Biological psychiatry is currently facing pervasive challenges to its hegemony. Mental illness has gained massive recognition and medical treatments for such disorders are virtually ubiquitous. At the same time, the field is beset by scandals around kickbacks from drug companies, embroiled in divisive arguments over its diagnostic bible (the DSM-V) and finding it ever harder to provide conclusive scientific proof of its effectiveness. The psychiatric profession is facing a crisis of confidence bigger than at the height of the antipsychiatry movements of the 1960s and 70s.
In the middle of this comes a compelling critique of some of psychiatry’s key claims by Richard Bentall, a UK clinical psychologist working within the NHS. In Doctoring The Mind: Why Psychiatric Treatments Fail, Bentall provides a lucid and accessible account of the meagre successes and substantial failures of psychiatry, following on from his earlier Madness Explained. Unlike many critics of the discipline, he remains committed to a scientific understanding, which he calls ‘rational antipsychiatry’.
Bentall starts with Emil Kraepelin, a German psychiatrist who meticulously studied asylum inmates over many years and from this defined the major diagnoses now known as schizophrenia and bipolar disorder. This sets the scene for criticism of a profession firmly rooted in a biological, medical-model frame. Following this are some shocking tales of asylum conditions, as well as the use of brutal and ineffective physical treatments for insanity, including insulin coma therapy and lobotomies (the latter winning one of psychiatry’s few Nobel Prizes). The 1950s breakthrough with the antipsychotic drug chlorpromazine, far from being a win for psychiatric research, is revealed as an accidental crossover from anaesthetics. Yet soon such medications were being used in massive doses, producing debilitating side effects and new suffering for patients.
In the context of anti-authoritarian social movements in the 1960s and 70s there emerged critiques like those of Thomas Szasz, RD Laing and Michel Foucault, sharing a view of psychiatry as a tool of social control resting on the subjective opinions of an uncaring medical elite. The crisis for mainstream psychiatry was worst in the United States, but a counter-movement soon developed, calling itself ‘neo-Kraepelinian’ and committed to reasserting the scientific (read: ‘biological’) basis of illness and treatment. This is the current that has dominated psychiatry since the DSM-III came out in 1980.
Yet, as Bentall shows, this renaissance rests on shaky foundations. Diagnosis is based purely on symptoms and behaviours, with heavy diagnostic overlap and poor reliability. It is not at all clear that DSM ‘disorders’ are discrete illnesses in the manner of, say, tuberculosis. Bentall counterposes a symptom-based approach, for example treating low mood, voices or paranoid beliefs each on their own merits.
He then debunks the idea that mental illnesses are simple products of genes. Mental illness is much more likely to be a complex result of the interplay of genetic and environmental factors, the latter both physical and non-physical. Bentall also shows that despite evidence that people with mental illness have (on average) different brain structure and function to ‘normals’, this doesn’t represent proof the causal chain must run from brain to mind.
Bentall concludes by scrutinising modern treatments. His grasp of the details of research methodology is reflected in clear explanations of the limitations of drug treatments and the Randomised Controlled Trials that have become the benchmark of ‘evidence-based medicine’. He explores the malign influence of Big Pharma in distorting science, leading to the production of expensive and harmful ‘new generation’ drugs marketed via aggressive promotion and bribery. Finally, he calls for a compassionate approach to treatment, suggesting clinical psychology as a relatively harmless but potentially powerful weapon for clinicians if they can just let go of their medical model approach.
In my practice I have drawn many conclusions similar to Bentall’s. There are also numerous areas where I disagree. For example, while I agree shock therapy is too often used inappropriately, in a narrow range of serious conditions its safety and efficacy actually have more evidence behind them than many of the drug or psychological treatments Bentall prefers. He also overplays the malice or ideological zeal behind past asylum conditions; most often they reflected the disinterest of the state in providing decent care for a highly marginalised social group. And in positing psychotherapies as the alternative to drug treatments in severe mental illness, Bentall is more projecting his hopes than any conclusive results.
But such differences can be forgiven – after all, Bentall’s book is a polemic. Its real limitation is a silence on the biggest theoretical and procedural gap in psychiatry itself – its dis-integration from the social organisation in which it has developed.
This is tied up with an uncritical view that ‘real’ medicine not only deals with real (i.e. biological) illnesses, it does so much more effectively than psychiatry does with mental illness. Yet medical illness is as much socially constructed as mental disorder. Behind each may lie particular processes in the natural and/or social realms, but they are only ‘illnesses’ once they are socially defined as such, invariably because they have an impact on social life that is considered harmful in some way*.
Such an understanding is not about relativism. Not any definition of what is an ‘illness’ will do. But such definitions are a product of specific, historical social processes, whose meaning can only be judged if one also has a theory of social structure and change. All illness is essentially deviancy from social norms, which themselves must be understood concretely. To be a critic of psychiatry requires more than having a more robust set of research trials to refer to, it means having a thoroughgoing social critique. Furthermore, it helps us to understand why there are struggles over ‘what is illness and what isn’t’, and whose interests different definitions serve. By taking an approach that suggests mental problems cannot be defined as illnesses – only as symptoms – Bentall misses such considerations.
While Bentall locates many mistakes in the overreach of a particular, narrow conception of science, he has no explanation for why that overreach occurs or how one could replace it with something better. In the same vein, despite some references to the constraints of the medical model more generally, he effectively lets it off the hook by exaggerating its achievements. Yet the problems he identifies with psychiatry – reductionism, neglect of social factors, commercial distortions, etc – operate across medicine.
Bentall seems to be a progressive, but he also accepts many of the ideological presuppositions of capitalist society. For example, he doesn’t question that psychiatry and psychology accept the centrality of the individual subject (‘self’) for study and treatment, a variation on methodological individualism. And his claims for a different research project for mental health are based more on a moral appeal than any systematic alternative to the corporate and state driven edifice that currently exists.
Consider these facts. Among the rich nations various mental disorders occur at higher rates in more unequal societies. There is growing evidence that pressure on people to succeed individually in a market society is deleterious to mental health. And the incidence, expression and impact of even allegedly ‘biological’ illnesses like schizophrenia vary widely across cultures, suggesting they too are socially mediated (though probably very differently to garden-variety anxiety or depression).
It is important that critics like Richard Bentall have shaken the complacent assumptions of mainstream psychiatry, but not sufficient. Bentall ultimately misses the fact that the achievement of genuine mental health cannot be divorced from the achievement of a healthy social organisation. It is not, then, a question of psychiatry versus antipsychiatry, but of addressing mental illness in the context of projects for social transformation.
*For these insights I am indebted to the book Psychopolitics (1982) by Peter Sedgwick