Things that were better not left unsaid

This established and well-respected American psychiatric book has plaudits for its first two editions placed prominently on its back cover. If it is a guide to psychiatry for psychiatrists, then professional applause will undoubtedly recur with the new edition. Non-psychiatrists or insiders with a more critical eye about the societal role of the profession may be less enamoured.

As the text amply demonstrates, psychiatry's central occupational disability is a lack of self-understanding. This task is left mainly to others who offer a countervailing discourse to that of professional self-flattery. A few dissident internal critics have existed on the margins of the profession for the past 30 years. They have been joined by other mental-health professions (like my own) making competing bids for legitimacy, disaffected service users and academic critics within social science.

With this in mind, it is particularly important to assess what is explored in "Psychiatry and society", the last of six sections in the book.The flyleaf boasts that this new edition mirrors a change in the profession of psychiatry, that it "has come to a sophisticated new understanding of the interplay between psychiatric knowledge and issues in the larger society". Being the last and shortest, the section in question may not quite indicate an afterthought, but it suggests that society is not at the top of the psychiatric agenda. The ordering of the first five sections signals other priorities: examination and evaluation; brain and behaviour; psychopathology; principles of treatment and management; and special populations. The chapters in the last are actually not phrased as populations but as individual patients: "the child", "the person with mental retardation", etc. Thus, even the hope of a population-level exploration is dashed by the clinical gaze and the individualisation of the social.

The current enthusiasm for technological gadgetry (neuro-imaging) summarised in the book reinvigorates the profession's preferred biodeterminism. It is as if repeating the obvious point that the brain is implicated in experience and behaviour is proof that biodeterminism at last offers a scientific justification for medical hegemony. But correlation studies from brain slicing and photography offer no certain proof of either causality or its direction. Taxi drivers might have brains altered by the Knowledge; "schizophrenics" might have different brains because of the psychiatric drugs they have taken, infantile privation or genetic "faults". Our hardware can affect our experience, but the reverse is also true. Nothing is certain.

The book also reflects a historical compromise about another tradition in the profession, psychoanalysis and its spin-offs. After the first world war, the profession could remain unified only if an accommodation between the biological, psychological and, later, social could be worked out. Rapprochement did ensue and it has been maintained in a strained eclecticism, albeit one still heavily biased towards the biological.

So how does the book's claim about a "sophisticated new understanding" fare? The self-assured image constructed may tally with the experience of the urbane American authors, but it helps little in our understanding of National Health Service psychiatry. Nor does it explain why "anti-psychiatry" and frustrated patients have sustained a hostile stance towards the profession for so long. The profession in Britain is not so much in crisis as in chronic decline. User surveys indicate that psychiatrists are the least favoured of the professionals in their midst. Young doctors are turning away from the speciality and older colleagues abandoning it. The reader would get no sense of the dire picture from this upbeat book (maybe everything in the American psychiatric garden is rosy).

There is a good chapter on race but little on class or gender. No analysis is offered about user self-advocacy as a new social movement. Jacques Lacan gets a section but R. D. Laing and Thomas Szasz are not on the map, even as no-go areas or examples of how daft you can get. Michel Foucault, who also does not exist in the text, once pertinently suggested that we should attend to all that is said and unsaid. The chapter on psychiatric epidemiology has nothing about lay epidemiology in the field of mental health. The chapter on electroconvulsive therapy (ECT) mentions public anxiety and hostility but dismisses it as ignorant prejudice, requiring a public-relations corrective. However, there is a substantial difference between what psychiatric research tells us about ECT and what its recipients tell in other, unmentioned studies. Will the fourth edition unsilence the unsaid or will the avoidance of critical self-reflection continue?

David Pilgrim is a clinical psychologist and professor of mental health, University of Liverpool.