Breaking the biomedical dominance of psychiatry
Psychiatry is very good at marginalising its critics. This is what I want to look at in this talk. My experience is that psychiatry does not like to be criticised and that it tries to make its critics conform to its views.
I have experienced such pressures personally. I remember being called "dangerous" as a trainee psychiatrist, apparently because I might mislead my colleagues. But I was new to psychiatry and all I was trying to do at that stage was ask questions, which is what I thought education was about. I think as far as I can remember I was merely questioning whether mental illness existed. Now obviously more experienced, I know it depends what you mean by mental illness. But surely someone should have explained that to me then, rather than undermining me by calling me dangerous. It suggests that psychiatry is resting on very fragile foundations. After all, do I look dangerous? How could a timid, meek, naive person like me be dangerous? Am I really going to bring down the whole edifice of psychiatry? Do I really look like an intimidating person?
Similar negative comments have also been made about me as a consultant. For example, I have been regarded as "too radical". Do I look like a revolutionary? I have not left the system of psychiatry - I have stayed within it. I have not "dropped out", like some so-called antipsychiatrists like Ronnie Laing. Maybe the problem is that psychiatry is too conservative rather than me being too radical. But is it really too radical to suggest that psychiatry should be open-minded and at least answerable to criticism?
Over recent years I have produced the Anti-psychiatry website (the address is www.anti-psychiatry.co.uk, if you are interested). The site encourages critical comment and debate about psychiatry. I have to defend my professional reputation for producing such a site. Just as an example, a junior doctor who works in the same Trust as me, told me that he could not access the site from work. When he had rung the IT department he was told that they did not want people looking at the site. In fact, I do not know why he could not get access to the site. The Trust has not blocked access. But he thought they might have done, as did several others that he spoke to. It would not have been surprising to him if our Trust had blocked such a disreputable site.
And on the site itself I have had to endure hostility from people who do not think I should be associating myself with such critical views. For example, a disgruntled nurse posted a comment on the message board to suggest it was very unfair that I should be allowed to hold my views. He had had to knuckle under the system for years - as far as he was concerned I was being hypocritical to draw my salary as a consultant. Clearly he was envious as he was only paid as a nurse, but the point I am making is that there are forces acting against people who want to be critical of psychiatry. Many users of the service know that, which is why there is a user movement in psychiatry.
I have recently reviewed Lucy Johnstone's second edition of her book Users and Abusers of Psychiatry and I think it is excellent. Yet, it is critical of psychiatry. Lucy too experienced difficulty holding her views in mainstream NHS practice and become an academic in a University department of clinical psychology. She described a few years ago in an article in Clinical Psychology Forum how she was once harangued for 45 minutes after a clinical presentation by three medically-minded psychiatrists trying to get her change her views. She only managed to stop being pestered by getting into her car and driving away.
All of this suggests there is something wrong with psychiatry. And this is the sense in which I use the term anti-psychiatry. Its most consistent meaning is the recognition that psychiatry is not always the solution to the problem of mental illness - sometimes in fact it is the problem itself.
But what is it exactly that is wrong with psychiatry? The main problem is what I am calling the biomedical model. Most psychiatrists will tell you that mental illness is due to a chemical imbalance in the brain. Of course it is something to do with the brain. All behaviour, thought and feelings derive ultimately from the brain. It is not really saying much to suggest that mental illness is due to the brain. Adolf Meyer, who was the foremost American psychiatrist in the first half of the last century was fond of calling the biological hypothesis a "neurologising tautology". It is interesting how his views have been eclipsed in the last half of the last century. Maybe they need to come back as part of a critical psychiatry renaissance.
Besides not telling us very much about mental illness, the biological hypothesis takes us away from any understanding of the patient as a person. In other words it reduces the person to the brain. A single-word diagnosis does not do justice to the complexities of understanding a person's problems. I do not know how many people saw the article in the Guardian yesterday about Rufus May, who is a clinical psychologist in Tower Hamlets. When he was 18 a psychiatrist told him he was a paranoid schizophrenic and should take medication for the rest of his life. He was compulsorily treated in hospital. To quote from the article, Rufus May said "When I was a patient I felt misunderstood and written off. I thought I was treated cruelly. When I was forcibly treated and injected, it felt like rape.... [I]t was believed that talking about psychosis made it worse, but [now as a clinical psychologist] I prefer making sense with a person about their experience."
None of this is new for psychiatry as Joanna Moncrieff and Mike Crawford's talk has shown. It has always been easier for psychiatry to avoid the uncertainty of human action by accepting the biomedical model. And of course it gives authority to psychiatrists. They are the people who understand the brain. It reinforces the control they have over people through the Mental Health Act.
How can attitudes be changed? I think we need to be sensitive to psychiatry's defensiveness. Not that I am excusing poor practice. Things need to improve. Society is expecting doctors in general to improve and I think we should take advantage of these cultural pressures for humanising medicine. We need to defend ourselves against those who regard us as disreputable. It is remarkable that taking an ethical stance in psychiatry is regarded as disreputable. Of course, psychiatry's defensiveness is understandable - dealing with people's abuse and traumata can be overwhelming. But this is no excuse for making people's situation worse and for being unhelpful. We need to educate professionals more about the implications of ideology. And we need to be more sceptical about the evidence which has been used to sustain the biomedical model - it is not as strong as the adherents as the biomedical model will have us believe.
The Critical Psychiatry Network is organising a conference with the same title as my talk - Breaking the Biomedical Dominance of Psychiatry - in Sheffield on Friday 27 April 2001 to take forward these themes. I hope as many people as possible will be there.