This important book provokes both admiration and indignation. It is a lucid and well written book which meets all the Stephen Pinker criteria for good style apart from the occasionally rhetorical flourish. Let us start with the negative bits.
Thomas depicts the early 21st-century psychiatrist as a reductionist prescriber who perceives patients (or service users/survivors) as a network of synapses and neurotransmitters whose aberrant thoughts, sensations, impulses and behaviour are determined by their genes. Through this neurotechnological lens the distressed or deviant individual is almost reduced to a disembodied brain suspended in metaphorical formaldehyde, bereft of biography, intention, sensibility or selfhood. The only remedy is psychoactive drugs.
Exciting developments in epigenetics, which unite the personal, the biological and the social are relegated in this book to a single footnote. Thomas refers dismissively to earlier speculation that genetic changes might contribute to the apparent increased risk of schizophrenia in African–Caribbean men born in the UK. This research was carried out ‘at a time when black people were taking to the streets in a blaze of anger in Brixton, Toxteth and Moss Side, [so] one is left with the image of psychiatry fiddling while inner-city England was aflame’ (p. 111). But when the social psychologist Angela Summerfield and the psychiatrist David O'Flynn devised an innovative training programme for unemployed, mainly African–Caribbean, long-term patients at Speedwell Day Hospital in the 1980s they were fiercely opposed by militant staff who claimed that the project was merely a reactionary scheme to instil a bourgeois work ethic. Resistance to creative innovation and reform is not just the prerogative of the conservative Establishment.
Dr Thomas and his post-psychiatry colleagues have agonised about the legitimate role of the medically qualified practitioner in the field of mental health. He concedes that the psychiatrist-as-physician can be useful to provide general medical help to people in distress and with psychotic symptoms. But so could a general practitioner.
So how can a critical psychiatrist justify his specialist role? Thomas asks: ‘If not as a neuroscientist, then what is the future role of the doctor in mental health care?’ In addition to general medical care he envisages five aspects of the future, socially aware psychiatrist's role: narrative psychiatry, engaging with communities, non-technological modes of care, placing ethics before technology, and what he calls ‘science and psychiatry’. This refers to the exciting model proposed by Harland, Morgan and Hutchinson Reference Harland, Morgan and Hutchinson1 in this Journal, which mobilises insights from phenomenology and anthropology to elucidate the relationship between subjective experience, social factors and the biological basis of psychosis in terms of neural plasticity.
This reviewer endorses all these proposals. Essentially they are already required knowledge, attitudes, enthusiasms and commitments for all biopsychosocially informed psychiatrists, whether critical, post- or mainstream. It is a pity that Thomas seems to have felt that an account of positive recent models of creative and sensitive care requires the rhetorical counterpoint of an alleged inhumane, coercive and technological system. The development of a patient-centred, individualised, narrative-based approach with shared decision-making is not being resisted by the psychiatric profession.
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