Jeremy Holmes, visiting professor

University of Exeter

Strong on diagnosis, but weak on prescription, Bracken et al's (1) critique of contemporary psychiatry suffers from the very difficulty which they decry. They rightly complain that current paradigms ignore the psychosocial, fail to combat stigma, and that academic psychiatry has little impact on clinical practice. They cogently argue that the relational aspects of treatment, whether avowedly psychotherapeutic or pharmacological, outweigh any supposed specificity in their effectiveness.

Sadly, their remedies are vague and anodyne: encouraging service user involvement, acknowledgement of complexity, taking account of 'systems of meaning'. Motherhood and apple pie anyone? This anti- psychiatry rehash sounds the retreat rather well, but as a call to arms is feeble; it knows what it is 'anti', but lacks a convincing 'pro'.

Yet there is in fact an exciting way forward, one where academic psychiatry and psychology convincingly combine to enhance work in the clinic. Developmental psychopathology is the current cutting edge, drawing on Attachment Theory, neuro-imagining and epigenetics (2). We are beginning to see how developmental experience inscribes itself on the brain, and sometimes on the genome; how the interaction of adverse developmental processes within the social milieu sows the seeds for psychiatric disorder. This provides the intellectual and evidential underpinning for effective psychotherapeutic treatments, which enhance resilience through fostering mentalising and mindfulness skills, promoting a sense of agency, and validating appropriate help-seeking. Psychiatrists-of-the-future's enthusiasm needs to be fanned by this flowering of environmental neuroscience, rather than doused with a thin foam of post-modern moaning.

Bracken, P. et al Psychiatry beyond the current paradigm. British Journal of Psychiatry 2012: 201, 430-434.

Holmes, J. Psychodynamic psychiatry's green shoots. British Journal of Psychiatry 2012: 200 439-441