Territorial disputes
Dear Sir or Madam:
Territorial disputes are a zero sum game: if one side gains ground it can only be at the expense of the other. As clinical psychologists, it was therefore with a wry smile that we read the recent paper by Bracken and colleagues (1), which calls for psychiatry "to move beyond the dominance of the current, technological paradigm" and towards an understanding of mental health problems not as diseases of the brain, but as involving "social, cultural and psychological dimensions".
We agreed with much of the paper's substance, yet found ourselves concerned by the implied route to implementation. Given their audience, Bracken and colleagues can be forgiven for failing to acknowledge the existence of clinical psychology; yet their arguments owe a great deal to advances, both theoretical and empirical, made in this field. By calling for psychiatry to shift its epistemology and praxis, it might seem not only that that they want to adopt an alternative philosophy, but quietly to move their tanks onto the lawns of fellow professionals.
One could follow their argument to a different conclusion. If the goal is a mental health care system in which problems are seen principally as "social, cultural, and psychological" in origin rather than biomedical, then the case for having medically trained professionals in positions of seniority is substantially weakened. Rather, clinical leadership would need to be provided by people who have received a comparably extensive training in psychological, social and cultural causes of distress.
Reforming the whole of psychiatry from the inside out can hardly be the most practical means of realising this vision. Instead, consider that there are some 10,000 clinical psychologists in the UK, the majority of whom work in the NHS. A substantial number of psychiatric posts go unfilled,(2) while clinical psychologist posts are being cut and downgraded across the country despite training places being vastly oversubscribed. We could begin by imposing a moratorium on filling psychiatric posts and use the money saved (in the order of ?100 million pounds, at a conservative estimate) to reverse the process of downgrading, increase the number clinical psychologists at higher leadership grades and expand the number of training places. That - at zero net cost to the NHS - could help move us toward Bracken and colleagues' vision.
To be clear, this is not an "antipsychiatry" argument. We do not dispute psychiatric expertise in several technical areas, principally psychopharmacology. Whilst the benefits of neuroleptic medication have often been gravely overstated (3) and the utility of diagnostic categories is a source of constant dispute,(4) we would not be amongst those who deny that pharmacological interventions are ever a useful part of the treatment armoury, nor would we join the ranks of those criticising the profession of psychiatry. But if we want mental health services to be structured around the epistemological and theoretical assumptions outlined by Bracken and colleagues, psychiatry should not aspire to colonise the territory of social, cultural, and psychological disciplines, but instead adopt a more genuinely equitable stance.
Yours sincerely
Professor Peter Kinderman Director, Institute for Psychology, Health and Society University of Liverpool Brownlow Street Liverpool L69 3GL +44- 151-794-5533
Dr Sam Thompson Trainee Clinical Psychologist University of East London Stratford Campus Water Lane London E15 4LZ
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