Out of the shadow of a creaking wall

Since the second world war, psychiatry has been a creaking wall. Attacked from within by "anti-psychiatry" and then from without by a new social movement of disaffected patients, the credibility of its theory and practice seemed to be crashing. These medical woes were aggravated by cogent conceptual and empirical critiques of psychiatric nosology from some clinical psychologists making competing bids for leadership within the mental health industry But these two books, at least, demonstrate a countervailing conservative tendency. The first is written by a psychiatrist with a specialist interest in trauma and the second by a clinical psychology trainer.

Traumatic Events and Mental Health provides a systematic review of the psychiatric literature about the topic in its title. This material is pre-digested for the reader in a clear and coherent way. The opening chapter, which purports to put the concept of what is now called post-traumatic stress disorder (PTSD) into an historical context, is one of the weakest. Important contributions about the social construction of shellshock in the first world war are missing. This is a very thin and selective history that in part may reflect the author's lack of disciplinary credentials as a social historian. It may also in part suit his professional interest.

This chapter opens a recurring campaign in the book to shift the status of the concept of PTSD from being an intelligible normal reaction to being not merely a "disorder" but emphatically an illness. Thus PTSD rapidly becomes PTI. An illness lexicon is elaborated, which includes epidemiology, etiology, nosological considerations and pre-disposing factors. This is not to say that the external nature of trauma itself is not addressed. But this is done within a mechanical billiard ball universe in which stimuli impact on individuals who then, depending on their pre-disposing level of vulnerability, do or do not produce symptoms.

Stephen O'Brien is interested in accounting for the failure of all comers exposed to similar or identical stressors becoming "ill". But there are no objective benchmarks to form a consensus on this topic. What is at issue is a conceptual and statistical assumption. An illness model assumes discontinuity in a population (some are ill and some are not), whereas a dysfunction model assumes people are connected on a continuum and professionals introduce a discretionary cut-off to distinguish one group from another. The notion of dysfunction reflects culturally specific behavioural norms. Mental health professionals reflect and reinforce those norms in their own contemporary culture by their assessment and treatment practices. O'Brien marshals his evidence and arguments to persuade us that the subjective outcome of accidents and oppression can be one of illness. But this "illness" is a product of his own textual reasoning. It is not an unambiguous read-out of a relationship between an invariant external reality and its impact on subjective experiences of distress.

By driving post-traumatic distress into an individualised and objectified pigeonhole of illness, O'Brien closes off a sensitivity to the nuances and meanings of trauma in its cultural context and the role of his own profession in contributing to the reproduction of that culture. We should be cautious about exporting westernised psychiatric models of trauma to understanding, for example, the mental health impact of child soldiers in developing countries. By contrast, O'Brien's production of a one-dimensional illness model of trauma radically decontextualises distress.

It is not surprising that psychiatrists usually operate a medical, rather than social model of distress. They are after all highly trained medical practitioners. O'Brien is a successful product of his professional socialisation.

Turning to the other book under review, why do clinical psychologists still hang on to the coat-tails of psychiatric knowledge? Understanding Abnormal Psychology starts by mentioning that "abnormal psychology is a social construction". This reader's hope of finding a social scientific reading of psychiatry was raised at this point. Neil Frude proceeds to acknowledge that clinical psychology "shadows" psychiatry and he defines abnormal psychology as the "psychological study of psychiatric disorders". The sociological error here is a failure to recognise that so much of the discourse about psychological abnormality has been produced by non-psychiatrists in a variety of medical and non-medical settings. Even within the confines of the NHS, most patients with psychological difficulties are never seen and diagnosed by a psychiatrist. The increasingly extensive work of clinical psychologists and counsellors in primary-care settings highlights this point.

Despite this lack of professional reflectiveness from Frude about the daily production of knowledge about abnormal psychology by non-psychiatrists, his central descriptive focus is the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. This has had several revisions since its inception in 1952 (by 1994 we are on number four, hence DSM-IV). Frude then has an opportunity, following his outline of DSM-IV, to critique this end-product of the North American psychiatric enterprise from a British psychological perspective. Indeed, he rehearses some criticisms of DSM but it is evident by page nine of the introduction that he is happy with psychiatric nosology. Accordingly, the rest of the book is organised on the basis of reifications created by medical positivism. Why was it not simply written as a text for medical students about psychiatry?

Psychology undergraduates should be exposed to a more critical body of knowledge than is present in this book. The low point is the chapter on schizophrenia. This diagnosis has been subjected to persuasive deconstructions from Frude's professional colleagues, which he ignores or dismisses briefly as a footnote. Frude's position on psychiatric knowledge demonstrates a broad division within his profession between those who are seeking a break from medical thinking and those who wish to legitimise its continuation.

Whereas, in the past, the relationship between clinical psychology and psychiatry was characterised largely by organisational tensions about the professional autonomy of the former from the dominance of the latter, now epistemological questions are begged. Will clinical psychology be able to generate a body of knowledge that is not recurrently parasitic upon psychiatry? Is this question, in turn, linked to the identity crisis of academic psychology: is it a biological or a social science?

Intimations of the death of psychiatric theory and practice, created by the pressures from internal and external critics, need to be reconsidered in the light of revitalising texts produced by mental health professionals like O'Brien and Frude.

David Pilgrim is a consultant clinical psychologist in the NHS in Blackburn, Lancashire.