Nor should any power struggle between psychiatry and clinical psychology lead to the promulgation of cognitive behavioural therapy merely because it is seen as a distinctive contribution from clinical psychology. For all its merits, the recent British Psychological Society (2000) report on Recent Advances in Understanding Mental Illness and Psychotic Experiences may have made this mistake. To the book's credit, it does seem to appreciate this point, quoting favourably from Mary Boyle, who acknowledges the "danger of conceptualising [cognitive behavioural] treatment as a kind of fixing of a faulty machine".
My minor cavillings should not detract from Lucy Johnstone's overall achievement in refining and developing the insights and analysis of her earlier account: this second edition of her book is an inspiring improvement.
British Psychological Society (2000). Understanding Mental Illness and Psychotic Experiences: A Report by the British Psychological Society Division of Clinical Psychology. Leicester: BPS
Johnstone L (1997) Psychiatry: are we allowed to disagree? Clinical Psychology Forum 100 31-4