Common sense, nonsense and the new culture wars within psychiatry. Invited commentary on … Beyond consultation

In their paper on working with user/survivor and carer groups, Bracken & Thomas ¹ throw down a significant challenge to mental health professionals of all disciplines, one that is rather more significant than the casual reader might believe. To fully understand this paper it needs to be read as part of a larger project, namely post-psychiatry. Relatively few readers of this journal will have read the book of this title by Bracken & Thomas ² but perhaps more would be familiar with their articles in the BMJ and Advances in Psychiatric Treatment where they outline the tenets of post-psychiatry, ^3,4 sometimes labelled critical psychiatry (although I may have missed subtle distinctions between the two constructs).

There is nothing exceptionable about the proposition that psychiatrists should engage in dialogue with users and carers. Medical managers working in England will have the various domains set out in Standards for Better Health ⁵ engraved on their hearts. The ‘patient focus’ domain of these standards states that: ‘Healthcare is provided in partnership with patients, their carers and relatives, respecting their diverse needs, preferences and choices, and in partnership with other organisations (especially social care organisations) whose services impact on patient well-being’. ⁵ The ways these domains are assessed has been continually updated by the Healthcare Commission ⁶ and will be in future by its successor organisation, the Care Quality Commission. It is, indeed, something of a truism that psychiatrists need to be sensitive to the explanatory frameworks that our patients and their carers hold. Every day of our working lives we are engaged in a dialogue about the causes of the distress that our patients are experiencing and how this distress might be best addressed. Effective dialogue is, in fact, a core element of good medical practice for all doctors working in the UK. ⁷

What is at issue is whether the dialogue that Bracken & Thomas recommend, what is now the Care Quality Commission requirement within the Standards for Better Health and what competent clinicians in any case engage in every day of their working life, has quite the subversive impact that the authors predict. They argue that the perspectives of groups that reject the biomedical and psychological approaches which psychiatrists are trained to adopt towards helping people experiencing particular mental health problems somehow undermine or invalidate the allegedly shaky edifice of psychiatric practice.

To support their case, Bracken & Thomas cite the influential philosopher of science Thomas Kuhn, ⁸ criticise descriptive psychopathology and quote the Editor of the British Journal of Psychiatry as providing ‘accumulating evidence that calls into question the benefits of many of the treatments that we use’. ⁹ This is good knock-about stuff, and it is certainly thought-provoking, but is it true?

Although I could not claim the undoubted philosophical expertise that Bracken & Thomas have, there are some oddities about their programme. Kuhn did not hold the radical anti-science, subjectivist views that are ascribed to him and he tried to make this clear in the second edition of his book The Structure of Scientific Revolutions. Kuhnian paradigm shifts (if they really occur) do not abolish previous scientific knowledge but absorb it into a better fit with the empirical evidence.

Bracken & Thomas allude to the alleged evils of descriptive psychopathology that is rooted in the phenomenological tradition (these concerns are much elaborated on in their book). ² It is hard to believe that they have not read the important book by Larry Davidson that uses detailed phenomenological analysis to construct an account of how people can and do recover from mental illness, ¹⁰ surely a project that Bracken & Thomas should be applauding. From an immediate practical perspective the abandonment of descriptive psychopathology that Bracken & Thomas espouse strikes me as indeed simply dangerous (their word) in the absence of an alternative, intellectually coherent programme. (The only obvious alternative is the psychometric tradition which gives us rating scales and personality profiles, a tradition that Bracken & Thomas would be likely to find even more distasteful than descriptive psychopathology.) The problems with abandoning the rigour of descriptive psychopathology are amply demonstrated by the authors’ cavalier use of the term ‘madness’ (which of course has been acquired by some more radical user groups with deliberate irony) as if it had any particular meaning.

Most egregious of all is the quotation of a throw-away remark by the Editor of the British Journal of Psychiatry which, to my mind, was a celebration of the fact that the knowledge base on which we work continues to evolve. What we once held as correct we can acknowledge as being wrong or at least superseded by a model that better fits the data or a technology for treatment or care that is demonstrably more effective. Scientific knowledge is always and appropriately provisional.

Within their conceptual world Bracken & Thomas clearly see some heroes (the more radical elements of the user movement, adherents of critical psychiatry and themselves) and some villains. Minor villains are perhaps the bulk of the psychiatric profession that plough the furrow of the outmoded biopsychosocial model (it is perhaps a minor comfort to those of us in this category that Bracken & Thomas are elsewhere equally scathing about psychological paradigms ² ). Major villains are the big beasts of academic psychiatry who have the temerity to explore the biomedical basis of psychiatric disorder. For some reason this activity according to Bracken & Thomas ‘works to undermine attempts to develop a genuine dialogue with the user/survivor movement in all its diversity’ - good rhetoric but not necessarily a logical consequence of biomedical research.

The world view promoted by the post-psychiatrists stands in interesting contrast with that set out in Wake-up call for British psychiatry ¹¹ recently published by 37 authors, mainly card-carrying academic psychiatrists who are undertaking biomedical research. This wake-up call includes a no-nonsense defence of a medical approach to ‘psychiatric assessment, diagnosis and treatment’, a blunt assertion that ‘patients have a right to expect more than non-specific psychosocial support’ and use of the metaphor of ‘not throwing the baby out with the bathwater’, which irresistibly comes to my mind when reading post-psychiatric texts.

There is some common sense in what Bracken & Thomas have to say about working with user/survivor groups and, despite the formidable philosophical underpinnings to post-psychiatry, perhaps more than a little nonsense. Their project is strikingly similar to the antipsychiatry movement of the 1970s, which, perhaps paradoxically, got me and many others of my generation interested in psychiatry. ¹² We now appear to be entering a possibly creative period of ‘culture war’ between the post-psychiatrists and academic psychiatry. It is to be hoped that this new culture war does not result in any casualties. Those in the firing line include most mental health professionals, who of necessity take an eclectic approach to their highly complex work, as well as our patients and their carers.

Declaration of interest

None.