Many psychiatrists will be reassured by Kendell's (2001) editorial. It gives its authority to the view that there is no difference between mental and physical illness. Psychiatrists will therefore feel better equipped to deal with challenges to this view from patients. The editorial reinforces the acceptance of so-called modern psychiatric treatment.
Psychiatrists who do not accept this premise are branded as "unthinking" by Kendell. This is despite his editorial apparently being written to end further debate about the matter.
Kendell's presumption cannot go unchallenged. The Critical Psychiatry Network was formed in Bradford in January 1999 precisely for the purpose of encouraging further reflection about the nature of psychiatric practice. This is not because the Network does not recognise the wish to identify mental illness with physical disease such as cancer. Such a perspective has always dominated psychiatric thinking. Nor does the Network intend to encourage dualism, separating the mind from the brain. It acknowledges the complexity of the notion of mental illness and the relative simplicity of the idea of physical disease.
The Network appreciates, like Kendell, the importance of the issue about the nature of mental illness. The difficulty of characterising mental illness previously led Kendell (1975) in his lecture when inaugurated as Professor of Psychiatry in Edinburgh to suggest that its definition necessarily implies biological disadvantage, in the sense of higher chances of infertility or early mortality. For some reason, he does not mention this claim in his recent editorial, perhaps because it is clearly mistaken. (Farrell 1979). He appears to continue to be biased in his view that there is no more than a pragmatic difference between psychiatry and neurology.
In support of his position, Kendell alleges extensive evidence of widespread, albeit subtle, brain pathology in mental illness, as well as strong evidence of genetic transmission. Such so-called evidence is used to justify his conceptual hypothesis. Those who do not accept his premise will find the evidence less obvious (Double 2001). The history of psychiatry reveals a recurrent failure of somatic and genetic theories. What may matter more than interpretation of evidence is recognition of the value-laden nature of the concept of mental illness. The notion of illness is inevitably an evaluative concept (Fulford 1990).
Linguistic distinctions between mental and physical illness cannot be ignored. As enunciated in the Meyerian tradition in psychiatry (Meyer 1951/2), the primary need is to understand the patient as a person. Psychological symptoms are real. Speculating about the physical nature of mental illness may be "neurologising tautology", as Meyer was fond of saying. Postulating underlying brain dysfunction does not provide reasons for human action.
Psychiatry has to continue to grapple with the mind/body divide. In contradistinction to Kendell's view, it is his misunderstanding that undermines the relationship between doctor and patient. Reducing relations between people to objective connections leads to a lack of openness to the potential of human development. As Kendell admits, most of us believe in 'free will' - however tempting it may be to believe in mechanistic treatments for mental illness, human responsibility cannot be ignored. Social interaction does have consequences. Such uncertainty should not produce a loss of confidence in psychiatric practice. Rather, it should lead to the recognition that practice does not need to be bolstered by defensive attitudes.
The Critical Psychiatry Neywork wishes to encourage those who are sceptical about solutions such as proposed by Kendell. Despite the pre-eminence of his views, reflexive practice should not be an anachronism in psychiatry.
Double DB (2001) Integrating critical psychiatry into psychiatric training. In: Holmes G, Dunn C and Newnes C (eds). This is madness too. Ross-on-Wye: PCCS Books. [In press]
Farrell BA (1979) Mental illness: A conceptual analysis. Psychological Medicine 9 21-35
Fulford KWM (1990) Moral theory and medical practice. Cambridge: CUP
Kendell RE (1975) The concept of disease and its implications for psychiatry. British Journal of Psychiatry 127 305-315
Kendell RE (2001) The distinction between mental and physical illness. British Journal of Psychiatry 178 490-493
Meyer, A. (1951/2) Collected Papers. Edited by Winters E. Baltimore: John Hopkins Press