The current recruitment problems in psychiatry have reopened the question of
whether the profession is in crisis and where its future lies.
A hard, honest look at how we have fared for the past 30 or so years might
help us to understand our current predicament and to plan for the future.
Overall it seems clear that the quality of psychiatric care has improved.
Unequivocal evidence for this is hard to obtain as changes over time vary for
different patient groups and different localities. However, compared with 1982
there is substantially more overall funding, the built environment and staffing
of most in-patient units is very much better, and a range of community-based
services have been established. More mental health professionals treat more
patients, and many are arguably better trained. More treatments are routinely
available, and practice is undoubtedly more consistent. Clinical governance and
quality management ensure that clinicians actually do what they are contracted
to do. So, overall things have become better, and this applies to practically
all high-income countries. Academic psychiatry has contributed rigorous trials
of interventions, reviews and meta-analyses consolidating knowledge on
interventions summarised in guidelines to inform practice. So far so good.
The role of research discoveries
The steady improvement in clinical services and rolling out of research
evidence have given an impression of substantial progress in psychiatry. This
impression may have obscured the real rate of recent scientific advances. It
can be questioned whether the past 30 years have witnessed any scientific
discoveries that have led to major improvements of practice.
The common service models, including day hospitals and community mental health
teams, had all been introduced 30 years ago. There have been no new
antipsychotics, antidepressants or mood stabilisers that are clearly more
effective than the drugs available at that time.
All current major psychotherapy schools had already outlined their
models including psychodynamic therapies, behavioural therapy, cognitive
therapy, solution-focused therapy, client-centred therapy and various forms of
family therapies. Randomised controlled trials were firmly established as the
gold standard for evaluating treatments, and psychometric principles were in
place for the development of assessment instruments.
Progress in fundamental research in subjects adjacent to psychiatry, such as
genetics and neuroscience, has been considerable and their applications to
practice are regularly presented as imminent. However, as of now, these
achievements in fundamental research have led to no obvious breakthrough in
Process and paradigms
Why has the enormous volume of increasingly well-funded and high-quality
psychiatric research produced so little? Two potential reasons are the rules
that regulate research activity and the models that guide its content, in
short, process and paradigm.
Increasingly, academic medicine is dominated by rigid rules that define
success and failure with short cycles for the evaluation of performance.
There is intense pressure to publish in high-impact-factor journals and to
be cited by others. This, in combination with the peer-review process of
publications and grant applications, leads to a narrowing focus on what is
mainstream and in fashion. Consequently, research groups across the world
conduct studies in the same areas that will generate funding and
impact-factor points here and now.
Such pressure to comply with mainstream expectations and the resulting
opportunism and short-term planning may not necessarily provide the best
conditions for creativity and innovation. Psychiatry shares this academic
environment and funding rules with other medical specialties but the nature
of our specialty means that their impact has been more profound.
We must also question whether the right paradigms have been used. Mental
disorders have a neurobiological, a psychological and a social dimension.
The prevailing paradigm in psychiatric research assumes a hierarchy between
these dimensions. It regards neurobiological aspects as the basis of
disorders, which are then expressed in psychological symptoms influenced and
managed within a social context. Neurobiological findings tend to be taken
as the explanations for disorders. Neurobiological processes have been
proposed as explanations for how and why interventions work, including psychotherapy.
Adopted enthusiastically by the pharmaceutical industry, this paradigm has
resulted in a criteria-based diagnostic system generating an ever increasing
number of disorders. These frequently occur as comorbid disorders in the
same person at the same time. This approach attempts to disentangle the
complex and holistic experience of an individual in their biographical and
Paradigms are neither true nor false, simply more or less useful for
generating testable hypotheses and fostering progress. There are good
historical reasons for the current paradigm and for operationalised
diagnostic systems. But surely the recent lack of progress is reason to
pause and consider alternative paradigms rather than simply pressing on with
‘more of the same’.
A social perspective
One possible alternative paradigm is a social one. This goes beyond the
established impact of poverty, wars, social inequality and unemployment on
mental health. We hardly need more research to demonstrate their importance,
but ensuring peace, social equality and full employment are political tasks.
A social perspective in psychiatry and psychiatric research encompasses the
social nature of human life. Mental disorders are defined as constructs in a
social debate (which is why they are endlessly controversial). Our
definitions reflect a consensus and this has been shifting over time, as
with the declassification of homosexuality as a mental disorder in 1973.
Mental disorders are expressed in social interactions. People with mental
disorders talk about their experience to someone else or they display
behaviour that has to be interpreted in the given social context to be
understood as a symptom. Whether someone walking alone and talking loudly in
the street is a cause for concern will mainly depend on whether they have a
mobile telephone in their hand. Psychiatric research cannot directly observe
processes in the mind, and neurobiological phenomena are ultimately
meaningless unless they are linked to the real lives of people in their
social reality. Observations of behaviour in a social context allow us to
conclude what may be going on in the mind and what may possibly be
correlated to neurobiological processes.
Finally, mental disorders are diagnosed and treated in interactions with
health professionals, whether face to face or using modern communication
technologies. They are at the centre of what psychiatrists do and how they
apply their professional skills.
Even the hardest sceptic must acknowledge the abundant evidence of the
importance of personal relationships in shaping both cause and cure of
disorders. Earlier relationship breakdown is implicated in the causal
pathway of adult disorders by how it shapes interpersonal trust and the
stability of relationships (the ‘conveyor belt’ of adversity).
A social paradigm requires research to study what happens between people rather
than what is wrong with an individual wholly detached from a social context.
This has conceptual and methodological implications. It would not ignore the
neurobiological and psychological dimensions of mental disorders, but link them
to social phenomena in the patient's life and in treatment. Methodologically,
much improved assessment approaches are required in a number of domains. First,
to assess how patients live in their various roles, for example as partners,
neighbours, friends, professionals, and how psychiatric treatment may have an
impact on these. Second, to assess how patients may interact in natural and
therapeutic groups, and how these interactions are associated with symptoms
expressed in other contexts. Last, to assess how relationships and interactions
with mental health professionals and non-professionals may be helpful, reduce
distress and bring about positive change. This may lead to a focus on treatment
factors that are commonly regarded as non-specific without, in any way,
diluting the core medical responsibilities.
This approach challenges the accepted distinction between basic and applied
sciences, which assumes that discoveries are first made in basic sciences and
then ‘translated’ into practice. Basic research on mental disorders as social
phenomena would have to be conducted in the ‘real world’. A fuller appreciation
of the social contribution to disorders and their treatment would not only be
of theoretical interest but have direct practical implications.
Service models such as the therapeutic community and day care were formulated
largely with an understanding of the therapeutic potential of social
interaction. These models have been in decline as psychiatry has shifted
towards a focus on the individual. At the same time, community care has been
established, with services that work in the community, but rarely with the
community. Few services actively work at increasing social cohesion and social
capital in their community to improve the mental health of local individuals.
In an increasingly fragmented society, work with the community would help
patients establish and maintain relationships with relatives, friends and wider
Finally, a focus on the social perspective would emphasise the role of
psychiatrists as agents in a social context. As Jaspers wrote in 1913,
‘Psychiatrists function primarily as living, comprehending and acting persons’.
This requires a focus on skills and not just on knowledge. These skills
may be related to, but are not identical with, what is required in conventional
psychotherapeutic settings. They include an ability to use personal strengths
in communicating with people with different mental disorders and influencing
groups. We believe that such a focus in training and practice has a potential
to strengthen our identity, give psychiatrists more societal relevance and make
psychiatry more attractive as a profession.
A tension between a neurobiological and a social model has characterised
psychiatry since the establishment of academic psychiatry in the mid-nineteenth
century. This tension has been productive and moved psychiatry forward.
However, psychiatry may have been at its most attractive as a profession and
most productive at times when the social perspective was fully embraced as
central to it.
Craddock, N, Antebi, D, Attenburrow, M-J, Bailey, A, Carson, A, Cowen, P, et al Wake-up call for British
psychiatry. Br J Psychiatry
Are psychiatrists an endangered species? Observations on
internal and external challenges to the profession.
2010; 9: 21–8.
Saraga, M, Stiefel, F.
Psychiatry and the scientific fallacy.
Acta Psychiatr Scand
2011; 124: 70–2.
Bolton, D, Hill, G.
Mind, Meaning and Mental Disorder: The Nature of Causal Explanation
in Psychology and Psychiatry. Oxford University
General Psychopathology: Volume 1.
Johns Hopkins University Press,