Psychiatrists around the world are currently engaged in efforts to critique the profession. Concern about the expansion of diagnostic terminology, the overly zealous use of pharmacotherapy, and the incursion of commercial interests – specifically by the pharmaceutical industry – into the workings of the profession are among the areas of concern. Many psychiatrists have come to a critical stance after years in practice. But each year, newly minted doctors join the profession. They are trained in a system that tends to reify concepts that demand more critical scrutiny. It is a challenge to formulate a way of educating them about the generally accepted body of knowledge of the field while simultaneously instilling a critical appreciation of the limits of our understanding and therapeutic capabilities. Hugh Middleton, the co-founder of the Critical Psychiatry Network, has written a remarkably eloquent yet concise book that fills this niche. "Psychiatry Reconsidered: From Medical Treatment to Supportive Understanding."
The book's first chapters provide a straightforward discussion of the current nosological systems in psychiatry, pharmacotherapy, and psychotherapies, followed by critical analyses. Middleton elucidates the distinction between classification and diagnosis, in particular what he identifies as "medical diagnosis," the process by which a doctor through some form of evaluative process attempts to identify the underlying abnormality causing the problem that brought the patient to clinical attention. While he argues that the DSM-5 and ICD-10, currently the most commonly used systems, may hold up as classifications, they are often interpreted to carry the meaning and heft of a medical diagnosis. He also draws distinctions among illness, disease, and pathology, arguing that a "medical diagnosis" implies to many that some pathological abnormality has been identified by the physician to explain the problem. As he points out, this connection – between classification and explanatory pathological process – has not come to fruition in psychiatry and this results in much confusion. He explores the ways in which this can cause harm.
In his discussion of pharmacotherapy, he raises questions regarding the complexity of brain function and the plausibility of claims that any particular molecule might have the nuanced effects on behavior and mood that are ascribed to psychiatric medications. He discusses the placebo effect and its implication for understanding drug effects and drug studies. His chapter on psychotherapies is another example of the author's ability to summarize complex topics. He reviews the major schools of psychotherapy, describing their theoretical underpinnings and applicability to daily practice.
Dr. Middleton then turns to the pragmatic. What brings people to specialized psychiatric care? He addresses that question by reviewing letters sent by primary care practitioners to specialists in the UK's National Health Service. His answer is that psychiatric problems are best understood as social problems: "It is social disruption rather than clear diagnostic criteria that prompts referral to mental health services" (154).
This concept – that it critical to understand the social nature of the problems that prompt psychiatric intervention – is the focus of the conclusion of the book. It is not that he disavows the potential value of biological understandings but rather, "Any attempt to define or describe what psychiatry is or does would be incomplete and insufficient without reference to the social world." (172). He turns his attention to sociology and ways in which scholars of that discipline have conceptualized social deviance. He discusses the phenomenon of "medicalization" and points out both its advantages and disadvantages. On the one hand, difficult behaviors may be easier to tolerate if they are considered manifestations of illness. On the other hand, "it also distances other participants from the full reality of the patient's life" (179).
The final chapter is titled, "So what can be learned?" The author suggests that the anti-psychiatry movement arose in part from the limitations of the medical approach. But he believes that the anti-psychiatry movement has not gained more traction in part because of the attraction of "simple solutions for complex problems" (188). What Middleton identifies as simple solutions have led to unrealistic expectations that have not been, and cannot be, fulfilled. In addition, he argues that the promotion of the sick role – inherent to medical conceptualizations – promotes a loss of personal agency and "distortions of self-perception towards incompetence and incapacity" (192) and that such self-perception may hinder recovery.
Middleton concludes with a discussion of what is arguably psychiatry's most problematic role in society – that of enforcing a form of social control over those "who have difficulty living amongst others" (203). He does not reject that role outright: "Psychiatry does need the authority to act on the client's behalf if not on their wishes" (203), but he suggests that psychiatrists are more likely to be helpful if, rather than trying to "'treat,' they "reach out and relate to" the people they are attempting to help (203).
I have some quibbles with Middleton. At times he draws, for my tastes, too sharp a distinction between what he is identifying as medical or surgical problems, on the one hand, and psychiatric ones, on the other. "There may be vivid evidence of emotional pain, but this evokes a different reaction from that evoked by an encounter with one tormented by physical pain" (170). I suspect that many who experience chronic pain might challenge this assertion. He claims that with medical problems, patients are more able to accept the limitations of medical care than they are with psychiatric problems. I would contend that there is uncertainty and unfulfilled expectations in all of medicine and this is played out in the often drawn out and expensive care offered at the end of life.
Overall, however, this remarkably concise and erudite text will have value for experienced practitioners as well as those new to the field. It provides a broad and compelling critical analysis of psychiatry and related professions.
© 2015 Sandra Steingard
Sandra Steingard, M.D., Chief Medical Officer, Howard Center, Burlington, VT