Wake-up call for British psychiatry: responses

One cheer at least for Craddock et al's ¹ polemic. Critical of the de-medicalisation and role-diffusion which they see as characterising contemporary British psychiatry, they argue that those with severe mental illnesses are best served by an initial consultation with a professional with the diagnostic skills of the consultant psychiatrist. Without such an intervention, they claim, the patient is likely to be psychopharmacologically disadvantaged, possible physical disorders may be overlooked and scientific advances not brought to bear on their illness.

Nevertheless a neutral observer might be tempted to see their ‘wake-up call’ as a tendentious attempt to regain hegemony by the psychiatric establishment. Their ad hominem ‘thought experiment’ – inviting readers to ask themselves whether they would be happy for ‘a member of their family’ to be cared for under the ‘distributed responsibility’ model – seems unworthy of such illustrious academics, a hostage to the possibility that many will take the contrary view. The two absent cheers are for the missing psychosocial components of Mayer's bio-psychosocial triad, first proposed a century ago, midway between Reil ² and Craddock et al. Indeed, that lack exemplifies the narrowness of vision which has arguably led to the very crisis which they bemoan. Nowhere do the authors consider the social forces driving de-professionalisation: the need to contain burgeoning healthcare budgets; flattening of social hierarchies, with leadership to be earned rather than role-bestowed; and technology-driven fragmentation of care.

Understanding these processes, and knowing how to work productively with the rivalries and distortions they create, is as essential to the psychiatrist's repertoire as the latest psychopharmacology update. Nor are these issues confined to psychiatry, not excluding the cardiology model so dear to their hearts. The good general physician who takes an overview of a whole patient, including psychological aspects, and is not merely a technical expert in the minutiae of a malfunctioning organ, is as rare a species as the putative ‘superlative’ psychiatrist.

Craddock et al's view of the science relevant to psychiatry is similarly limited, confining itself to molecular biology and neuroscience. There is no mention of recent advances in developmental psychopathology ³ which illuminate the psychological deficits of psychiatric illness, and the interpersonal skills needed by therapists of ameliorate them, or of psychotherapy process–outcome research which is beginning to tell us which kinds of therapy work best for which kinds of condition and personality. Waking up is the instant when dreams momentarily enter consciousness. Behind their grumpy growling, Craddock et al's reverie sounds like regressive nostalgia for an idealised past with which it is hard not to feel sympathetic, but is devoid of plans – as opposed to wishes – for the future.

A more hopeful straw in the wind is the recent Royal Colleges of Psychiatry and General Practitioners joint document on psychological therapies. ⁴ This argues the case for structured training in psychosocial skills for psychiatrists and general practitioners. Craddock et al might consider the possibility that a psychotherapeutically informed psychiatrist – whose abilities include dream interpretation – is more likely to regain a key role in the surely-here-to-stay multidisciplinary team than one whose expertise is narrowly confined to ‘excellence’ in prescribing, desirable though that no doubt is.