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Authors' reply

Published online by Cambridge University Press:  02 January 2018

Pat Bracken
Affiliation:
Centre for Mental Health Care and Recovery, Bantry General Hospital, Bantry, Co Cork, Ireland. Email: Pat.Bracken@hse.ie
Philip Thomas
Affiliation:
University of Bradford, UK
Sami Timimi
Affiliation:
Lincolnshire Partnership NHS Foundation Trust Child and Family Services Horizons Centre, Lincoln, UK
Eia Asen
Affiliation:
Marlborough Family Service, Central and North West London Foundation NHS Trust, UK
Graham Behr
Affiliation:
Central and North West London Foundation NHS Trust, UK
Carl Beuster
Affiliation:
Southern Health NHS Foundation Trust, UK
Seth Bhunnoo
Affiliation:
The Halliwick Centre, Haringey Complex Care Team, St Ann's Hospital, Barnet, Enfield and Haringey Mental Health NHS Trust, London, UK
Ivor Browne
Affiliation:
University College Dublin, Ireland
Navjyoat Chhina
Affiliation:
Early Intervention Team, Cumbria Partnership NHS Foundation Trust, Penrith, UK
Duncan Double
Affiliation:
Norfolk & Suffolk NHS Foundation Trust, Norwich, UK
Simon Downer
Affiliation:
Severn Deanery School of Psychiatry, Bristol, UK
Chris Evans
Affiliation:
Nottinghamshire Healthcare NHS Trust, Nottingham, UK
Suman Fernando
Affiliation:
Faculty of Social Sciences & Humanities, London Metropolitan University, UK
Malcolm R. Garland
Affiliation:
St Ita's Hospital, Portrane, Ireland
William Hopkins
Affiliation:
Barnet, Enfield and Haringey Mental Health NHS Trust, London, UK
Rhodri Huws
Affiliation:
Eastglade Community Health Centre, Sheffield, UK
Bob Johnson
Affiliation:
Rivington House Clinic, UK
Brian Martindale
Affiliation:
Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
Hugh Middleton
Affiliation:
School of Sociology and Social Policy, University of Nottingham and Nottinghamshire Healthcare NHS Trust, Nottingham, UK
Daniel Moldavsky
Affiliation:
Nottinghamshire Healthcare NHS Trust, Nottingham, UK
Joanna Moncrieff
Affiliation:
Department of Mental Health Sciences, University College London, UK
Simon Mullins
Affiliation:
Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK
Julia Nelki
Affiliation:
Chester Eating Disorders Service, Chester, UK
Matteo Pizzo
Affiliation:
St Ann's Hospital, London, UK
James Rodger
Affiliation:
South Devon CAMHS, Devon Partnership NHS Trust, Exeter, UK
Marcellino Smyth
Affiliation:
Centre for Mental Health Care and Recovery, Bantry, Ireland
Derek Summerfield
Affiliation:
CASCAID, Maudsley Hospital, London, UK
Jeremy Wallace
Affiliation:
HUS (Helsinki University Sairaala) Peijas, Vantaa, Finland
David Yeomans
Affiliation:
Leeds & York Partnership NHS Foundation Trust, Leeds, UK
Corresponding
E-mail address:
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Abstract

Type
Columns
Copyright
Copyright © Royal College of Psychiatrists, 2013 

Our central argument is that, for too long, academic psychiatry has been in the grip of a bioreductionist ideology that has prevented a truly ‘evidenced-based’ discourse to emerge. This ideology has encouraged us to see our discipline as simply ‘applied neuroscience’ and we have been promised over and over that the neurosciences will deliver insights and results ‘in the future’. But this promised future never materialises. Our analysis of the literature about how drugs and therapies actually work, about how recovery from serious mental illness is promoted in the real world and about what service users and their organisations are telling us about their lives and their encounters with services has led us to seek a post-technological psychiatry: one that is able to acknowledge the primary importance of relationships, meanings and values in mental health work. We believe that the available scientific evidence endorses this position and the demands from service users and their organisations for a very different sort of medical engagement with mental suffering.

Of course, there is work to be done in mapping the implications of this analysis. Moving ‘beyond the current paradigm’ is not about a search for another singular framework, but a realisation that the complex world of mental health demands openness to multiple paradigms. We believe that a mature psychiatry will be one whose practitioners are comfortable with the epistemological, political and therapeutic implications of this. Many psychiatrists strive to work in this way already and there is evidence that an increasing number are keen to move towards recovery-oriented service models. Reference Baker, Fee, Bovingdon, Campbell, Hewis and Lewis1

We do not claim to have all the answers and value the work of Professor Holmes, for example in relation to the role of narrative in mental health practice. Reference Holmes2 However, we would caution against any attempts to explain the insights of psychodynamics through the discourse of neuroscience. We fear that this is another example of what the physician and philosopher Raymond Tallis calls ‘neuromania’, Reference Tallis3 a contemporary intellectual fashion which seeks to explain every aspect of the human condition through the terms of neuroscience. One of Freud's greatest insights was the realisation that relationships are at the heart of mental health work, both in terms of explaining how problems emerge as well as offering solutions. Although neuroscience can offer some speculative ideas, it cannot be used to ground a science of interpersonal dynamics. In reality, human relationships, meanings and values are given their coordinates by the social context in which they exist. This context is deeply textured with cultural, linguistic, political and economic dimensions. It is the product of centuries of human history and simply cannot be grasped with the reductionist logic of biomedicine.

We are not too sure what to make of Professor Holmes's tone in referring to our ‘encouraging service user involvement’. We would like to reiterate that we do indeed see this as a vital ingredient in any progressive debate about the future of psychiatry.

Kinderman & Thompson support our analysis but seem afraid that we are attempting to create a psychiatry that will seek to colonise the territory of other disciplines such as their own (psychology). This is a misreading of our project and our intentions and we can reassure them that we have no tanks to move onto anyone's lawn! If human suffering fell neatly into specific domains there would probably be no need for psychiatry at all. Neurologists would deal with the brain and its disorders, endocrinologists would grapple with our hormones and psychologists could work with thoughts and feelings. However, human reality is not neat, and human suffering is often multidimensional. There aren't discrete domains. At its best, psychiatry involves an attempt to bring medical insights and practices to bear on the complex nature of mental problems. Such problems can emerge through purely psychological pathways but, most often, they involve social, economic, political and biological factors as well. Psychopharmacology is an important aspect of our work but so too is our understanding of the physical body and its diseases and our skills in relating this knowledge appropriately. We do not seek a psychiatry that has abandoned biology but a discipline that is more engaged with the humanities and the social sciences.

We do not accept the accusation that we failed to acknowledge ‘the existence of clinical psychology’, given the number of direct references to psychological research in our paper. Most of our discussion of the literature on counselling and psychotherapy is based on research by psychologists and our discussion of the ‘recovery approach’ points directly to the work of Professor Mike Slade (a psychologist).

We seek a different, not an expanded, psychiatry. We are not colonisers but neither do we believe that the answer is simply to replace psychiatrists with psychologists. Indeed, much of contemporary academic and clinical psychology is also guided by a technological paradigm.

The change we seek is not a replacement of one group of professionals with another. It is about a different ‘way of seeing’ what mental health work is about. Moving beyond the technological paradigm does not involve a rejection of everything we do now. It offers a different way of understanding why some of the things that we do work well, while at the same time appreciating the fact that some people are damaged by the way in which psychiatry frames their problems and intervenes in their lives. Crucially, it involves a rethinking of the nature of mental health expertise and, with this, a commitment to rethinking the power structures of our field.

References

1 Baker, E, Fee, J, Bovingdon, L, Campbell, T, Hewis, E, Lewis, D, et al From taking to using medication: recovery-focused prescribing and medicines management. Adv Psychiatr Treat 2013; 19: 210.CrossRefGoogle Scholar
2 Holmes, J. Narrative therapy in psychiatry and psychotherapy: the evidence? Med Humanit 2000; 26: 92–6.CrossRefGoogle Scholar
3 Tallis, R. Aping Mankind: Neuromania, Darwinitis and the Misrepresentation of Humanity. Acumen, 2011.Google Scholar
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