A din set to fall on deaf ears

The section on psychiatry in bookshops tends to be small compared with other academic disciplines with legitimate insights about mental health. Under attack from so many sources, the profession generally defines itself in narrow, conservative and medical terms, which makes for a stultifying self-referential discourse. Like most psychiatric textbooks, this one contains no healthy exchanges with other versions of human science. The vast majority of citations used are from psychiatric articles and books.

For those on the inside of this narrow professional frame, this book, now in its fourth edition, will be well received. It contains 26 chapters, covering all of the main bases of the medical specialism, from diagnosis and treatment through to ethics and psychiatric service organisation. (Apparently we still have psychiatric services not mental-health services.) The authorial elders offer elegant advice to their juniors on all professional fronts. But the book provides no honest appraisal to neophytes about the troubled trade they are joining.

Quality improvement in mental-health services now demands robust user involvement but I could find only one sentence that recognises this crucial point (on page 788). Even in this fleeting allusion, users are just part of a list of interest group also-rans who are not psychiatrists.

The experience of patients is let in earlier in the text, only as an adjunct to making an accurate diagnosis or to offer advice to practitioners when patients are being "uncooperative". It is certainly true that people with mental-health problems are not often overly keen to "access" psychiatric service. But research about, rather than from, psychiatry now tells us that a lack of patient "insight" is a reductionist explanation.

The silences in the text suggest that patients have little to say that is meaningful about themselves, about mental health in general, the services that they encounter or the social context, which shapes and responds to their distress and difference. This will leave junior psychiatrists having to discover these other dimensions of their client group in their own time.

If you are an outsider, you will find this a book that does not know how to deal with an unpopular profession. Both the text and the medical specialism it champions are wary of engaging properly with the perspectives of disaffected patients, internal dissenters and competing mental-health professionals. This din from without provokes a few reactive dismissals in the book (in chapter four) but, by and large, it is simply ignored. However comforting blinkers and defensiveness are for the body of a profession under siege, eventually they will probably produce brittle bones.

David Pilgrim is professor of mental health, University of Liverpool.