Psychiatry in Dissent: Anthony Clare's critique, defence and reinvigoration of psychiatry

Summary

Psychiatry in Dissent: Controversial Issues in Thought and Practice was published in 1976. In the book, Irish psychiatrist Anthony Clare (1942–2007) both defended and critiqued contemporary psychiatry. He demystified the field, analysed its problems and argued that psychiatry, for all its flaws, offered a reasoned and reasonable path forward. His arguments remain fiercely relevant today, sometimes eerily so.

In 1976, Psychiatry in Dissent: Controversial Issues in Thought and Practice was published in London, written by Irish psychiatrist Anthony Clare (1942–2007) (Clare 1976). Tavistock Publications were clear about what readers could expect: ‘This timely book will cause controversy [ … ] The assumptions of psychiatrists and anti-psychiatrists are questioned in this challenging book’. They were right: Psychiatry in Dissent was comprehensive and coruscating about contemporary psychiatry, but – unusually – was also constructive and inspiring. As a result, Clare's book became an instant classic of modern psychiatry, with all its potential and possibility as well as its many imperfections.

Psychiatry in Dissent appeared at a time when psychiatry was under fire from all angles: the existence of ‘mental illness’ was continually questioned, the efficacy of treatments widely debated and the legitimacy of psychiatry as a branch of medicine was the topic of endless, agonised discussion (Kelly 2020). Into this melee, Psychiatry in Dissent brought engagement, reasonableness and respect for all perspectives. Most importantly, Clare brought an awareness that different audiences had different needs in these debates: the public deserved an honest account of the true state of psychiatry as a branch of medicine, and people working in mental health services required a robust intellectual framework that inspired their confidence. Psychiatry in Dissent provided both, along with a lively intellectual approach and a careful, compassionate tone that fostered unity and collaboration rather than division and despair.

Plus ça change, plus c'est la même chose

Almost five decades later, Clare's book has stood the test of time, as key themes and arguments remain valid and relevant today, sometimes eerily so. Psychiatry in Dissent started with a lucid, open-minded exploration of ‘the concept of mental illness’, arguing that ‘it is probably a mistake’ to conceptualise mental health and mental illness ‘as dichotomous’ (Clare 1976: p. 32). Instead, Clare argued, ‘they are best thought of as opposite ends of a continuum’ – a prescient position which was richly validated over subsequent decades (Kelly 2006).

Clare discussed ‘models of mental illness’ and noted that, when the ‘diagnostic process’ is ‘approached in a rational and competent manner, the results in terms of diagnostic agreement and all that follows it compare favourably with those in a comparable field of medicine’ (Clare 1976: p. 114). Clare devoted two chapters to schizophrenia, the first asking ‘What is schizophrenia?’ and the second exploring ‘causal factors’. ‘Whether there is one condition, called schizophrenia, or several which are currently mixed up together under a common classificatory label is still an open question’, he wrote (p. 157). This, too, is a position which remains vital, relevant and debated today, many decades later (Murray 2017).

Next, Clare tackled two controversial treatments, ‘electroconvulsive therapy’ and ‘psychosurgery’, followed by a quite brilliant analysis of ‘responsibility and compulsory hospitalisation’. Clare concluded Psychiatry in Dissent with an account of ‘the grim realities of the psychiatric services’ (Clare 1976: p. 382), writing that lapses in standards ‘are inevitable as long as the psychiatric services are starved of skilled resources, are inadequately staffed, and are poorly funded’ (p. 396). Yet again, decades later, plus ça change, plus c'est la même chose.

All told, Clare did not hold back about the lamentable state of public mental health services in the UK, but also offered compelling arguments that things could be better, that psychiatry offered a reasoned and reasonable path forward and – implicitly – that honest public discussion was an important part of this process. Clare defended contemporary psychiatry, pointed out its flaws, restored public confidence and inspired a generation of doctors to enter this branch of medicine with confidence, enthusiasm and self-belief. As a field, we are in his debt.

Reviewing Clare's book in the Guardian, Peter Sedgwick described Psychiatry in Dissent as ‘a liberal riposte to the last ten years’ anti-psychiatric and radical campaigning against mental medicine’:

‘Essentially Clare is advocating the provision of State funds to refurbish and develop an administratively flexible, socially informed but still highly medical model of treatment [ … ] Clare's book is a courageous journey into a dissent which one senses may be just beginning to define itself. Latent within it is a critique of a social order which continually summons us out to perform on the high wire of competitive striving, and then chops away at the last remaining safety net if ever we falter and crash’ (Sedgwick 1976).

‘The perfect media intellectual…’

In the years following Psychiatry in Dissent, Clare continued to present his careful, reasoned arguments in professional and general media, and soon became a well-known public figure, commenting on not only psychiatry but a wide range of other matters too. A gifted debater and communicator, he was in constant demand. Ten years after Psychiatry in Dissent, David Berry wrote in the Guardian that Clare had become ‘the perfect media intellectual of the Eighties’:

‘Respected in his field, he is able to talk with wit and ease about others [ … ] It is little wonder then that Anthony Clare is such an attractive personality to editors and producers. In these times of radicalism and ideology, it is his elegant, very reasonableness that marks him out [ … ] It is as if in his chosen Maudsley-influenced psychiatric world of scepticism and distrust of grand theory, something has been missing. In the media, he can generalise, make intuitive statements, play for higher stakes’ (Berry 1986).

I was 3 years of age in 1976, when Psychiatry in Dissent was published, and 7 when a second edition appeared (Clare 1980). As a result, I read neither at the time, but became acquainted with Clare's media interviews in the 1980s. As a medical student in the 1990s, I read Psychiatry in Dissent and was inspired to enter psychiatry. As a trainee in Dublin, I met Clare, and we corresponded until just before his death in 2007. In 2020, I was privileged to co-author his official biography, with Muiris Houston (Kelly 2020).

Clare's contributions were many, but Psychiatry in Dissent remains his greatest, most iconic work. It changed psychiatry and it changed me.