What justification can there be for yet another book attacking psychiatry? After all, as the authors of this book say, "many critical books about psychiatry and the disease model have been published, especially recently" (p. 300). Their answer is that this is the first book to examine the links between three major areas: the role of coercion; the emptiness of descriptive diagnosis since the third revision of the Diagnostic and Statistical Manual (DSM); and the madness of psychiatric drugs. Actually, consideration of these matters is kept rather separate in different chapters of the book and I don't think there is really any new material that has been introduced. It's not until the last chapter that alternatives are discussed. But if we give due accord to their claim, then maybe this book is the clearest to argue for the abandonment of coercive psychiatry since the death of Thomas Szasz.
What is more obviously probably unique about this book is that it has been written by three social workers. They first began meeting in 2004 in New York City. All have an independent history of academic critical publications challenging the disease model of distress and behavior. They clearly understand the social dimension of mental health interventions. Yet they conclude that the thoughts, feelings and behaviors of those identified as mentally ill are "normal human experiences in all their varieties" (p. 322). They think that professionals should only offer voluntary treatment and that physicians' prescription privileges should be abolished. The motivation for this position is the gross misinterpretation by mainstream psychiatry of the empirical evidence.
They appreciate that their conclusion about non-coercion is historically inconsistent with the modern origins of psychiatry in the detention of people in lunatic asylums. In England, voluntary admission was only possible after the Mental Treatment Act 1930. Even then, application needed to be made in writing to the person in charge of the hospital. The Mental Health Act 1959 set the foundations for modern psychiatric treatment and made informal admission the usual method of admission.
The locked doors of the psychiatric hospitals started to be opened in the 1950s. The peak of the mental health population in the UK and USA was the mid-1950s and later in other Western countries. The traditional asylums became increasingly irrelevant to the bulk of mental health problems and began their decline as alternative services were developed. True, most of these community services are provided on a voluntary basis but the incidence of detention in hospital has become more common, not less, as the length of admission to hospital has reduced. And, despite even my concerns, supervised community treatment was introduced in England following the amendment of the Mental Health Act in 2008, paralleling similar developments such as outpatient commitment in the USA. So, although the focus of psychiatry has broadened from inpatient detention, the role of coercion has endured against the wishes of the authors of this book.
I agree with the authors about the unscientific nature of the claim that mental disorders have been established to be brain diseases. I am also aware of psychiatry's history of abusive treatment and of course want to minimise the use of coercion. I'm not a social worker, but my social understanding leads me, contrary to the authors, to recognise the degree to which psychiatry is inevitably a social intervention. However much they may wish to abandon psychiatry's social role, even with the expansion of community psychiatry beyond the asylum, I think their aim is wrong and unrealistic. Of course the autonomy of mentally disordered people should be encouraged and realistic hope given to them in their recovery, but psychiatric illness can be mentally incapacitating. If this wasn't the nature of mental illness, psychiatry, in my view, would not have a raison d'être. Of course psychotherapy has developed as an individual practice in the same way that the authors would presumably like their "social" treatment to develop. But, I think that psychiatry is inevitably more than individual practice and I would have liked to have seen more discussion of this issue in the book.
Most of the book is taken up with the critique of mainstream psychiatry. That's relatively easy and any attempt to create a solution in the last chapter is relatively thin by comparison. I thought there were particularly useful aspects in all three main areas of the critique that they discussed. For coercion, their assessment of the value of assertive outreach was pertinent. For diagnosis, their insights into the politics of the development of DSM were valuable. For medication, their emphasis on three large scale evidenced based studies (CATIE, STAR*D and STEP-BD) sponsored by the National Institute of Mental Health (NIMH) that had poor therapeutic results is important. I thought it was also helpful that they pointed out the extent to which historians of psychiatry may have tended to hanker after a biological view of mental illness, even though their historical narrative highlighted the importance of context. This perspective may have always tended to be the case, as, for example, even the most interpersonal of psychiatrists, such as Harry Stack Sullivan, still believed that severely damaged schizophrenic presentations have an organic cause.
My different perspective from the authors of this book could be said to reflect the division in so-called anti-psychiatry between RD Laing and Thomas Szasz. I have always tended to be attracted to the Laingian view, whereas the authors of this book follow Szasz's line. It's probably about time that the number of critiques of psychiatry came to an end. The focus may need to shift to providing a way forward. There may be more disagreement about this than the more consensual nature of the critique, with which mainstream psychiatry has essentially failed to engage anyway.
© 2014 Duncan Double
Duncan Double is a Consultant Psychiatrist and Honorary Senior Lecturer, Norfolk & Suffolk NHS Foundation Trust and University of East Anglia, UK; blogs at critical psychiatry.