For those readers who would like a more detailed outline of the
contents of Doctoring the Mind I proceed as follows. In Chapter 1, I ask whether there is any evidence that psychiatry has made a positive
impact on human welfare. Surprisingly, it seems that there is not. For
example, whereas the recent history of physical medicine has been
marked by dramatic breakthroughs, leading to measurable improvements
in the likelihood of surviving life-threatening diseases, there is
no evidence of similar advances in our ability to treat severe mental
illness. This leads me to ask why psychiatry has failed when other
branches of medicine have been so successful.
The historical section of the book, which occupies the next three
chapters, explains how the current ineffective approach to psychiatric
care has evolved. Whereas the historical chapters in Madness
Explained focused exclusively on the development of theories of psychiatric
classification, in this book I focus much more on the evolution
of different kinds of psychiatric treatment. Of course, any history
must be selective, emphasizing some events and neglecting others in
an attempt to weave a coherent narrative. For obvious reasons, I have
tried to provide an antidote to the kind of Whig history contained
in books such as Michael Stone’s Healing the Mind,5 and Edward
Shorter’s A History of Psychiatry which, despite having many
strengths, inaccurately portray the glorious present as the culmination
of centuries of steady scientific progress. Along the way, I consider
the impact of the creation of the new profession of clinical psychology
at the end of the Second World War, which has been completely
overlooked by conventional histories. (A psychiatrist reviewing Madness
Explained argued that naked professional rivalry had undermined
its arguments. This observation made me think carefully about
how I portrayed the relationship between clinical psychology and
psychiatry in this book. However, in the end, it seemed to me that
ideological and professional conflict between the two professions has
been a historical reality and so I decided that it was pointless to pretend
otherwise.) After describing how the discovery of chlorpromazine
prompted renewed optimism in biomedical approaches to mental
illness, I explain how the emergence of the new technologies of neuroimaging
and molecular genetics has reinforced the modern view that
psychiatric disorders are genetically determined brain diseases that
must be treated with drugs.
The next three chapters deal with some myths about the nature
of severe mental illness that underpin current psychiatric practice.
Chapter 5 is the only chapter that overlaps considerably with Madness
Explained, and considers the value of psychiatric diagnoses. In
Chapter 6, I review what the current evidence tells us about the genetic
and environmental determinants of psychosis, contrasting theories
that locate the causes of illness within the person with those that
locate them in the world. A particular target of my critique is the
statistical measure of heritability, which is often cited by those who
believe that psychiatric disorders are genetic diseases. This is probably
the most technically demanding chapter in the book but I hope that I
have explained the relevant concepts in a way that will be easily
followed by the intelligent lay reader. In Chapter 7, I consider whether
and to what extent psychiatric disorders can be said to be caused by
brain disease. It turns out that this question is much more easily
addressed if we attempt to explain particular kinds of complaints
(symptoms) such as hallucinations and delusions, rather than meaningless
diagnostic categories such as ‘schizophrenia’. The picture that
emerges is much more consistent with the idea that severe mental
illnesses are influenced by the social environment, than with the idea
that they are genetically determined disorders of the brain.
The following three chapters consider the effectiveness of modern
psychiatric therapies. I begin by describing the emergence of the
evidence-based medicine movement, which has led to widespread faith
in the randomized controlled trial (RCT) as a measure of treatment
effectiveness. Focusing on antidepressants, I show how the pharmaceutical
industry has systematically distorted RCT data to promulgate
a wildly over-optimistic impression of what psychiatric drugs can do.
In Chapter 9, I extend this analysis by showing that the evidence in
favour of antipsychotic drugs is much less compelling than is usually
supposed, and that psychiatrists have been blinded to the adverse
effects of these drugs in much the same way that they were blind to
the effects of the crude brain operations and other extreme remedies
used in the middle years of the twentieth century. Unfortunately, as
we discover in Chapter 10, this does not mean that drug therapies can
be entirely replaced by psychological treatments. Although the last
decade has shown growing enthusiasm for one particular type of
psychological treatment for severe mental illness – cognitive behaviour
therapy (CBT) – the evidence that any one type of therapy is better
than any other is by no means clear-cut. This observation provokes
two kinds of responses. Some hard-line biological psychiatrists have
concluded that CBT is just some form of elaborate placebo but a
better conclusion is that it is the quality of the therapeutic relationship
that determines outcome. Hence, by paying attention to this relationship,
and placing it at the centre of psychiatric practice, we can see a
way to develop services that are more humane and effective. As much
as psychiatric services today are an improvement on those of the past,
it is because they are kinder and more respectful of the needs of
patients, rather than because of the availability of new therapies.
This conclusion leads me to the last chapter, in which I address
what is to be done to improve psychiatric services in the future. It will
be no surprise that I think that they need to be much less medically
orientated, but perhaps a disappointment to some of my colleagues
that I do not see the solution as a full-scale takeover bid by Clinical
Psychology Inc. Indeed, I argue that it is the engagement of patients
in the design and development of services that is most likely to lead
to lasting improvements.